Why is Diagnostic Peritoneal Lavage (DPL) used for suspected intrabdominal bleeding?

From the Guidelines

Diagnostic Peritoneal Lavage (DPL) is used for suspected intrabdominal bleeding because it provides a rapid and sensitive method to detect the presence of blood in the peritoneal cavity, with a sensitivity of 98% for hemoperitoneum 1. The procedure involves inserting a catheter into the peritoneal cavity and aspirating fluid to check for gross blood. If no blood is immediately aspirated, a liter of warm saline is infused and then drained to analyze for red blood cell count, white blood cell count, and other parameters.

Key Points:

• A positive DPL (typically >100,000 RBCs/mm³) indicates significant intraabdominal hemorrhage requiring surgical intervention 1.
• DPL can detect as little as 20 mL of intra-peritoneal blood, making it a valuable tool in diagnosing hemoperitoneum 1.
• While DPL has practical limitations in identifying retroperitoneal, diaphragmatic, and enteric injuries, it remains a useful diagnostic tool in resource-limited settings or when other imaging modalities are unavailable 1.
• The procedure's high sensitivity makes it effective for ruling out significant intraabdominal bleeding, though it cannot specify which organ is injured and may lead to non-therapeutic laparotomies due to its lower specificity 1.

Considerations:

• DPL is particularly useful in hemodynamically unstable patients who cannot be transported for CT scanning 1.
• The false-positive rate for DPL is between 13% and 54%, highlighting the need for careful interpretation of results and consideration of other diagnostic modalities 1.
• Nontherapeutic laparotomies can have significant complications, with a complication rate of up to 20% in some studies 1.

From the Research

Diagnostic Peritoneal Lavage (DPL) for Intrabdominal Bleeding

• DPL is used for suspected intrabdominal bleeding due to its ability to rapidly and accurately diagnose intra-abdominal hemorrhage or contamination 2, 3.
• The procedure is invasive, but it is cheap and has a primary role in documenting intra-abdominal bleeding or contamination in hypotensive patients with blunt trauma or selected stable patients with penetrating stab wounds 2.
• DPL is highly accurate for evaluating intraperitoneal hemorrhage or a ruptured hollow viscus, but its use has decreased with the increased use of focused abdominal sonography for trauma (FAST) and helical computed tomography (CT) 3.

Indications for DPL

• DPL is indicated for diagnosing suspected internal abdominal injury when an ultrasound machine is not available, there is no trained person to perform FAST, or the results of FAST are equivocal or difficult to interpret in a hemodynamically unstable patient 4.
• It is also used in critically ill patients suspected of harboring intra-abdominal pathology such as acute mesenteric ischemia, where it is associated with reduced operative intervention and mortality 5.

Comparison with Other Diagnostic Modalities

• DPL is compared to CT scan, which is noninvasive, time-consuming, expensive, and accurate, but may miss gastrointestinal perforations or ruptures 2.
• FAST is useful as the initial diagnostic tool for abdominal trauma to detect intraabdominal fluid, but DPL is used when FAST is not available or the results are equivocal 4.
• The combination of DPL and CT scan can improve the diagnosis of blunt abdominal trauma, especially in cases with small bowel and mesenteric injuries (BBMI) 6.

Limitations and Future Directions

• DPL has limitations, such as missing small and large injuries to the diaphragm and unable to rule out injury to retroperitoneal structures 2.
• Further investigation is needed to better define the proper place and timing of DPL in evaluating the acute abdomen, especially in stable trauma patients with unexplained CT abnormalities 6.