Diagnostic peritoneal lavage
- Ronald J Simon, MD
Ronald J Simon, MD
Diagnostic peritoneal aspirate and lavage is a rapid and easily performed but invasive bedside procedure that was once the gold standard for the evaluation of abdominal trauma . The procedure was initially used in patients with blunt abdominal trauma, but its use quickly evolved to include some patients with penetrating trauma [2,3]. It can provide information about injury to the solid or hollow organs, peritoneal penetration, and may also aid the diagnosis of diaphragm injury [4-6]. The procedure entails inserting a catheter into the peritoneal cavity, initially to aspirate blood or fluid, and subsequently to infuse fluid and lavage the cavity, if necessary. The initial portion of the procedure is often referred to as a diagnostic peritoneal tap or aspirate (DPA); the latter portion is a diagnostic peritoneal lavage (DPL). DPL is highly sensitive for detecting the presence of intraperitoneal blood and organ injury in blunt abdominal trauma; however, advances in technology, specifically the widespread use of computed tomography (CT) and ultrasound imaging, has led to a diminishing role for this procedure primarily because of low specificity and high rates of unnecessary laparotomy . For penetrating abdominal injury, there was a great deal of controversy over the optimal cell counts that indicated the need for laparotomy, which limited its utility.
The current role for diagnostic peritoneal lavage in the trauma patient will be reviewed here. The initial evaluation of patients with blunt and penetrating abdominal injury is presented separately. (See "Initial evaluation and management of blunt abdominal trauma in adults" and "Initial evaluation and management of abdominal stab wounds in adults" and "Initial evaluation and management of abdominal gunshot wounds in adults".)
ADVANTAGES AND DISADVANTAGES
Ultrasound (US) and abdominal computed tomography (CT) have largely replaced the use of diagnostic peritoneal lavage (DPL) in the hemodynamically stable trauma patient, but DPL
The advantages of DPL in the hemodynamically unstable trauma patient include:
●Simple and readily available instrumentation
- ROOT HD, HAUSER CW, MCKINLEY CR, et al. DIAGNOSTIC PERITONEAL LAVAGE. Surgery 1965; 57:633.
- Thal ER. Evaluation of peritoneal lavage and local exploration in lower chest and abdominal stab wounds. J Trauma 1977; 17:642.
- Galbraith TA, Oreskovich MR, Heimbach DM, et al. The role of peritoneal lavage in the management of stab wounds to the abdomen. Am J Surg 1980; 140:60.
- Gonzalez RP, Ickler J, Gachassin P. Complementary roles of diagnostic peritoneal lavage and computed tomography in the evaluation of blunt abdominal trauma. J Trauma 2001; 51:1128.
- Nagy KK, Roberts RR, Joseph KT, et al. Experience with over 2500 diagnostic peritoneal lavages. Injury 2000; 31:479.
- Sriussadaporn S, Pak-art R, Pattaratiwanon M, et al. Clinical uses of diagnostic peritoneal lavage in stab wounds of the anterior abdomen: a prospective study. Eur J Surg 2002; 168:490.
- Pryor JP, Reilly PM, Dabrowski GP, et al. Nonoperative management of abdominal gunshot wounds. Ann Emerg Med 2004; 43:344.
- Lee MJ, Sperry JL, Rosengart MR. Evaluating for acute mesenteric ischemia in critically ill patients: diagnostic peritoneal lavage is associated with reduced operative intervention and mortality. J Trauma Acute Care Surg 2014; 77:441.
- Ceraldi CM, Waxman K. Computerized tomography as an indicator of isolated mesenteric injury. A comparison with peritoneal lavage. Am Surg 1990; 56:806.
- Meyer DM, Thal ER, Weigelt JA, Redman HC. Evaluation of computed tomography and diagnostic peritoneal lavage in blunt abdominal trauma. J Trauma 1989; 29:1168.
- Ekeh AP, Saxe J, Walusimbi M, et al. Diagnosis of blunt intestinal and mesenteric injury in the era of multidetector CT technology--are results better? J Trauma 2008; 65:354.
