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09. Reza Jalli Turkish Journal of Trauma & Emergency Surgery Ulus Travma Acil Cerrahi Derg 2009;15(1):23-27 Original Article Klinik Çal›flma Accuracy of sonography in detection of renal injuries caused by blunt abdominal trauma: a prospective study Künt abdominal travman›n neden oldu¤u böbrek yaralanmalar›n›n saptanmas›nda sonografinin do¤rulu¤u: Prospektif bir çal›flma Reza JALLI,1 Nazafarin KAMALZADEH,2 Mehrzad LOTFI,1 Siamak FARAHANGIZ,1 Mahdi SALEHIPOUR3 BACKGROUND AMAÇ This prospective study was conducted to evaluate the accura- Bu prospektif çal›flmada, künt abdominal travman›n neden ol- cy of sonography in detection of renal injuries caused by blunt du¤u böbrek yaralanmalar›n›n saptanmas›nda sonografinin abdominal trauma. do¤rulu¤u de¤erlendirildi. METHODS GEREÇ VE YÖNTEM One hundred sixty-four patients (131 M, 33 F) with a history Bu çal›flmaya, yak›n zamanlarda künt kar›n travma öyküsü of recent blunt abdominal trauma who were stable enough to olan, hem sonografi hem de bilgisayarl› tomografi (BT) ala- undergo both sonography and CT scan were included in this cak kadar stabil durumda olan 164 hasta (131 erkek, 33 kad›n) study. All of the cases had accepted indications for renal imag- dahil edildi. Olgular›n hepsi renal görüntüleme endikasyonu- ing. Ultrasound, as simultaneous gray scale B-mode scan and nu kabul etti. Ultrason, bütün hastalarda ilk görüntüleme yön- color-Doppler study, was achieved in all of the patients as the temi olarak, simültane gri skala B-mod tarama ve renkli first imaging modality. Considering CT scan as the imaging Doppler çal›flmas› fleklinde gerçeklefltirildi. Travman›n neden modality of choice in evaluation of renal injuries caused by oldu¤u böbrek yaralanmalar›n›n de¤erlendirilmesinde BT’nin trauma, sonography findings were compared with CT scan seçkin görüntüleme yöntemi oldu¤u göz önünde bulundurula- results. rak, sonografi bulgular› BT sonuçlar› ile karfl›laflt›r›ld›. RESULTS BULGULAR Of the 164 patients referred for kidney sonography and CT Böbrek sonografisi ve BT taramas› için gönderilen 164 hasta- scan, renal damage was detected in 103 cases by CT scan n›n 103’ünde (%63), BT görüntüleme ile böbrek yaralanmas› (63%). In 14 patients (13.5%), bilateral renal injuries were saptand›; 14 hastada (%13,5), bilateral böbrek yaralanmas› identified. Considering grading classification proposed by the saptand›. Amerikan Travma Cerrahisi Birli¤i (AAST) taraf›n- American Association for the Surgery of Trauma (AAST), dan önerilen grade s›n›flamas› göz önünde bulundurularak, 57%, 24%, 9.5%, 6% and 3.5% of renal injuries were diag- böbrek yaralanmalar›n›n %57’si, %24’ü, %9,5’i, %6’s› ve nosed as grade I, II, III, IV and V, respectively, by CT scan. O f %3,5’ine BT tarama ile s›ras›yla grade I, II, III, IV ve V o l a r a k the 164 patients, ultrasound results were consistent with renal tan› konuldu. Yüz altm›fl dört hastan›n 66’s›nda (%40) ultrason damages in 66 cases (40%). Of these patients, signs of bulgular›, böbrek yaralanmalar›yla uyumlu b u l u n d u. Bu hasta- parenchymal hematoma, perinephric hematoma and pelvo- larda, internal ekojenite ile birlikte olan parankimal hematom, caliectasis associated with internal echogenicity were the most perinefrik hematom ve pelvokaliektazi en yayg›n ultrason bul- prevalent ultrasound findings. Overall sensitivity and speci- gular› idi. Böbrek yaralanmalar›n›n saptanmas›nda sonografi- ficity of sonography in detection of renal injures were 48% nin genel duyarl›l›¤› ve özgüllü¤ü, 0,8’lik bir pozitif öngörme and 96%, respectively, with a 0.8 positive predictive value, a de¤eri, 0,57’lik bir negatif öngörme de¤eri ve %79’luk bir ge- 0.57 negative predictive value and an overall accuracy of 79%. nel do¤rulukla birlikte s›ras›yla %48 ve %96 olarak bulundu. CONCLUSION SONUÇ In spite of the availability and ease of performance of sonog- Travmal› olgular›n de¤erlendirilmesinde sonografinin kullan›- raphy in evaluation of trauma victims, this imaging modality labilirli¤i ve uygulanmas›n›n kolay olmas›na karfl›n, bu görün- has low sensitivity in detection of renal injuries and overlooks tüleme yöntemi, böbrek yaralanmalar›n›n saptanmas›nda düflük significant damages. CT scan should be considered as the duyarl›l›¤a sahiptir ve önemli hasarlar› gözden kaç›r›r. BT g ö- diagnostic modality in victims of kidney trauma who are rüntüleme, hemodinamik olarak stabil olan ve böbrek görün- hemodynamically stable and have clear indications for renal tülemesi bak›m›ndan aç›k endikasyonu bulunan böbrek travma- imaging. l› kiflilerde tan› yöntemi olarak göz önünde bulundurulmal›d›r. Key Words: Kidney; trauma; sonography. Anahtar Sözcükler: Böbrek; travma; sonografi. D e p a r t m e n tsof 1R a d i o l o g y, 2Trauma, and 3Urology Shiraz Üniversitesi