Preoperative leukocytosis as predictor of intraabdominal injury in penetrating abdominal trauma

482 Cirugía y Cirujanos

Cir Cir 2012;80:482-487.

Preoperative leukocytosis as a predictor of intraabdominal injury in penetrating

abdominal traumaJuan de Dios Díaz-Rosales, Lenin Enríquez-Domínguez, Jose Romeo Castillo-Moreno,

and Fernando Herrera-Ramírez

Servicio de Cirugía General, Hospital General de Ciudad Juárez, División de Posgrado, Universidad Autónoma de Ciudad Juárez, Ciudad Juárez, Chihuahua, México

Correspondence:Juan de Dios Díaz RosalesAvenida del Charro 350Álamos de San Lorenzo32310 Ciudad Juárez, Chihuahua, MéxicoE-mail: [email protected]

Received for publication: 2-24-2012Accepted for publication: 9-7-2012

abstract

introduction: In Mexico, management of penetrating abdominal trauma does not follow algorithms of Trauma Center Level I because our limitations and laparotomies are inevitable in this context. Is it possible to use some degree of leukocytosis to suspect intraabdominal injury? methods: We carried out a retrospective, descriptive and analytical study that included patients with penetrating abdominal trauma who underwent exploratory laparotomy. We excluded patients with severe soft tissue damage to extremities, chest cavity, fractures, or central nervous system damage. We divided patients into two groups: group I (therapeutic laparotomy) and group II (nontherapeutic laparotomy). Dependent variables were age, gender, type of injury, number of wounds, peripheral injuries, time lapse (between occurrence of injury and taking of blood samples), mean grade of leukocytosis, percentage of neutrophils, leukocytosis ≥12,500/mm3, and hemoperitoneum. We compared variables between groups using Pearson χ2 test and Student t test, and percentages as summary of measures. results: We included 231 patients: group I—159 patients and group II—72 patients. Overall leukocytosis was 13,200 mm3 and neutrophils were in the range of 70.3%; 26% of patients did not have leukocytosis upon arrival and evaluation; however, they underwent laparotomy due to peritoneal irritation. Leukocytosis ≥12,500/mm3 was statistically significant in patients with intraabdominal injuries (74.2% vs. 27.7%, p <0.001). Conclusions: Leukocytosis ≥12,500/mm3 may be an early serum marker in intraabdominal injuries due to penetrating abdominal trauma.

Key words: standard leukocyte count, predictive value, laboratory testing, leukocytosis, injuries.

introduction

In Ciudad Juarez, penetrating trauma due to civil violence and narcoviolence is a serious public health problem.1 This condition is addressed in three referral hospitals. The most influential is the Hospital General de Ciudad Juarez where the majority of survivors of aggressions are admitted and has become the point of referral in the city and throughout the state.2-4

Abdominal trauma is a serious abdominal injury affect-ing all layers of the abdominal wall to the parietal perito-neum and is a common cause of significant disability and mortality during productive ages.5-7 Currently, treatment of abdominal trauma is twofold: surgical and conservative. The category of patients where surgical intervention is im-perative is clear (shock, evisceration, peritonitis), whereas other patients can be treated conservatively and success-fully.8-10

Algorithms of approach in trauma centers are established in Level I Trauma Centers in countries with all the techno-logical resources [computed tomography (CT], serial scans such as Focused Assessment with Sonography in Trauma (FAST), selective angiography and even laparoscopy) and trained personnel.8-10 However, in second-level centers in developing countries, there are shortages of these resources for the appropriate approach to patients with doubtful di-agnoses.

In our setting, the clinic is essential in the evaluation of trauma patients, especially abdominal trauma. This assess-ment is useful in cooperative patients, those not under the effects of toxic substances (drugs, alcohol), and patients without other associated injuries (fractures, traumatic brain

Volume 80, No. 6, November-December 2012 483

Preoperative leukocytosis in penetrating abdominal trauma

or spinal cord injuries) and, although initially intraabdomi-nal injury is not ruled out, it is helpful during primary and secondary evaluation in the first 12-24 h.

