CLINICAL JUDGMENT IS SUPERIOR TO DIAGNOSTIC-TESTS IN THE MANAGEMENT OF PEDIATRIC SMALL-BOWEL INJURY

Traumatic solid organ injuries are easily recognizable on computed tom ography (CT) scans and usually are treated nonoperatively, Small bower injuries may be difficult to diagnose and require prompt operation. T his study was done to assess the role of clinical examination versus d iagnostic tests in evaluating these injuries. The medical records of a ll pediatric (less than or equal to 18 years old) patients treated at a pediatric trauma center from 1984 to 1995 were reviewed. Statistical analysis was performed using SAS software, with P values of less than .05 considered significant. Small bowel injury occurred in 48 patient s (21 blunt, 27 penetrating). Most blunt injuries were automobile rela ted (11 patients) or attributable to recreational activities (4) or bi cycle accidents (2). Penetrating injuries were primarily caused by ass aults with guns (21) or knives (4). All conscious patients with small bower injury had abnormal physical examination findings at the time of presentation. Nineteen patients had generalized peritonitis, and 14 h ad localized abdominal tenderness. The serum amylase level was abnorma l in 2 of 18 cases. Abdominal CT scans were obtained in six patients a nd showed the injury in only three. Peritoneal lavage (DPL), performed in 10 patients, led to the diagnosis in five. There was no significan t difference in the complication rate (30%) between patients operated on immediately because of a diagnostic test result and those operated on later, after a period of clinical observation (P = 1.0, Fisher's Ex act test). Associated injuries were common (60%) among both blunt and penetrating cases. In this nonoperative era of pediatric trauma care, small bowel injury is best diagnosed clinically. The physical examinat ion is 100% sensitive in the conscious patient, and specificity is ach ieved by serial examination. Serum amylase, CT scan, and DPL are not r eliable diagnostic tests to exclude these injuries. Patients can be ob served until physical findings suggest bowel injury without increased morbidity. Associated injuries are common; thus, patients are best tre ated where multidisciplinary support is available. Copyright (C) 1996 by W.B. Saunders Company