T›p Fakültesi, 1Radyoloji Anabilim Dal›, Shiraz University Faculty of Medicine, Shiraz, Iran. 2Travma Anabilim Dal›, 3Üroloji Anabilim Dal›, Shiraz, ‹ran. Correspondence (‹letiflim): Reza Jalli, M.D. Department of Ra d i o l o g y, Nemazee Hospital, Shiraz, I r a n. Tel: +0 9 8 - 7 1 1 - 6 2 6 3 2 3 3 e-mail ( e - p o s t a ) : j a l l i r e z a @ y a h o o . c o m 23 Ulus Travma Acil Cerrahi Derg Traumatic injury is a leading national and inter- interval: approximately 3 hours). Any longer interval national health problem and is the leading cause of may cause urinoma formation and render any com- mortality and morbidity for persons between 1 and parisons inaccurate. [1] 44 years of age. Renal trauma occurs in 3% of The patients’ ages ranged from 2.5 to 71 years old patients hospitalized for trauma and in 8 to 10% of (mean: 24.2 years). Ultrasound study was based on all patients with abdominal trauma. Blunt force is gray scale B-mode scanning and color- D o p p l e r responsible for 70 to 80% of renal trauma, whereas encoding in all of the patients, and was performed by 6 to 14% of penetrating abdominal wounds result in an expert radiologist in genitourinary imaging on [2] kidney damage. Since conservative, non-operative one of two machines (General Electric LOGIQ 500 management is preferred even in major renal or General Electric LOGIQ700, both manufactured injuries, accurate assessment with imaging modali- in Milwaukee, Wisconsin). Certain conditions such ties becomes central for guiding patient manage- as obesity, overlying gas-distended bowel loops and ment. inappropriate positioning of the patients owing to rib Sonography is an easy-to-perform imaging fracture were the limiting and disturbing factors for modality with relatively high diagnostic yield, and optimal ultrasound investigation of kidneys in our its availability and lack of ionizing radiation are study. other advantages of its use in the early investigation Computed tomography scan of the patients was of patients, including cases of blunt abdominal trau- performed on one of two CT units (Toshiba X vision ma. In spite of considerable accuracy of sonography 1/EX, Japan, and High Speed NX/I, General Electric in detection of free fluid in the abdomen of trauma Medical Systems). Routine oral contrast agent, in the victims, there is significant controversy about the form of 2% diluted ionic iodinated contrast, was accuracy of this imaging modality in the diagnosis of given 40-60 minutes before the study. All of the renal damage caused by blunt trauma. Our prospec- patients received intravenous (i.v.) bolus of nonionic tive study was thus conducted to determine the use- iodinated contrast agent (1.5-2 ml/kg of 300 mg fulness of this imaging modality in this respect. iodine/ml). CT scan of the patients was done 30 sec- onds after the start of injection of contrast agent. The MATERIALS AND METHODS protocols employed in this study were: rate of 2 ml/s, This prospective study was carried out over 26 collimation 7 mm, pitch 1.2 and reconstruction inter- months (February 2003 to May 2006) at the trauma val of 7 mm. center of Namazee Hospital, the largest hospital and Delayed scans were also incorporated whenever referral center in the south of Iran, which is under the there was suspicion of kidney injury (mean delay: 15 purview of Shiraz University of Medical Sciences. minutes). CT scan images were reviewed by an Of all trauma victims referred to the trauma center, experienced radiologist disregarding the ultrasound 164 patients with history of recent blunt abdominal results. Considering CT scan as the modality of trauma (131 M, 33 F), who had accepted indications choice for investigation of renal injuries caused by [3] for radiological evaluation of the kidneys and were trauma, sensitivity and specificity of ultrasound in stable enough to be evaluated by both sonography detection of renal injuries were determined. and computerized tomography (CT) scan, were selected and underwent investigation. Adult patients RESULTS with gross or microscopic hematuria and shock (sys- Of the 164 selected patients who were referred to tolic blood pressure <90 mm Hg) as well as pediatric the Radiology Department for sonography and CT cases with any degree of hematuria were our indica- scan, kidney damage was detected in 103 patients by tions for renal imaging in the cases of blunt abdomi- CT scan (67%). Bilateral renal injury (13.5%) was nal trauma. Patients with blood in the urethral mea- determined in 14 patients, so the overall renal tus or hematuria associated with pelvic fractures injuries were 117 in our study (Fig. 1). Using the were evaluated for lower genitourinary trauma and grading classification developed by the American were excluded from the study.
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