Given the scenario of penetrating abdominal trauma where it is verified that the peritoneal cavity or the retro-peritoneum or both were penetrated, in patients with clear data of hemodynamic instability and peritoneal irritation, exploratory laparotomy is mandatory, without the need for additional tests or serial scans. However, hemoperitoneum arising from the abdominal wall is sufficient to irritate the peritoneum. Pain at the site of injury entry and the coexis-tence of associated injuries are a frequent cause of confu-sion about the injury in an intraabdominal organ.11 With the advent of CT12,13 and FAST in trauma cases,14 conservative management has been established in penetrating injuries with a high success rate; however, lack of availability of these resources limits the application of treatment algo-rithms, making them almost not feasible.

In the literature search we performed, early serum mark-ers in penetrating abdominal trauma have not been exten-sively studied,15-19 and the average leukocytosis related to penetrating abdominal trauma is unknown and much less if this measurement is related to the injury. For this rea-son, we evaluated the range of preoperative leukocytosis in penetrating abdominal trauma. Its predictive character ac-cording to the severity of the intraabdominal damage was found and we evaluated when correlating an early marker of intraabdominal injury with data from the clinical exami-nation. A prediction can be made whether or not there is intraabdominal injury.

methods

We carried out a retrospective and descriptive study in the Department of General Surgery, General Hospital of Ciu-dad Juarez, which is a teaching hospital center and trauma center concentrated in the city. We evaluated patients ad-mitted with a diagnosis of penetrating abdominal trauma and who underwent exploratory laparotomy for this reason between April 1, 2008 and December 31, 2010. To obtain information and selection of participants, we requested all electronic records of hospital admissions and discharges with a diagnosis of penetrating abdominal trauma. Prior approval was obtained from the Bioethics and Research Committee of the Autonomous University of Ciudad Juarez and the Committee on Trauma of the General Hospital of Ciudad Juarez. We included patients with penetrating ab-dominal injury in the peritoneal cavity caused by firearm and/or knife injury and who underwent emergency explor-atory laparotomy for suspected intraabdominal organ in-jury, with time between injury and the start of surgery <6

h and who were discharged in improved condition at the end of their hospital stay. We excluded patients with hemo-dynamic instability in their initial assessment, with added injury to the chest, limbs, head and neck, and who required surgical intervention, traumatic brain and/or spinal cord in-jury, fractures at any site, major central vessel injury and/or peripheral organs, absence of blood count on admission, and death from trauma-related complications. Exclusion criteria were patients with established treatment in the hos-pital and selected for the study but who were transferred to another medical facility postoperatively, patients who were pregnant or given birth, postmenopausal patients or patients with seizures and death in the pre-, intra- and postoperative period due to any cause.

Preoperative diagnosis was made based on clinical crite-ria and local wound exploration. All patients with documen-tation that the injury penetrated all layers of the abdominal wall including the peritoneum and organ evisceration (or both conditions) were considered positive. CBC was ob-tained in the emergency room during the primary evaluation of the patient and was sent to the laboratory (processed with a COULTER Ac. T5diff AL computer, Beckman Coulter, Fullerton, CA). We compared two groups: group I patients with therapeutic laparotomy vs. group II patients with non-therapeutic laparotomy. Variables studied were age, gender, type of trauma, number of wounds (point of entry), estimat-ed time between injury and taking of blood count, hemato-crit, hemoglobin, number of leukocytes/mm3, percentage of neutrophils, leukocytosis ≥12,500/mm3, hemoperitoneum and length of hospital stay. Leukocyte values ≥5,120/mm3 were used to test the hypothesis of intraabdominal organ injury.

