A 12-year-old boy falls off a ramp while skateboarding. He is hemodynamically stable but complains of abdominal pain. CT scan of the abdomen and pelvis is interpreted as displaying a grade II splenic laceration and a hematoma in the soft tissue of his left lateral abdominal wall. A moderate amount of free fluid, with elevated Hounsfield Units, is noted in his pelvis. He has diffuse tenderness on his left side. He is admitted for overnight observation. The following day he continues to complain of diffuse abdominal pain and his exam is unchanged. His hemoglobin levels are unchanged. Further immediate management should be:

 

 

 

[size=20px]A Discharge home after oral challenge

 

B Surgical exploration

 

C Continued inpatient observation

 

D Repeat CT[/size]

B

C

C

C

C

C

D

c

C

Correct answer

B Surgical exploration

 

Hollow viscus injuries are rare in blunt trauma and are notoriously difficult to diagnose. The classic teaching has been that CT is not accurate in detecting these injuries. However, recent retrospective studies in adults actually suggest that CT is quite sensitive in detecting hollow viscus abnormalities after blunt trauma; however, it is relatively poor in discriminating which are surgically important. Findings such as bowel wall thickening, abnormal bowel wall enhancement, free intra- or retroperitoneal air and free fluid are all suggestive, but often not diagnostic. Further compounding the problem is that these injuries often do not exist in isolation and CT findings could be attributed to other injuries. Most studies recommend a combination of clinical and radiographic predictors to determine the need for exploration. In this case, the splenic injury is relatively minor, and there is significant bowel wall thickening of the proximal jejunum and a small amount of extraluminal retroperitoneal air. While these findings may not mandate immediate exploration, in the face of ongoing pain and tenderness after a brief period of observation, they should. In adults, repeat CT scan has been shown to be useful in equivocal cases. However, in children this would result in additional exposure to ionizing radiation and would likely delay definitive treatment.