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Diagnostic peritoneal lavage (DPL) or aspiration (DPA)

Diagnostic peritoneal lavage (DPL) or aspiration (DPA)
Literature review current through: Jan 2024.
This topic last updated: Oct 03, 2022.

INTRODUCTION — Diagnostic peritoneal lavage (DPL) is a rapid and easily performed but invasive bedside procedure that was once the gold standard for the evaluation of abdominal trauma [1]. The initial portion of the procedure is often referred to as a diagnostic peritoneal tap or aspirate (DPA). The procedure was initially used in patients with blunt abdominal trauma, but its use quickly evolved to include some patients with penetrating trauma [2,3]. It can provide information about injury to the solid or hollow organs, peritoneal penetration, and may also aid the diagnosis of diaphragm injury [4-6]. The procedure entails inserting a catheter into the peritoneal cavity, initially to aspirate blood or fluid, and subsequently to infuse fluid and lavage the cavity, if necessary.

The current role for DPL/DPA in the trauma patient is reviewed. The initial evaluation of patients with blunt and penetrating abdominal injury is presented separately. (See "Initial evaluation and management of blunt abdominal trauma in adults" and "Initial evaluation and management of abdominal stab wounds in adults" and "Initial evaluation and management of abdominal gunshot wounds in adults".)

ADVANTAGES AND DISADVANTAGES — DPL is highly sensitive for detecting the presence of intraperitoneal blood and organ injury in blunt abdominal trauma; however, advances in technology, specifically the widespread use of computed tomography (CT) and ultrasound imaging, has diminished the role for this procedure primarily because of low specificity and high rates of unnecessary laparotomy [7]. For penetrating abdominal injury, a great deal of controversy over the optimal cell counts that indicated the need for laparotomy limited its utility.

The advantages of DPL in the hemodynamically unstable trauma patient include:

Simple and readily available instrumentation

Low cost

Well-known values for assessing test results in patients with blunt injury

Technical simplicity

Few contraindications

Rapid assessment of test results

Easy to teach

Taught internationally as an element of Advanced Trauma Life Support (ATLS) training

The disadvantages of DPL include:

Invasive

Technical errors (incorrect catheter placement) can lead to false positive or negative results

Increased technical difficulty in obese patients or those with prior abdominal surgery

Low sensitivity can lead to unnecessary laparotomy

Potential for organ injury caused by the procedure

Although highly sensitive to the presence of intra-abdominal blood, DPL cannot determine the source or severity

There is increasing discussion about use of DPA versus DPL. While DPA is an easier technique to perform, the risk of intraperitoneal injury remains with both techniques. Compared with each other, an advantage of DPA is a shorter time interval from procedure completion to definitive results compared with DPL. However, the risk for nontherapeutic laparotomy is increased with DPA compared with DPL since any aspiration of blood is considered a positive DPA, while DPL has more stringent diagnostic criteria that are specifically designed to avoid false positive and nontherapeutic laparotomy. Both are associated with a risk for causing intraperitoneal injury.

In a retrospective study of 41 hemodynamically unstable trauma patients who underwent DPA after trauma, 35 of 41 had a negative or equivocal focused assessment with sonography for trauma (FAST) or had a positive FAST in the scenario of known cirrhosis. While the study did not compare FAST with DPL directly, it reiterated that DPL can be limited in an unstable patient when there will be a delay waiting for laboratory analysis of the fluid. By using any aspirated blood as indicative of a positive test, a clinician can act on the findings immediately. However, the study was limited by its definition of a true positive DPA as confirmed by hemoperitoneum at laparotomy, which is misleading. Prior studies included not just only the presence of hemoperitoneum as a true positive result but also the need for some therapeutic procedure at the time of laparotomy. The finding of a small nonbleeding liver injury resulting in 100 mL of hemoperitoneum does not warrant the consequences of a nontherapeutic laparotomy. In this study, the utility of DPA in a patient with known cirrhosis is an interesting approach to a difficult diagnostic dilemma but warrants further study before accepting this into the mainstream.

INDICATIONS — The main role for DPL/DPA is in the evaluation of the unstable trauma patient when a focused assessment with sonography for trauma (FAST) is inconclusive or negative with no other obvious explanation for their instability. Although DPL has been applied to diagnose certain other abdominal conditions in hemodynamically unstable patients not related to trauma [8], DPL in these populations is not well studied. The indications for DPL/DPA in adults and children involved in trauma include the following:

Aid in the evaluation of the hemodynamically unstable patient – DPL becomes the first-line diagnostic evaluation to detect or rule out intra-abdominal hemorrhage when ultrasound equipment for FAST examination is not available or is technically inadequate, there is no one skilled in the performance or interpretation of the FAST, or CT is ill advised due to ongoing patient resuscitation. In these situations, a DPL can be performed looking for the presence of blood. If peritoneal aspirate is positive (>10 mL of gross blood is aspirated), then abdominal exploration is indicated and lavage is not necessary. In hemodynamically unstable patients, it is less likely that the cause of hypotension is intra-abdominal bleeding when the initial aspiration is negative. (See 'Fluid interpretation' below.)