To collect information, a sole instrument was made that captured the recorded information. All information col-lected was gathered in an Excel 2010 database. This data-base was stripped and simple frequencies were corrected, searching for inconsistencies. Subsequently, data were cap-tured and processed using the statistical program STATA v.10 (College Station, TX) and results were obtained. In-formation is presented in frequency tables. Pearson χ2 test and Student t test were used for statistical differences in continuous and grouped data, respectively. Also included were mean values, standard deviations (SD) and range of continuous variables.

results

We included 231 patients; 218 (94.4%) were male (male:female ratio 17:1). Overall average age was 27 years (±8.9 years). Figure 1 shows the number of patients accord-ing to age group. Group I included 159 (68.8%) patients and


Díaz-Rosales JD et al.

group II included 72 patients (31.2%). Of the total patients, 120 (52%) suffered gunshot wounds and 111 (48%) stab wounds. The average time between injury and blood count sample was 104 min. The average number of injuries per location in both groups was 1.1/patient. The areas most af-fected were the mesogastrium, both flanks and epigastrium, which constituted 55% of the injuries. Table 1 shows the number of injuries per area. The most common clinical pre-sentation was abdominal pain in 219 (95%) patients. Other less frequent data were evisceration, rectal bleeding, hema-turia and palpable abdominal mass.

Hemoglobin and hematocrit in all patients were within normal limits, and there were no significant differences sep-arating these according to type of laparotomy performed. In both groups the average preoperative leukocytosis was 13,200 (±3.7)/mm3 with 70% (±10%) neutrophilia. Overall, 171 (74%) patients had leukocytosis (≥11,000/mm3) on ad-mission, whereas 60 (26%) patients did not. The average leukocytosis in group I was 14,000/mm3 with neutrophilia of 71%, whereas in group II it was 11,300/mm3 leukocyto-sis with neutrophilia of 68%.

Leukocyte difference between groups was 2,700/mm3 and for neutrophils was 3% (both with a statistically sig-nificant difference, p <0.001). Using the degree of leu-kocytosis ≥5,120/mm3 as a reference value4 in predicting whether or not the patient had intraabdominal injury, there was a significant difference in favor of group I (p <0.001). Leukocytosis ≥12,500/mm3 was found in 74.2% of cases in group I and in 27.7% of cases in group II, with subsequent leukocytosis ˂12,500/mm3 in 26% of cases in group I and 72% of cases in group II. In 85% of patients with leukocy-tosis ≥12,500/mm3, intraabdominal injuries were found that required treatment, whereas in patients with leukocytosis ˂12,500/mm3, 52% had a nontherapeutic laparotomy. Leu-kocytosis ≥12,500/mm3 had a sensitivity of 74% and speci-

ficity of 72% for predicting intraabdominal injury in this study (Table 2).

When the mechanisms of injury and type of laparotomy were compared, a statistically significant difference was found. Nontherapeutic laparotomies were more common in the group of patients with stab wounds and therapeutic laparotomy was more common in patients with gunshot wounds (Table 3). There was virtually no difference in leu-kocytosis between the mechanism of action (stab wound vs. gunshot wound) in the same group, but there was a marked difference between the primary mechanism of action be-tween groups, whose tendency towards stab wound (62%) favored group I (p <0.001), whereas in group II the trend was toward gunshot wound (69%) (p <0.001). As expected, there was an important difference in the hemoperitoneum between groups (600 mL), which was significant (p <0.001) in the between-group comparison (Table 2).

In group II, 16 injuries were found (0.22/patient) in eight different organs that did not require treatment, only assess-ment, triage and evacuation of hemoperitoneum (243 mL on average). In group I, there were 263 injuries (1.6/patient) to intraabdominal organs, most of which required treatment (except for liver and spleen injuries that were not actively bleeding) and evacuation of hemoperitoneum (641 mL on average). The most common injuries occurred in the small intestine, colon, stomach and liver. The remaining injuries are shown in descending order in Table 4.

