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Three Part Question

In [a patient with an anterior abdominal stab wound] does [CT tractography] reliably detect [intra-abdominal injury including peritoneal or hollow viscus perforation].

Clinical Scenario

A 35-year-old male presents to the Emergency Department with an anterior abdominal stab wound (AASW). He is haemodynamically stable; you are unsure of the best method of investigation to detect significant intra-abdominal injury including hollow viscus perforation.

Search Strategy

NICE Healthcare Databases (1985-2016) including: AMED, PubMED, BNI, EMBASE, HBE, HMIC, Medline, PsycINFO, CINAHL. Search terms included (anterior abdominal stab).ti,ab OR (abdominal stab investigations).ti,ab.

Search Outcome

82 papers were found. Abstracts were reviewed for relevance of which 16 were duplicates and 64 were irrelevant. 2 papers were relevant and of sufficient quality and are included in this BET. Relevant papers are shown in the table below.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Ertan et al. 2015 United States	20 haemodynamically stable patients with AASW. Patients with single and multiple stab wounds included.	Case series / prospective observational study of new protocol	Detecting peritoneal penetration	Sensitivity 100% Specificity 90%	Limited number of patients. No direct comparison with other methods e.g. CT alone
Uzunosmanoglu et al. 2017 Germany	73 patients with AASW. Managed with combined contrast abdominal enhanced CT scans and CT tractography, later undergoing laparotomy. Comparison with CT alone.	Retrospective study	Detecting peritoneal penetration	Sensitivity 100% Specificity 100% PPV 100% NPV 100% Accuracy 100%	Unknown exclusion criteria. Patient stability unknown.

Comment(s)

This search revealed only one prospective observational study and one retrospective study with no randomised controlled trials comparing CT tractography to other methods of investigation (e.g. CT scanning or laparoscopy). Total patient numbers for the studies were small (total n=93). The above studies suggest CT tractography is sensitive in identifying the need for laparotomy with specificity between 90-100%. Nonetheless, further research using clear patient selection is required before recommendation can be made regarding the utility of CT tractography as a routine diagnostic procedure.

Editor Comment

retained for Trauma

Clinical Bottom Line

Due to limited evidence as a result of only two studies and small patient numbers, further research is needed into the use of CT tractography as a diagnostic procedure. However the current reported sensitivity and specificity would suggest it could be a useful tool in the management of haemodynamically stable anterior abdominal stab wound patients.

References

1. Ertan T, Sevim Y, Sarigoz T et al. Benefits of CT tractography in evaluation of anterior abdominal stab wounds. Am. J.Emerg. Med 2015; 1;33(9):1188-90.
2. Uzunosmanoglu H, Çorbacgiolu SK, Çevik Y et al. What is the diagnostic value of computed tomography tractography in patients with abdominal stab wounds?. Eur J Trauma Emerg Surg 2017; 1;43(2):273-7.