Diagnostic peritoneal lavage

Diagnostic peritoneal lavage
Intervention
ICD-9-CM	54.25
MeSH	D010533

Diagnostic peritoneal lavage (DPL) or diagnostic peritoneal aspiration (DPA) is a surgical diagnostic procedure to determine if there is free floating fluid (most often blood) in the abdominal cavity.

Indications

This procedure is performed when intra-abdominal bleeding (hemoperitoneum), usually secondary to trauma, is suspected.^[1] In a hemodynamically unstable patient with high-risk mechanism of injury, peritoneal lavage is a means of rapidly diagnosing intra-abdominal injury requiring laparotomy, but has largely been replaced in trauma care by the use of a focused assessment with sonography for trauma (FAST scan) due to its repeatability, non-invasiveness and non-interference with subsequent computed tomography (CT scan). Abdominal CT and contrast duodenography may complement lavage in stable patients, but in an unstable or uncooperative persons, these studies are too time-consuming or require ill-advised sedation. Magnetic resonance imaging is extremely accurate for the anatomic definition of structural injury, but logistics limit its practical application in acute abdominal trauma.^[2]^[3] The procedure was first described in 1965 by Hauser Root.^[4]^[5]

Procedure

After the application of local anesthesia, a vertical skin incision is made one third of the distance from the umbilicus to the pubic symphysis. The linea alba is divided and the peritoneum entered after it has been picked up to prevent bowel perforation. A catheter is inserted towards the pelvis and aspiration of material attempted using a syringe. If no blood is aspirated, 1 litre of warm 0.9% saline is infused and after a few (usually 5) minutes this is drained and sent for analysis.^[6]

Interpretation of results

If any of the following are found then the DPL is positive of trauma and operative exploration is warranted:^[7]

10 cc/blood
100,000 RBCs/mm³
500 WBCs/mm³
Presence of bile, bacteria or food particle
Amylase level > 175 IU/ml
Bilirubin level > 0.01 mg/DL
ALP > 2 IU/L

References

↑ Rosen 2009, p. 422-4
↑ Tintinalli JE, Kelen GD, Stapczynski JS (2004). Emergency Medicine: A Comprehensive Study Guide, ed 6. McGraw-Hill. pp. 1615–1616.
↑ Townsed CM Jr, Beauchamp RD, Evers BM et al. (2008). Sabiston Textbook of Surgery: The Bilogical Basis of Modern Surgical Practice, ed 18. Saunders. pp. 502–504.
↑ Jagminas, Liudvikas (June 18, 2012). "Diagnostic Peritoneal Lavage". Medscape. Retrieved December 31, 2012.
↑ Root H, Hauser C, McKinley C, Lafave J, Mendiola R (1965). "Diagnostic peritoneal lavage.". Surgery 57: 633–7. PMID 14295771.
↑ Kim, Dennis(Narrator) (July 17, 2012). Diagnostic Peritoneal Lavage (DPL). San Diego: "The Division of Trauma/Surgical Critical Care/Burns is part of the Department of Surgery, UC San Diego Health System. Event occurs at 4:00.
↑ Andrew B., MD Peitzman; Andrew B. Peitzman; Michael, MD Sabom; Donald M., MD Yearly; Timothy C., MD Fabian (2002). The trauma manual. Hagerstwon, MD: Lippincott Williams & Wilkins. ISBN 0-7817-2641-7.

Bibliography

Rosen, Peter; John J. Ratey MD; Marx, John A.; Robert I. Simon MD; Hockberger, Robert S.; Ron Walls MD; Walls, Ron M.; Adams, James L. (2010). Rosen's emergency medicine: concepts and clinical practice. St. Louis, Mo: Mosby/Elsevier. ISBN 0-323-05472-2.