Average hospital stay was 6 days (±5.5 days). The length of stay for patients in group I was 7.3 days (±6 days), whereas in group II the average stay was 3 days (±2 days) with a statistically significant difference (p <0.001). All pa-tients in this study were discharged due to improvement in their condition.

14-19 20-29 30-39 40-49 ≥ 50

120

100

80

60

40

20

0

48

99

55

27

2

Age groups

Num

ber

of p

atie

nts

figure 1. Age groups affected. Source: Servicio de Cirugía, Hospital General de Ciudad Juárez.

table 1. Injuries per area (%)

Injury site %

Mesogastrium 16.9Left flank 13.4Right flank 12.5Epigastrium 12.1Right hypochondrium 10.4Left hypochondrium 9.1Right iliac fossa 6.1Hypogastrium 5.2Buttocks 5.2Right dorsum 3.5Left iliac fossa 3.0Left dorsum 2.6

Source: Servicio de Cirugía, Hospital General de Ciudad Juárez.



discussion

As observed in Mexican studies in regard to trauma, males in the third decade of life are the most affected.1-7 It was observed that, in Ciudad Juarez, low sociocultural level is a risk factor for this type of injury. The activities related to organized crime are also considered high risk for suffering from this type of injury. The average time from injury to blood sampling was considered reasonable.

In our center we have a higher rate of penetrating trauma by firearm (52 vs. 48% in this study), contrary to what is reported by the major European trauma centers20 and simi-lar to what occurs in the U.S.9 The reason is obvious—the high rate of drug-related crime along our border is known worldwide.

Of patients with abdominal trauma included in this study, 31.2% underwent nontherapeutic laparotomy. It is impor-tant to mention that patients had injuries spanning all layers

of the abdominal wall, verified by escape of fluid from the omentum or digital exploration of the wound, despite being a limited universal study due to the inclusion criteria. Per-centage of nontherapeutic laparotomies is within average limits, as with other studies.20,21

This is despite not having advanced imaging studies and is based on clinical and scarce paraclinical evidence to corroborate our diagnosis. The highest percentage of patients with nontherapeutic laparotomy came from the group of patients with stab wounds. Obviously, the ki-netics and type of trauma directly influence the risk of injury requiring corrective surgery which, as has been observed, is higher for gunshot wounds than for stab wounds.

This study avoided the variables that may have been related with increased leukocytosis and that may have in-fluenced the results. Therefore, we excluded patients with severe abdominal injuries and injuries to other areas. Leu-kocytosis increases considerably when abdominal trauma is accompanied by a fracture, but that will be the subject of a future study. Associated injuries in this study were only soft tissue injuries.

Although patients with gunshot wounds were slightly higher in number, the average injury per patient was low. This is due to the inclusion, exclusion and elimination cri-teria, which filtered patients with more critical injuries and conditions that caused higher morbidity. It stands to rea-son that the greater the number of injuries, the poorer the condition of the patient. The central and upper areas of the abdomen are the most commonly affected, but it should be noted that a percentage of patients had abdominal injuries caused by points of entry in the pelvis, back and buttocks. Therefore, patients with such injuries are not exempt from having intraabdominal injury.

table 2. Laboratory results according to laparotomy carried out in patients with penetrating abdominal trauma at the Hospital General de Ciudad Juárez

General Type of LAPE

Characteristic Mean (SD) Range Group I Group II *p

Leukocytes 13.2 ( 3.7) 5 - 23 14 ( 3.4) 11.3 ( 3.7) 0.001Neutrophils 70.3 (10.3) 33 - 90 71.2 ( 9.9) 68.1 ( 10.6) < 0.001Hemoglobin (g/dl) 13.6 ( 1.8) 8 - 19 13.6 ( 1.8) 13.8 ( 1.6) 0.273Hematocrit (%) 40.9 ( 5.4) 25 - 62 40.5 ( 5.4) 41.5 ( 5.3) 0.583Hemoperitoneum (ml) 641.6 (652.7) 185.4 (142.4) < 0.001Leukocytosis ≥12,500/mm3