Detect blunt bowel injury in hemodynamically stable patients under observation – DPL remains the most sensitive test for the presence of hollow viscus injury [9-11]. In a systematic review, the sensitivity of DPL was between 92 and 98 percent, and DPL had the highest sensitivity for detecting mesenteric and hollow organ injury, but a high rate of false positives [12]. DPL is optimally used for the patient with blunt abdominal injury with CT findings of free abdominal fluid but no obvious source of abdominal hemorrhage. Most alert, cooperative patients can be followed with serial abdominal examinations under this circumstance; however, DPL may be particularly helpful for guiding management in the patient when physical examination is not reliable, such as in those with altered mental status, whether from injuries to the brain or spinal cord, or altered from drugs and/or alcohol. For these patients, DPL can be used to assess for the presence of bowel injury. (See "Traumatic gastrointestinal injury in the adult patient".)

In a few institutions, DPL may still play a role in stab wounds to the anterior abdomen. Although hemodynamically unstable patients with penetrating trauma should proceed directly to laparotomy, hemodynamically stable patients with anterior or flank stab wounds can be observed. An alternative strategy is to perform a local wound exploration, and, if penetration is present, a DPL can be performed to determine the presence of injury [13-16].

Aid in the diagnosis of diaphragmatic injury in select patients – Lavage fluid exiting from a chest tube is pathognomic for diaphragmatic injury. In one guideline on the management of patients with thoracoabdominal stab wounds, the authors recommend using DPL initially rather than laparoscopy when diaphragmatic injury is suspected and chest radiograph and FAST examination are negative [17]. DPL is less invasive compared with laparoscopy, and a red blood cell count threshold of 5000/mL provides acceptable accuracy to rule out injury. Given that neither CT nor ultrasound are highly accurate for determining the presence of a diaphragmatic injury, DPL is a useful alternative. (See "Recognition and management of diaphragmatic injury in adults", section on 'Role of diagnostic peritoneal lavage'.)

Contraindications and cautions — The only absolute contraindication to performing a DPL is the presence of a clear indication for immediate laparotomy.

Relative contraindications include prior abdominal operations, coagulopathy, advanced cirrhosis, and morbid obesity. In one retrospective review, the accuracy and complication rate of DPL in patients with prior abdominal surgery were similar to those without [18].

Although pregnancy is not a contraindication to performing the procedure, it does mandate the use of the open technique, and a supraumbilical incision is preferred. This is also the preferred technique in patients with a pelvic fracture to avoid entering the pelvic hematoma with the lavage catheter and obtaining a false positive result. (See 'Open' below and 'Insertion site' below.)

DPL/DPA TECHNIQUE

Preparation — Prophylactic antibiotics are not necessary for this procedure. A Foley catheter and nasogastric tube must be placed prior to performing DPL to avoid injuring the bladder or stomach, which may be full and at risk for injury with placement of the intra-abdominal catheter. The procedure is performed with the patient in the supine position. Local anesthesia with 1% lidocaine with epinephrine (1:100,0000 or 1:200,000) generally provides adequate anesthesia.

Several kits are commercially available for the performance of DPL. In the absence of such a kit, a typical tray used for abdominal access for laparoscopy can be used with a rigid peritoneal dialysis catheter used as a substitute.

Procedure overview — The basic technique involves first gaining abdominal access and then inserting the DPL catheter into the abdomen. (See 'Abdominal access' below.)

Once inserted, a gentle attempt at direct fluid aspiration is performed. Aspiration of >10 mL of blood or enteric contents is considered grossly positive, and instillation of the lavage fluid is not necessary. If no fluid or <10 mL fluid is aspirated, then 1 liter of warm normal saline is run into the abdomen and, once instilled, is immediately allowed to drain passively. It is important not to separate catheter and tubing when transitioning from instillation to removal. If the system is disturbed, the siphon effect will be lost and will need to be manually reestablished. This can easily be done by running another 50 cc of fluid into the abdomen, reestablishing a fluid column and then allowing the fluid to passively run out. Fluid analysis is performed on a sample of the returned fluid. Optimally, most of the liter should be returned, but, if this is not possible, analysis can be performed on as little as 300 cc of the returned fluid.

Abdominal access — There are three choices for insertion site, and three methods for insertion of the lavage catheter. Younger surgeons may be uncomfortable performing this procedure due to lack of exposure to it during training. This concern can easily be eliminated when realizing that the procedure is the same as open placement of an umbilical port for laparoscopy. With this in mind, DPL can easily become part of the routine practice of any trained general surgeon. Abdominal access is reviewed in detail separately. (See "Abdominal access techniques used in laparoscopic surgery", section on 'Initial port placement'.)