External links

Trauma Man: Images of DPL being performed on a simulator

Trauma

Principles

Assessment

Clinical prediction rules	Revised Trauma Score Injury Severity Score Abbreviated Injury Scale NACA score

Investigations	Diagnostic peritoneal lavage Focused assessment with sonography for trauma

Management

Principles	Advanced trauma life support Trauma surgery Trauma center Trauma team Damage control surgery Early appropriate care

Procedures	Resuscitative thoracotomy

Pathophysiology

Injury	MSK Bone fracture Joint dislocation Degloving Soft tissue injury Resp Flail chest Pneumothorax Hemothorax Diaphragmatic rupture Pulmonary contusion Cardio Internal bleeding Thoracic aorta injury Cardiac tamponade GI Blunt kidney trauma Ruptured spleen Neuro Penetrating head injury Traumatic brain injury Intracranial hemorrhage

Mechanism	Blast injury Blunt trauma Burn Penetrating trauma Crush injury Stab wound Ballistic trauma Electrocution

Region	Abdominal trauma Chest trauma Facial trauma Head injury Spinal cord injury

Demographic	Geriatric trauma Pediatric trauma

Sequelae

Index of bones and cartilage

Description	Anatomy bones skull face neurocranium compound structures foramina upper extremity torso pelvis lower extremity Physiology Development Cells

Disease	Congenital Neoplasms and cancer Trauma fracture Other Symptoms and signs eponymous

Treatment	Procedures Drugs Surgery approaches

Digestive system surgical and other procedures / Digestive system surgery (ICD-9-CM V3 42–54, ICD-10-PCS 0D)

Digestive tract

Upper GI tract

SGs / Esophagus	Esophagectomy Heller myotomy Sialography Impedance–pH monitoring Esophageal pH monitoring Esophageal motility study

Stomach	Bariatric surgery Adjustable gastric band Gastric bypass surgery Sleeve gastrectomy Vertical banded gastroplasty surgery Collis gastroplasty Gastrectomy Billroth I Billroth II Roux-en-Y Gastroenterostomy Gastropexy Gastrostomy Percutaneous endoscopic gastrostomy Hill repair Nissen fundoplication Pyloromyotomy

Medical imaging	Endoscopy: Esophagogastroduodenoscopy Barium swallow Upper gastrointestinal series

Lower GI tract

Small bowel	Bariatric surgery Duodenal switch Jejunoileal bypass Ileostomy Intestine transplantation Jejunostomy Partial ileal bypass surgery

Large bowel	Appendicectomy Colectomy Colonic polypectomy Colostomy Hartmann's operation

Rectum	Abdominoperineal resection / Miles operation Lower anterior resection Total mesorectal excision

Anal canal	Anal sphincterotomy Anorectal manometry Lateral internal sphincterotomy Rubber band ligation Transanal hemorrhoidal dearterialization

Medical imaging	Endoscopy: Colonoscopy Anoscopy Capsule endoscopy Enteroscopy Proctoscopy Sigmoidoscopy Abdominal ultrasonography Defecography Double-contrast barium enema Endoanal ultrasound Enteroclysis Lower gastrointestinal series Small-bowel follow-through Transrectal ultrasonography Virtual colonoscopy

Stool tests	Fecal fat test Fecal pH test Stool guaiac test

Accessory

Liver	Artificial extracorporeal liver support Bioartificial liver devices Liver dialysis Hepatectomy Liver biopsy Liver transplantation Portal hypertension Transjugular intrahepatic portosystemic shunt [TIPS] Distal splenorenal shunt procedure

Gallbladder, bile duct	Cholecystectomy Cholecystostomy ERCP Hepatoportoenterostomy Medical imaging: Cholangiography IV MRCP PTC Cholecystography Cholescintigraphy

Pancreas	Frey's procedure Pancreas transplantation Pancreatectomy Pancreaticoduodenectomy Puestow procedure

Abdominopelvic

Peritoneum	Diagnostic peritoneal lavage Intraperitoneal injection Laparoscopy Omentopexy Paracentesis Peritoneal dialysis

Hernia	Hernia repair: Inguinal hernia surgery Femoral hernia repair

Other

CPRs

Index of digestion

Description	Anatomy tract glands other Physiology enzymes Development

Disease	Congenital Neoplasms and cancer Inflammatory bowel disease Gluten sensitivity Other Symptoms and signs eponymous Blood tests

Treatment	Procedures Drugs anabolic steroids antacids diarrhoea and infection bile and liver functional gastrointestinal disorders laxatives peptic ulcer and reflux nausea and vomiting other Surgery