118 / 159 20 / 72 < 0.001

LAPE, laparotomy; SD, standard deviation.*Student t test.

table 3. Type of laparotomy carried out according to the mechanism of injury of patients with penetrating

abdominal trauma

mechanism of injury *pGroup Injury due to

knife woundFirearminjury

0.0001Group I—therapeutic 55% 82%Group II—nontherapeutic 45% 18%

Total 100% (n=111)

100% (n=120)

*χ2.


Díaz-Rosales JD et al.

The clinical picture was always abdominal pain, which occurred in patients undergoing therapeutic and nonthera-peutic laparotomy. The ability to discern between intensity and type of pain between these groups may be the subject of another study. Abdominal pain is not a decisive factor for differentiating patients with suspected intraabdominal injury from those patients in whom this has been ruled out. Evisceration is also not necessarily an indicative factor for intraabdominal injury. Hematuria can occur with genito-urinary injuries ranging from contusions (not requiring surgery) to injuries requiring emergency surgery. Rectal bleeding may be the only data that when present along with penetrating abdominal trauma, prompts us to search for an intraabdominal injury (specifically of the gastrointestinal system) and, therefore, to perform laparotomy.

Average leukocytosis values and patients with leukocy-tosis on admission were higher than in other similar stud-ies22 (13.2 ± 3.7 vs. 11.6 ± 5 and 70 vs. 59%, respectively), perhaps because of the higher incidence of gunshot wounds. In our study, patients with intraabdominal injuries had higher leukocyte counts on admission than those without injuries. Average leukocyte count in patients with intraab-dominal injury due to gunshot wounds was almost equal to leukocyte count in patients with stab wounds.

There was also no difference in the leukocyte count be-tween the same group and mechanism of action, suggesting that leukocytosis is in proportion to the presence or absence of intraabdominal injuries and, therefore, we may expect similar ranges of leukocytosis between mechanisms in one or the other group. Gunshot wounds are more often associ-

ated with intraabdominal injuries than stab wounds. This shows that the risk of intraabdominal injury is greater if the injury is due to a gunshot than to a stab wound. Hemo-peritoneum found was as expected, significantly higher in patients with intraabdominal injury than in those without.

Preoperative hemoglobin and hematocrit were within the normal range and do not predict or discern acute bleeding in patients with penetrating abdominal trauma, as seen in our results. Leukocytosis ≥12,500/mL between groups had a significant difference (p = 0.001), with a sensitivity of 74% and specificity of 72%. This suggests that preoperative leukocytosis ≥12,500/mL may be an indicator or early se-rum marker of intraabdominal injury in penetrating abdom-inal trauma. As reported by Schnüriger et al.,15 leukocytosis ≤12,500/mL can exclude intraabdominal organ injury; how-ever, we believe that the leukocytosis values in the first 24 h has limited predictive value. We use it as a reference value to distinguish those patients with intraabdominal injury from those without intraabdominal injury with the results reported here.

Our study coincides with other trauma studies5-7 in fre-quently affected intraabdominal organs. In group II, one nontherapeutic laparotomy was carried out. There were also minor injuries found, most grade I, as well as one hemoperi-toneum with an average of 185 mL evacuated. It is impor-tant to mention that, even in nontherapeutic laparotomies, we also found a significant degree of injury (22%). This shows the importance of having advanced imaging studies to facilitate the monitoring of injury evolution in these pa-tients.

table 4. Organs injured and degree of injury in patients with intraabdominal injuries at the Hospital General de Ciudad Juárez

Degree of injuryInjured organ n I II III IV V

Small intestine 76 40% 25% 20% 15%Colon 74 16% 62% 18% 4%Liver 35 34% 37% 26% 3%Stomach 24 4% 83% 13%Kidney 21 5% 14% 19% 43% 19%Bladder 17 6% 47% 29% 18%Spleen 14 14% 7% 14% 29% 36%Appendix 4 50% 50%Pancreas 4 75% 25%Diaphragm 4 100% Gallbladder 3 100% Duodenum 2 50% 50%Ureter 1 100%

Source: Servicio de Cirugía/Hospital General de Ciudad Juárez.