Insertion site — The location of catheter insertion depends on the clinical scenario. An infraumbilical (2 cm below) location is the standard site for catheter insertion to improve fluid instillation and drainage by facilitating catheter placement into the pelvis, which is the most dependent region of the abdomen (figure 1). In the pregnant trauma patient or in the presence of a pelvic fracture, a supraumbilical insertion site is preferred. An alternative site is a periumbilical site [19].

Method — A systematic review that included seven randomized trials found that open compared with closed (percutaneous) DPL was comparable in terms of accuracy and major complications [20]. Although closed DPL was quicker to perform, there were more technical issues.

Open — For the open method, all three layers (skin, fascia, peritoneum) are opened under direct vision. This is the method of choice when precise insertion of the catheter is critical. Prime examples include pelvic fracture, for which a large hematoma may be tracking anteriorly, and in the pregnant patient. Direct visualization of the peritoneum gives confidence that the catheter is being placed intraperitoneal and not extraperitoneal directly into the pelvic hematoma, which will yield a false positive result.

Semi-open — For the semi-open method, the fascia is opened under direct vision, but then a needle is used to penetrate the peritoneum, and wire passed through the needle into the pelvis. Next, the catheter is advanced over the wire. Another alternative semi-open method opens the skin and subcutaneous tissue to the level of the fascia, then the needle is passed through the intact fascia and peritoneum followed by the wire and catheter.

Closed — For the closed method, a small nick is made through the skin, then the needle is blindly passed through the linea alba and the peritoneum. The wire and catheter are then inserted following the same method as above. Although faster, there is a greater risk of complications and catheter malposition using this technique. This method should be avoided in the presence of a pelvic fracture or prior midline incision [21].

Troubleshooting — If fluid does not return once instilled, it is probably due to either catheter malposition or an abundant omentum blocking egress of fluid into the holes in the catheter. Both of these situations can often be overcome by catheter repositioning. Extra effort should be placed on inserting the catheter along the undersurface of the peritoneum of the anterior abdominal wall in an attempt to steer it into the cul-de sac, rather than a more angled insertion, which may get it tangled in loops of bowel or omentum.

Closure and dressing — An absorbable suture, sized "0," should be placed to close the fascial defect securely (for open procedures). The sutures should be placed while the fluid is infusing and should not be tied until adequate catheter placement is confirmed by the free return of fluid. The catheter can be removed once the fluid stops flowing out of the abdomen. It is important to disconnect the catheter from the drainage system prior to removing the catheter. If the siphon effect is still ongoing, there is a risk of sucking a piece of omentum into the fascial closure, increasing the risk of hernia formation in the future. The skin can be closed with staples or with 4-0 nylon sutures. A standard gauze dressing should be placed over it at the completion of the procedure.

FLUID INTERPRETATION — For patients with blunt abdominal injury, the interpretation of DPL is well established.

Abnormal results — As mentioned above, aspiration of >10 mL of blood or enteric contents is considered positive, and instillation of the lavage fluid is not necessary [5]. If these are not present, a sample of the returned lavage fluid is sent to the laboratory for analysis.

Results from the cell analysis should return within 30 to 60 minutes. If an immediate decision is necessary and <10 mL of gross blood was returned, another approximation of positivity can be made using the density of cells in the intravenous tubing used to remove the fluid. If text can be read through the tubing, it can be considered unofficially negative until the official cell counts return. If the density of cells in the tubing is so high that you cannot read through it, then it can be considered a positive lavage. This is an inexact method and should only be used when a delay in decision making may be life-threatening, and only applied to determine positivity of a red blood cell (RBC) count. If one is concerned about the presence of bowel injury, the white blood cell (WBC) count is the critical determinant, and one must wait for the official results for a final determination.

A RBC count of >100,000/mm3, WBC count >500/mm3, elevated fluid amylase, or the presence of enteric contents or bacteria is considered positive in the presence of blunt abdominal injury. DPL is usually performed early in the resuscitative period of the hemodynamically unstable patient. However, if DPL is being used to determine the presence of bowel injury, there may be benefit to waiting for four to six hours post-injury and then using the WBC count as the marker for the presence of bowel injury. One small study used the ratio of WBCs in peritoneal fluid versus blood (cell count ratio [CCR]) to better detect those with bowel injuries in whom CT scans were concerning for, but nondiagnostic of, bowel injury [22]. A CCR ≥4 increased specificity from 43 to 90 percent. Unfortunately, the authors did not provide the absolute WBC count, which would have helped make a more compelling argument for using the ratios rather than the absolute count.

