L. M. Dean1, B. Johnson2, A. Vogel1,2, S. Fallon1,2, B. Naik-Mathuria1,2 1Baylor College Of Medicine,Houston, TX, USA 2Texas Children’s Hospital,Houston, TX, USA
Introduction: Hollow viscus injuries (HVI) in children are infrequent, have subtle clinical and imaging findings at presentation, and can lead to significant morbidity. In adults, the Bowel Injury Prediction Score (BIPS) which includes abdominal pain, WBC > 17K, and a novel CT scoring system, has been shown to identify HVI at initial presentation. Additionally, delay in surgery more than 6 hours is associated with increased mortality from abdominal sepsis. Our purpose was twofold: to determine the validity of the BIPS for early identification of pediatric HVI, and to evaluate whether delayed surgery also leads to worse outcomes in children.
Methods: Retrospective chart review (2014-2019) of children treated at a level I pediatric trauma center with HVI confirmed at surgery following blunt or penetrating trauma. Demographics, presenting findings, injuries, time to surgery, and outcomes were analyzed.
Results: Of 42 patients, median age was 8.4 years, 67% were male, and 88% of the injuries were blunt. The most common injury mechanisms were motor vehicle collisions (38%) and child abuse (21%). Almost all (90.5%) patients had CT at presentation and 29% had another CT to confirm HVI. For calculation of the BIPS at presentation, all patients (100%) had abdominal pain (1 point), 34% had WBC >17K (1 point), and the median CT score was 5 (1 point if ≥4).BIPS ≥ 2, which is predictive of HVI in adults, was present in 92% (33/36) of all patients.
Surgery was performed within 12 hours of injury (0.75-11.7 hours) in 42% (18/42), and after 12 hours (13-175 hours) in 57% (24/42). The early and delayed surgery groups had similar presentation and injury types (Table 1). There were no differences in need for ostomy (early 17% vs delayed 4%, p=0.2), infectious complications (early 17% vs delayed 12.5%, p=1.0), readmission related to surgery (early 5.5% vs delayed 8%, p=0.7), and death (early 5.6% vs delayed 0%, p=0.24) between the groups. The early group did have a significantly shorter hospital stay (early 7 vs delayed 12 days, p=0.01). BIPS ≥ 2 was similar in the early and delayed surgery groups (early 72% vs delayed 83%, p=0.5), as well as the CT score (median early score 5 vs delayed score 4, p=0.6).
Conclusion: In pediatric patients, the BIPS may be beneficial in providing guidance on early diagnosis of HVI to avoid delay in treatment, although further study is needed. Delay in surgery more than 12 hours from injury does not appear to worsen clinical outcomes except for prolonged recovery. Thus, when the diagnosis of HVI is unclear, initial observation rather than early operation is likely appropriate in pediatric patients in order to avoid unnecessary surgery.
