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Original Article

The value of ultrasound in the management of

blunt abdominal trauma in Zaria, Nigeria
Jerry G. Makama, Ekundayo S. Garba, Istifanus A. Joshua1
Department of Surgery, Ahmadu Bello University Teaching Hospital, Shika, 1University Health Services,
Ahmadu Bello University, Zaria, Nigeria

ABSTRACT
Background: Abdominal ultrasound has assumed a major role in the management of blunt abdominal trauma. The aim of the study
is to evaluate the role and vile of the use of ultrasonography in screening for blunt abdominal trauma in an emergency setting of a
tertiary hospital in Nigeria.
Materials and Methods: It is a retrospective study at a university hospital Zaria. All patients who presented with blunt abdominal
trauma from 2008 to 2010 were reviewed retrospectively, using patients’ case notes, ultrasonographic findings, operating theatre
log books, and surgical audit data. Abdomino-pelvic ultrasound findings of all the patients were noted and compared with actual
findings at operation followed by the analysis of the sensitivity and specificity of the ultrasound including positive predictive value
and negative predictive value. The grade and experience of the principal Ultrasonographer were also noted.
Results: In a total of 107 patients, 94 (87.8%) were males and 13(12.14%) were females. The mean age was 33.417.42 year (range 2-69).
With the ultrasound, positive findings were present in 44 (41.1%) patients while negative findings in 2 (1.9%). Of these positive
ultrasound findings, 18 (16.8%) had free intra-abdominal fluid only, 13 (12.1%) had both free intra-abdominal fluid and intra-abdominal
organ injury, and 13 (12.1%) had intra-abdominal organ injury only. The major organs with injury included liver 18 (5.2%), spleen
16 (4.7%), stomach or bowel injury 6 (1.7%), and kidney or urinary bladder 3 (0.9%). The sensitivity of ultrasonography was 95.7%,
while its specificity was 92%. The positive predictive value was 90% and the negative predictive value was 96.7%.
Conclusion: Ultrasonography is an accurate and safe method for managing patients with blunt abdominal trauma.

Key words: Abdominal trauma, blunt, ultrasonography, vanity, vile

Introduction a significant diagnostic challenge to the most seasoned

trauma surgeon. Trauma surgeons must have the ability
Ultrasonography (USS) for blunt abdominal trauma (BAT) to detect the presence of intra-abdominal injuries across
was first described in 1971,[1] and it is currently growing this entire spectrum. While a carefully performed physical
rapidly as a primary screening examination for BAT examination remains the most important method to
in most trauma centers of the regions in the world.[2-4] determine the need for exploratory laparotomy, there is
Evaluation of patients who have sustained BAT may pose evidence to support that ultrasound (US) in BAT is an
extension of the physical examination. The effect of altered
Address for correspondence: Dr. Jerry Godfrey Makama, level of consciousness as a result of neurologic injury,
Department of Surgery, Ahmadu Bello University Teaching Hospital, alcohol or drugs, is another major confounding factor in
Shika-Zaria, Nigeria. assessing BAT. The aim of the study is to evaluate the role
E-mail: jerlizabeth@yahoo.com and the drawback of the use of USS in screening for BAT
in an emergency setting of a tertiary hospital in Nigeria.
Access this article online
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Website: Materials and Methods
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This was a retrospective study done at Ahmadu Bello
DOI:
University Teaching Hospital Shika Zaria. All patients,
10.4103/2278-9596.110026 regardless of age that presented with BAT from January 2008
to December 2010, were reviewed retrospectively, using