There is less consensus about the interpretation of DPL in patients with penetrating abdominal trauma [14,23]. In one study, a RBC count of >100,000/mm3 (standard for blunt trauma) was used in 500 patients with stab wounds to the anterior abdomen [24]. The sensitivity was 96.3 percent and specificity was 88.2 percent. Seven patients had a false negative DPL, including one with an RBC count of 7700 who had a combined duodenal and colon injury. Nineteen patients had false positive lavages, all the result of abdominal wall bleeding as a result of the abdominal wound (not related to the DPL). This and other studies led trauma surgeons to lower their thresholds for exploration [24-27]. A commonly used threshold is >10,000 RBC/mm3. A range of 5000 to 10,000 RBCs/mm3 is often used to determine the presence of injury in thoracoabdominal (low chest) wounds as this lowered threshold allows greater sensitivity for detecting isolated diaphragmatic or small bowel injury [5,28]. To avoid the problem of missed injuries, some trauma surgeons have even lowered RBC counts to the 1000 to 2000/mm3 range, accepting a higher negative and nontherapeutic laparotomy rate [29]. Such confusion has led this author to rely primarily on wound exploration, clinical observation, and serial abdominal examination for penetrating wounds to the anterior abdomen as advocated by others [30-33]. (See "Initial evaluation and management of abdominal stab wounds in adults" and "Initial evaluation and management of abdominal gunshot wounds in adults".)

False positives — A false positive result can occur if the catheter is accidently placed into a pelvic hematoma that has dissected along the anterior abdominal wall, or when a large pelvic hematoma ruptures into the peritoneal space. (See "Pelvic trauma: Initial evaluation and management" and "Severe pelvic fracture in the adult trauma patient".)

False negatives — False negatives are usually technical in nature with the catheter placed into an extraperitoneal location. However, retroperitoneal injuries can also produce a false negative. DPL cannot reliably identify injuries to retroperitoneal structures, including the pancreas, portions of the duodenum, kidneys, ureter, and major abdominal vessels (inferior vena cava, aorta).

COMPLICATIONS — Most complications are technical in nature and relate to catheter placement. Bowel injury is the most common. Vascular injuries can occur with the closed technique. When a Foley catheter insertion is omitted, there have been reports of intravesicular catheter placement in patients with a distended bladder. (See 'Preparation' above.)

SUMMARY AND RECOMMENDATIONS

Background – Diagnostic peritoneal aspiration (DPA) and diagnostic peritoneal lavage (DPL) was the gold standard for the diagnosis of blunt abdominal injury until it was largely replaced by ultrasound and CT scan. However, there remains a role for DPL or DPA in the evaluation of trauma patients. (See 'Introduction' above and 'Advantages and disadvantages' above.)

Advantages and disadvantages – DPL and DPA have advantages and disadvantages when compared with imaging methods for evaluating abdominal trauma as listed above. Compared with each other, an advantage of DPA is a shorter time interval from procedure completion to definitive results compared with DPL. However, the risk for nontherapeutic laparotomy is increased with DPA compared with DPL given the less stringent criteria that define a positive result. Both are associated with a risk for causing intraperitoneal injury. (See 'Advantages and disadvantages' above.)

Role in trauma – The physician must recognize the need for DPL and DPA. The main role of these is in defining the need for laparotomy in hemodynamically unstable trauma patients. DPL is indicated when ultrasound equipment or individuals appropriately trained in the performance of an interpretation of focused assessment with sonography for trauma (FAST) are not available or the FAST examination is indeterminate, and the patient remains hemodynamically unstable. DPL can also be used to aid the detection of blunt bowel injury or diaphragmatic injury. (See 'Indications' above.)

Technique – The physician must be able to perform the procedure and interpret its results. It is also important to recognize the limitations of DPL and how the presence of associated injuries, such as pelvic fracture, alters how the procedure should be performed. (See 'DPL/DPA technique' above.)

The basic technique involves first gaining abdominal access and then inserting the DPL catheter into the abdomen and then aspirating for blood. If <10 cc of blood is aspirated, then instill one liter of normal saline; once instilled, the fluid is immediately allowed to drain passively.

Interpretation of results – Fluid analysis is performed on a sample of the returned fluid. For blunt abdominal injury, DPL is considered positive if (see 'Fluid interpretation' above):

Prior to fluid instillation, >10 mL of gross blood can be aspirated, or enteric contents are returned

From a sample of returned fluid (minimum 300 mL)

-Red blood cell (RBC) count of >100,000/mm3 from a sample of drainage fluid (minimum 300 mL returned)

-White blood cell count (WBC) >500/mm3

-Enteric contents or bacteria present

For patients with penetrating abdominal trauma, there is less consensus about the interpretation of DPL. Lower values of RBC count can be used to reduce the potential for missed injuries and accept a higher rate of negative and nontherapeutic laparotomy. (See 'Fluid interpretation' above.)

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References

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