- Griffin XL, Pullinger R. Are diagnostic peritoneal lavage or focused abdominal sonography for trauma safe screening investigations for hemodynamically stable patients after blunt abdominal trauma? A review of the literature. J Trauma 2007; 62:779.
- Oreskovich MR, Carrico CJ. Stab wounds of the anterior abdomen. Analysis of a management plan using local wound exploration and quantitative peritoneal lavage. Ann Surg 1983; 198:411.
- Thompson JS, Moore EE. Peritoneal lavage in the evaluation of penetrating abdominal trauma. Surg Gynecol Obstet 1981; 153:861.
- Boyle EM Jr, Maier RV, Salazar JD, et al. Diagnosis of injuries after stab wounds to the back and flank. J Trauma 1997; 42:260.
- Whitehouse JS, Weigelt JA. Diagnostic peritoneal lavage: a review of indications, technique, and interpretation. Scand J Trauma Resusc Emerg Med 2009; 17:13.
- Moore GP, Alden AW, Rodman GH. Is closed diagnostic peritoneal lavage contraindicated in patients with previous abdominal surgery? Acad Emerg Med 1997; 4:287.
- Felice PR, Morgan AS, Becker DR. A prospective randomized study evaluating periumbilical versus infraumbilical peritoneal lavage: a preliminary report. A combined hospital study. Am Surg 1987; 53:518.
- Hodgson NF, Stewart TC, Girotti MJ. Open or closed diagnostic peritoneal lavage for abdominal trauma? A meta-analysis. J Trauma 2000; 48:1091.
- Saunders CJ, Battistella FD, Whetzel TP, Stokes RB. Percutaneous diagnostic peritoneal lavage using a Veress needle versus an open technique: a prospective randomized trial. J Trauma 1998; 44:883.
- Otomo Y, Henmi H, Mashiko K, et al. New diagnostic peritoneal lavage criteria for diagnosis of intestinal injury. J Trauma 1998; 44:991.
- Feliciano DV, Bitondo CG, Steed G, et al. Five hundred open taps or lavages in patients with abdominal stab wounds. Am J Surg 1984; 148:772.
- Cha JY, Kashuk JL, Sarin EL, et al. Diagnostic peritoneal lavage remains a valuable adjunct to modern imaging techniques. J Trauma 2009; 67:330.
- 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.
- Hashemzadeh S, Mameghani K, Fouladi RF, Ansari E. Diagnostic peritoneal lavage in hemodynamically stable patients with lower chest or anterior abdominal stab wounds. Ulus Travma Acil Cerrahi Derg 2012; 18:37.
- Henneman PL, Marx JA, Moore EE, et al. Diagnostic peritoneal lavage: accuracy in predicting necessary laparotomy following blunt and penetrating trauma. J Trauma 1990; 30:1345.
- Gonzalez RP, Turk B, Falimirski ME, Holevar MR. Abdominal stab wounds: diagnostic peritoneal lavage criteria for emergency room discharge. J Trauma 2001; 51:939.
- Tsikitis V, Biffl WL, Majercik S, et al. Selective clinical management of anterior abdominal stab wounds. Am J Surg 2004; 188:807.
- Ertekin C, Yanar H, Taviloglu K, et al. Unnecessary laparotomy by using physical examination and different diagnostic modalities for penetrating abdominal stab wounds. Emerg Med J 2005; 22:790.
- Alzamel HA, Cohn SM. When is it safe to discharge asymptomatic patients with abdominal stab wounds? J Trauma 2005; 58:523.
- Robin AP, Andrews JR, Lange DA, et al. Selective management of anterior abdominal stab wounds. J Trauma 1989; 29:1684.
- ADVANTAGES AND DISADVANTAGES
- Contraindications and cautions
- DPL TECHNIQUE
- Procedure overview
- Abdominal access
- - Insertion site
- - Method
- Closure and dressing
- FLUID INTERPRETATION
- Abnormal results
- False positives
- False negatives
- SUMMARY AND RECOMMENDATIONS