Diagnosis and management of blunt small bowel injury: A survey of the membership of the American Association for the Surgery of Trauma

Background: Blunt small bowel injury (SBI) may be difficult to diagnose acc urately. Diagnostic delays are associated with increased morbidity and mort ality. Methods: A cross-sectional survey of members of the American Association fo r the Surgery of Trauma was conducted. A Likert-type multiple-choice scale was used to evaluate use and usefulness of diagnostic and laboratory tests. Data were analyzed by using univariate and multivariate techniques. Results: A total of 461 of the 702 members (68%) surveyed responded, of whi ch 133 members (29%) were excluded because they did not currently manage ad ult SBI. Of the remaining 328 respondents, 244 members (74%) reported prior experience as the most important influence on their current practice of di agnosing blunt SBI. None of the standard laboratory tests were reported as useful, Seventy-seven percent of respondents use computed tomographic (CT) scan most or all of the time for diagnosis (p < 0.05 compared with other mo dalities). Most respondents estimated their annual incidence of SBI at 5% w ith a >15% frequency of delay in diagnosis. Forty-four percent of the respo ndents estimated the mortality associated with a delay in diagnosis at less than or equal to 5%. Respondents varied significantly in their management of the patient with an unreliable abdominal exam and a CT scan finding of i solated free fluid. In patients with head injuries, 28% observe, 12% repeat the CT scan, 42% perform diagnostic peritoneal lavage, and 16% operate. Fo r intoxicated patients, 51% observe, 11% repeat the CT scan, 26% perform di agnostic peritoneal lavage, and 10% operate. A more aggressive approach wit h diagnostic and operative intervention was significantly (p < 0.05) advoca ted by respondents practicing without residents, more than 15 years out fro m residency, or by those with a perception of higher morbidity and mortalit y from delays in diagnosis. Conclusion: There is significant variation in the diagnostic approach to th e patient with suspected SBI. The perceived mortality of delayed diagnosis is much less than reported. Those surgeons with more experience or percepti on of greater morbidity and mortality from a delayed diagnosis are more agg ressive. Further investigation into the diagnosis and treatment of this inj ury is needed.