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11. Thacker LK, Parks J, Thal ER. Diagnostic peritoneal lavage: is 100,000 RBCs a valid figure for penetrating abdominal trauma? J Trauma 2007;62:853-857.

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17. Santucci CA, Purcell TB, Mejia C. Leukocytosis as a predictor of severe injury in blunt trauma. West J Emerg Med 2008;9:81-85.

18. McCarthy DA, Grant M, Marbut M, Watling M, Wade AJ, Macdonald I, et al. Brief exercise induces an immediate and delayed leukocytosis. Br Sp Med 1991;25:191-195.

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20. Casali M, Di Saverio S, Tugnoli G, Biscardi A, Villani S, Cancellieri F, et al. Penetrating abdominal trauma: 20 years’ experience in a Western European Trauma Center. Ann Ital Chir 2008;79:399-407.

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Santucci et al.17 showed that, in blunt abdominal trau-ma, leukocytosis is associated with severe damage. The same results were reproduced by this study in the setting of penetrating abdominal trauma. Chang et al.22 found that the level of leukocytosis in trauma patients is not re-lated to the mechanism of injury or to the affected organ, but with the severity of damage with results similar to ours. Furthermore, these authors concluded that the level of leukocytosis in these patients does not predict the vol-ume for resuscitation, need for transfusions, or surgery. Length of hospital stay was consistent with expectations, i.e., more days required for patients undergoing thera-peutic laparotomy than for those who had a nonthera-peutic laparotomy. This was probably due to the greater inflammatory response in the former and also monitoring for the appearance of complications in patients with or-gan repair.

In conclusion, leukocytosis is a common finding in the study of routine hospital laboratory examinations. There-fore, level of leukocytosis may be an early serum marker for intraabdominal injury in penetrating abdominal trauma. This information in no way changes the algorithm study of these patients. We should always be cautious and examine the patient from a holistic standpoint, taking into account serious injuries to soft tissues, injuries to blood vessels, and thoracic and central nervous system involvement. In addi-tion, fractures at any site may elevate the degree of leu-kocytosis above the expected values in our study for both groups.

references

1. Díaz-Rosales JD, Enríquez-Domínguez L, Arriaga-Carrera JM, Gutiérrez-Ramírez PG. Trauma penetrante en abdomen y tórax: estudio de casos en el Hospital General de Ciudad Juárez. Cir Gen 2009;31:9-13.

2. Díaz-Rosales JD, Enríquez-Domínguez L, Arriaga-Carrera JM, Cabrera-Hinojosa JE, Gutiérrez-Ramírez PG. Trauma penetrante abdominal con lesión en intestino delgado, aislada y asociada a otros órganos: la relación respecto a la morbilidad y mortalidad en Ciudad Juárez Chihuahua. Cir Gen 2009;31:91-96.

3. Enríquez-Domínguez L, Díaz-Rosales JD, Arriaga-Carrera JM, Gutiérrez-Ramírez PG, Castillo-Moreno JR, Rivas-Serna J. Trauma penetrante en colon: comparativa de tratamientos. Cir Gen 2009;31:230-235.

4. Díaz Rosales JD, Arriaga-Carrera JM, Enríquez-Domínguez L, Castillo-Moreno JR, Montes-Castañeda JG. Trauma penetrante abdominal: comparativa de morbimortalidad en heridas por arma de fuego y arma punzocortante. Cir Gen 2010;32:24-28.

Preoperative leukocytosis as predictor of intraabdominal injury in penetrating abdominal trauma

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