96 Archives of International Surgery / July-December 2012 / Vol 2 / Issue 2

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Makama, et al.: The value of ultrasounds in blunt abdominal trauma
patients’ case notes, ultrasonographic findings, operating
theatre log books, and surgical audit data. Confirmatory
diagnosis of BAT was based on clinical evidence of BAT
and intra-operative findings at exploratory laparotomy.
Intra-operative findings such as evidence of pre-peritoneal
hematoma, peritoneal bruise or tear, free fluid or blood in
the peritoneal cavity including the pelvis, intra-abdominal
organ injury, retroperitoneal hematoma and/or organ
injury following BAT were considered “confirmed BAT.”
Abdomino-pelvic US findings of all the patients were noted
and compared with actual findings at operation. Those
who were already operated or had penetrating injuries
or burns were excluded. The presence and volume of free
fluid within the abdominal cavity was accepted as a positive
sign for hemaperitoneum. Visceral organs were evaluated
for parenchymal injuries consisting of intraparenchymal
hematomas, lacerations, and evidence of shattered organ.
Other investigations performed included diagnostic
peritoneal larvage (DPL), biochemical, and haematological
assessments. CT scan was never done in any of the patients
due to urgency required for further operative care. Data
collected included demographic characteristics, clinical
and ultrasonographic findings, and intra-operative findings
of patients. The type of ultrasonographic machine used,
the probe, the grade and experience of the principal
ultrasonographer were also noted.
Results
A total of 109 patients were admitted with an initial
diagnosis of BAT, during the study period. Those with
associated chest trauma, postoperative patients, and
burns patients were excluded. Only 107 patients satisfied
inclusion criteria. Vehicular accident was the most common
cause of blunt abdominal injury [Figure 1]. All the patients
had US done on them by different consultant radiologists
48 (44.9%) and radiologists in training at the level of registrar
18 (16.8%) and senior registrar 41 (38.3%). In a total of
107 patients, 94 (87.86%) were males and 13 (12.14%) were
females. The mean age was 33.417.42 years (range 2-69).
Ninety seven (55.8%) patients had their USS done within
Figure 1: Common causes of blunt abdominal trauma (BAT; n107)
Archives of International Surgery / July-December 2012 / Vol 2 / Issue 2
first 24 hours of accident, while 22 (12.6%) patients
delayed seeking medical help for a variable number of
days (2 days to 1 week). The reasons for delay was (1)
gradual development of abdominal symptoms in a patient
11 (6.3%), (2) absence of an ultrasonographer 3 (1.7%),
lack of A/E staff commitment 7 (4.0%), and faulty US
machine 1 (0.6%). The mean duration of experience of
the ultrasonographer was 2.3 years ranging from 1 year
to 23 years. They all had US using a 3.5/5.0-MHz convex
probe on Aloka Doppler US Machine (Model: SSD-5500).
With the US, free intraperitoneal fluid or organ injuries
were present in 44 (41.1%) patients, while they were absent
in 2 (1.9%). Of these positive US findings, 18 (16.8%) had
free intra-abdominal fluid only, 13 (12.1%) had both free
intra-abdominal fluid and intra-abdominal organ injury, and
13 (12.1%) had intra-abdominal organ injury only [Figure 2].
The major organs with injury [Table 1] included
liver 18 (5.2%), spleen 16 (4.7%), stomach/bowel injury
6 (1.7%), kidney/urinary bladder 3 (0.9%). Real-time USS
was the interventional agent used (Table 2 and using a
22 contingency table [Table 3] sensitivity and specificity
including the positive predictive value and negative
predictive value were the predictors of clinical outcome.
The sensitivity of USS was 95.7%, while its specificity was
92%. The positive predictive value was 90% and the negative
predictive value was 96.7%.
Discussion
Patients with BAT[5] present a special challenge to the
surgeons. Physical examination is inaccurate in detecting
organ injury even if the patient is awake. Frequent
co-existence of head injury exacerbates this problem.
Duplex sonography allows derivation of Doppler-signal
curves in color. The direction of flow is indicated by
blue or red, according to flow from or to the probe. This
permits a rapid investigation and yields intelligible images.
With the color Doppler imaging technique, peripheral
parenchymal vessels can be studied, which is of great
Figure 2: Positive ultrasound findings
97
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Makama, et al.: The value of ultrasounds in blunt abdominal trauma

