Clinical value of peritoneal signs and computed tomography in hemodynamically stable patients with abdominal gunshot...

Selective non-operative management (SNOM) is increasingly used for hemodynamically stable patients with abdominal gunshot wounds (GSW). Although peritoneal signs traditionally mandate emergency laparotomy, the clinical value in the era of computed tomography (CT) remains unclear. This study evaluated the clinical value of peritoneal signs and the adjunctive use of CT for identifying patients requiring therapeutic laparotomy.

We conducted a retrospective cohort study of patients with abdominal GSW admitted to a Level I trauma center between 2016 and 2023. Patients with systolic blood pressure < 90 mmHg, Glasgow Coma Scale<9 or intubation in the emergency department were excluded. Patients were categorized by the presence of peritoneal signs upon arrival. Clinical data, CT, and operative findings were reviewed. The primary outcome was intra-abdominal injuries requiring therapeutic laparotomy.

Among 308 patients, 57 (18.5%) had peritoneal signs. Of those, 50 (89.3%) had therapeutic laparotomy. Peritoneal signs alone demonstrated sensitivity of 36.8% and specificity of 95.9% (95% confidence interval [CI]: 28.7-45.4 and 91.7-98.3, respectively). Among 251 patients without peritoneal signs, 95 underwent laparotomy based on CT findings, with 85 (89.5%) having therapeutic laparotomy. Only two of 157 patients managed non-operatively after CT required laparotomy following clinical observation. Combining peritoneal signs with CT findings yielded sensitivity of 99.3% and specificity of 87.8% (95% CI: 96.0-100.0 and 81.8-92.4, respectively).

Peritoneal signs alone had high specificity but limited sensitivity for detecting intra-abdominal injuries requiring therapeutic laparotomy. With selective CT use, our results supported the safety of SNOM in hemodynamically stable patients with abdominal GSW.