Elsevier

Journal of Surgical Research

Volume 242, October 2019, Pages 151-156
Journal of Surgical Research

Shock/Sepsis/Trauma/Critical Care
Pediatric Liver Injury: Physical Examination, Fast and Serum Transaminases Can Serve as a Guide

https://doi.org/10.1016/j.jss.2019.04.021Get rights and content

Abstract

Background

The aim of our study was to determine if the combination of physical examination (PE), serum transaminases along with Focused Assessment with Sonography in Trauma (FAST) would effectively rule out major hepatic injuries (HIs) after blunt abdominal trauma (BAT) in hemodynamically stable pediatric patients.

Methods

We conducted a 9-year retrospective study of pediatric patients (<18 y) with BAT. We collected data on liver enzymes (aspartate transaminase [AST] and alanine transaminase [ALT]), FAST, and PE findings. Definitive diagnosis and staging of HI were based on abdominal CT scanning. The sensitivity and specificity of ALT/AST, FAST, and PE were then calculated individually and in combination.

Results

We identified a total of 423 pediatric patients with BAT. Mean age was 11 y, median abdominal Abbreviated Injury Scale was 3 [2-4], and mean ED-SBP was 132 mm Hg. One hundred ninety-eight patients had HI of which 107 were major HI, defined by the American Association for the Surgery of Trauma as ≥grade III. Using ROC curve analysis, optimum ALT and AST thresholds were determined to be 90 U/L and 120 U/L, respectively. The sensitivity of FAST was 50% while that of PE was 40%. Combining PE with AST/ALT and FAST had an overall sensitivity of 97%, a specificity of 95%, a positive predictive value of 87%, and a negative predictive value of 98%.

Conclusions

In hemodynamically stable pediatric blunt abdominal trauma patients, CT scanning can be avoided using a combination of readily available tests thus avoiding unnecessary radiation exposure. However, pediatric patients with positive PE, FAST, and elevated AST/ALT may eventually require CT scan to further evaluate liver injuries.

Introduction

Trauma is the leading common cause of morbidity and mortality among pediatric patients in the United States. According to the Center of Diseases Control, more than 12,000 children die annually because of traumatic injuries and more than 9.8 million sustain nonfatal injuries.1 Abdominal trauma is one of the most common causes of adverse outcomes after blunt injury.2 The liver and the spleen are the two most common solid organs injured in these patients.3

The timely diagnosis of abdominal injuries in pediatric patients can be challenging. A missed or delayed diagnosis is associated with a significant morbidity and mortality. The currently available modalities to evaluate a pediatric patient with blunt abdominal trauma include physical examination (PE), laboratory studies (aspartate transaminase [AST] and alanine transaminase [ALT]), Focused Assessment with Sonography in Trauma (FAST), CT scan, and MRI. FAST is a noninvasive and rapid imaging modality that has demonstrated good accuracy and reliability for interrogating blunt abdominal trauma in adults; however, its efficacy in the pediatric population remains questionable. FAST has a low sensitivity and negative predictive value when used as a screening tool for pediatric patients with blunt abdominal trauma (BAT).4 CT scan, however, is one of the most sensitive tests for solid organ injuries but the concern for radiation exposure limits its use in the pediatric population as children are more sensitive to radiation compared to adults increasing the lifetime risk of cancer.5 Elevated liver enzymes have been shown to be correlated with intra-abdominal injuries especially hepatic injuries (HIs) in the setting of blunt abdominal trauma.6

The optimal use of FAST is still controversial in the pediatric population, and its role as an appropriate screening tool is still questioned because of low negative predictive value.4, 7 Currently, there are no clear guidelines for screening HIs in pediatric blunt trauma patients. We sought to determine if FAST and PE combined with serum transaminases (ALT and AST) would reliably rule out major HI after blunt abdominal trauma. We hypothesized that combining FAST, PE with serum transaminases will significantly rule out major HI.

Section snippets

Study setting and population

We performed a 9-year (2008-2016) retrospective analysis of all pediatric (age <17 y) trauma patients who presented at our trauma center. Our trauma center is American College of Surgeons–verified level-I trauma center providing care for over more than 4000 trauma patients per year of which 15% belong to the pediatric age group. The University of Arizona Institutional Review Board approved this study with a waiver of consent.

Inclusion and exclusion criteria

We included all pediatric patients with a blunt abdominal injury who

Results

A total of 423 patients with blunt abdominal injury were included in the analysis. Mean age was 11 ± 5 y, and 63% were male. Table 1 summarizes the demographics and injury parameters of the study population. Median GCS was 14 [13-15], median abdominal–Abbreviated Injury Scale was 3 [2-4], and median Injury Severity Score was 17 [9-29]. Most patients sustained a mild head injury and were hemodynamically stable on presentation. The most common mechanism of injury was involvement in a motor

Discussion

Our study has shown that combining FAST, PE, and ALT and AST levels had significantly increased both the sensitivity and negative predictive value for screening pediatric blunt trauma patients with liver injury. These screening modalities can be used to risk stratify patients and to guide further diagnostic workup. Early diagnosis of solid organ injuries after BAT is challenging yet very crucial. Major HIs are associated with high morbidity and mortality in pediatric trauma patients. Two to

Conclusion

We conclude that although FAST alone is a less sensitive tool to rule out major liver injuries, FAST combined with PE and elevated AST or ALT is an effective screening tool for major HIs in children after BAT. Therefore, observation may be recommended in hemodynamically stable pediatric BAT patients with a negative PE, FAST, and liver transaminases (AST <120 and ALT <90 IU/L). This reduces unnecessary exposure to CT scan radiation and reduces health care–related costs.

Acknowledgment

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Authors' contribution: B.J., M.H., M.Z., T.O., K.H., N.K., and A.T. designed this study. B.J., M.H., M.Z., T.O., K.H., and A.T. searched the literature. B.J., M.H., M.Z., T.O., K.H., A.T., and N.K, collected the data. B.J., M.H., M.Z., T.O., and N.K. analyzed the data. All authors participated in data interpretation and manuscript preparation.

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    The sensitivity of FAST alone was 50% while that of physical exam alone was 40%. Combining physical exam with AST/ALT and FAST had an overall sensitivity of 97%, a specificity of 95%, a positive predictive value of 87%, and a negative predictive value of 98%.30 The FAST exam allows a rapid evaluation of the abdominal and thoracic cavities to infer the presence of bleeding by diagnosing free peritoneal or pericardial fluid.

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