Table 1: Organ injury

Organ/Degree Spleen Liver Gallbladder Kidney/urinary bladder Stomach/bowel injury Others Total
of injury (%) (%) (%) (%) (%) (%) (%)
Minor 9 (2.6) 15 (4.3) 1 (0.3) 2 (0.6) 4 (1.0) 7 (2.0) 38 (11.0)
Moderate 4 (1.2) 2 (0.6) 0 (0) 0 (0) 2 (0.7) 1 (0.3) 9 (2.6)
Severe 3 (0.9) 1 (0.3) 0 (0) 1 (0.3) 0 (0) 1 (0.3) 6 (1.7)
Total 16 (4.6) 17 (4.9) 1 (0.3) 3 (0.9) 6 (1.7) 9 (2.6) 52 (15)

Table 2: Ultrasound and operative findings

Recently, American surgeons reconsidered USS in trauma
and codified its use into FAST (Focused Assessment for
USS Operative findings Negative Total
(%) (%)
the Sonographic examination of the Trauma patients).
FF (%) FF+OI OI (%)
The goal is to detect hemoperitoneum and pericardial
(%)
Positive effusion. Advantages are remarkable: US is cost-effective,
FF 15 (14) 2 (1.9) 1 (0.9) 2 (1.9) 20 (18.7) fast, non-invasive, can be performed by surgeons even on
FF+OI 2 (1.9) 11 (10.3) 0 (0) 3 (2.8) 16 (15) unstable patients. FAST[9,10] is now included in the ATLS
OI 1 (0.9) 5 (4.7) 7 (6.5) 0 (0) 13 (12.1) framework for examination of thoraco-abdominal trauma.
Negative 1 (0.95) - 1 (0.95) 56 (52.3) 58 (54.2)
In the trauma setting, the Focused Assessment for the
Total 19 (17.8) 18 (16.8) 9 (8.4) 61 (57.0) 107 (100)
FF = free fluid OI = Organ injury FF+OI = Organ injury and free fluid USS = Ultrasonographic Sonographic examination of the Trauma patient (FAST)
scan accurately detects hemoperitoneum. Currently, only an
approximate evaluation of the volume of free intraperitoneal
Table 3: Comparison of ultrasound and operative findings fluid (FIPF) can be done by imaging modalities such as US.[11]
USS Operative findings Total
Cost data and time to disposition were determined
Positive Negative
Positive (a) 44 (b) 5 49
for analysis. The sensitivity (95.7%), specificity (92%),
Negative (c) 2 (d) 56 58 a n d a c c u r a c y [10] o f U S w e r e s i m i l a r t o t h o s e
Total 46 61 107 reported (sensitivity: 88%, specificity: 100%) in previous
Sensitivity = a/a+c44/4610095.7% Specificity = d/b+d56/61100 92%
PPV = a/a+b44/49100 90% NPV = d/c+d56/58100 96.7%
studies. There was a significant difference in time
to disposition with the US group being significantly
use in the diagnosis of tumors and in cases of abdominal[6] lower (P0.001). The total procedural cost was 2.8 times
trauma. The efficacy and effectiveness of US in evaluating greater for the CT/DPL group than for the US group.[10] US
patients suspected of having BAT are near that of computed is not only effective in diagnosing BAT, but it is also more
tomography (CT) and DPL.[7] efficient and cost-effective than is CT/DPL. Emergency
US in patients with abdominal trauma has become a
US is used worldwide to evaluate patients with BAT. routine diagnostic exam thanks to both its high reliability
Sometimes referred to as an extension of the physical and its short acquisition time. US allows the overall
exam, US can rapidly help distinguish patients with evaluation of the patient, relative to both the localization
injury requiring CT or surgery (typically 5-10%) from of even very small fluid collections and the evaluation
those with no abdominal injury (90%).[3,7] US has several of traumatic changes in parenchymatous abdominal
advantages in the setting of[7] trauma. It is portable, organs, especially the spleen which is often injured.[12] In
integrates easily into the resuscitation of trauma victims addition, US has advantages over DPL in the detection of
without causing delay in therapy, is noninvasive, and intraperitoneal organ injuries with or without concomitant
has no associated morbidity. Limitations of US include free intraperitoneal fluid, retroperitoneal injuries, and
its dependence on operator skill and technique, poor intrathoracic injuries. Is there any correlation between
image quality in patients with morbid obesity or the amount of free intraperitoneal fluid collection and
extensive subcutaneous gas, limited visualization of the need for operative intervention in BAT? The present
the retroperitoneum, and less reliable localization of study has showed that US is inaccurate in detecting solid
visceral injury compared to CT [3,5] Successful use of intra-abdominal injuries; however, it is reliable in detecting
abdominal US in the setting of trauma can be maximized FIPF produced as a result of intra-abdominal organ injuries
with adequate sonographer training, appreciation of and retroperitoneal organ injuries. We suggest the use of
technical limitations, and adherence to an appropriate US as the objective initial evaluation method of choice
trauma US protocol.[8] on a routine basis.[13-15] It has been suggested that DPL

98 Archives of International Surgery / July-December 2012 / Vol 2 / Issue 2

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Makama, et al.: The value of ultrasounds in blunt abdominal trauma
is now obsolete in UK hospitals with access to either
skilled USS or emergency physician or surgeon-performed
focused abdominal sonography in trauma. We believe that
abdominal US should be considered an important tool
and an integral part in the work-up of major abdominal
trauma victims.
There is a growing body of literature pertaining to the use of
US in the evaluation of patients with BAT. Multiple studies
have looked at the use of this modality as a screening
examination for the detection of intra-abdominal fluid
and as a means of diagnosing specific organ injuries.[16,17]
Although US has been used extensively in Europe and
Asia, it has only recently been used in the United States.
In many centers, US is now being performed by emergency
medicine physicians and trauma surgeons as part of the
initial trauma evaluation.[18]
The purpose of this study was to evaluate the efficacy of
sonography in our algorithm when differentiating patients
with BAT who need immediate surgery from patients who
would benefit from further diagnostic workup or who
need no treatment. Our algorithm that uses sonography
as the primary diagnostic tool provides accurate, fast,
cost-effective, and noninvasive initial management of
patients with BAT. Sonography also achieves high values in
revealing relevant injury. Our algorithm produced medically
satisfactory and economically prudent management of
patients with BAT.[19] Handheld US using the Sonosite 180
system can be successfully used by appropriately trained
doctors as the primary investigation in the acute evaluation
of BAT.[20] In order to avoid unnecessary laparotomies for
patients with BAT, the emphasis is now on early ultrasonic
examination of the abdomen in combined trauma. The
radiological evaluation of patients with BAT can be done
with either US or CT with strategies varying considerably
among institutions.
FAST is an US investigation that can discover the presence
of peritoneal fluid. The availability of an investigation
that can be used directly at the patient bed optimizes the
Emergency Room Service. The learning curve is short[21]
and all doctors working in Emergency Room can use it.
Patients underwent complete US examination, including
free fluid search and solid organ analysis. No diagnostic
test beats a good history and careful examination[22] USS
has proved to be a thoroughly reliable,[21,23] cost efficient,
and noninvasive modality in primary evaluation and
follow-up of BAT. US is highly sensitive for the detection of
free intraperitoneal fluid[24] but not specific in identification
of organ injuries. Other factors affecting the sensitivity
were type of USS machine, the experience of sonographer,
Archives of International Surgery / July-December 2012 / Vol 2 / Issue 2
the size of the patient (obesity, abdominal distention). In
hemodynamically stable patients, the value of US is mainly
limited by the large percentage of organ injuries that are
not associated with free fluid. A large intraperitoneal[24]
fluid accumulation on USS in combination with unstable
vital signs is sensitive for determining the need for
exploratory laparotomy in patients presenting with blunt
trauma. Because of its high negative predictive value, we
recommend that clinical follow up is adequate for patients
whose US results are negative for intra-abdomial organ
injury.
Conclusion
Ultrasonography is accurate for screening patients with
blunt abdominal trauma in a tertiary institution. It is cheap
and can be performed in the emergency department of
hospital. It has high sensitivity and specificity. It is the
method of first choice in the evaluation of blunt abdominal
trauma.
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How to cite this article: Makama JG, Garba ES, Joshua IA. The value
of ultrasound in the management of blunt abdominal trauma in Zaria,
Nigeria. Arch Int Surg 2012;2:96-100.
Source of Support: Nil. Conflict of Interest: No.
Archives of International Surgery / July-December 2012 / Vol 2 / Issue 2