Scoring for early diagnosis of traumatic bowel injury without solid organ injury in stable patients: Where do we stand?

To the Editor: We have read with great interest the article titled ‘‘Early surgical intervention for blunt bowel injury: The Bowel Injury Prediction Score (BIPS)’’ by McNutt et al. in 2015. The authors stated that their study is the first study that combined radiographic, laboratory, and physical examination findings present at the time of admission to predict the need for early intervention for blunt bowel and mesenteric injury. Herein, we would like to bring your attention to the work, which was published earlier in 2014 by Zarour et al., ‘‘A novel practical scoring for early diagnosis of traumatic bowel injury without obvious solid organ injury in hemodynamically stable patients. ’’ Zarour et al. developed a novel scoring criteria for early diagnosis of traumatic bowel and mesenteric injury without obvious solid organ injury in hemodynamically stable patients. The z score was based on a combination of clinical and radiologic findings that might be useful for surgeons to make an objective decision for surgical intervention of hollow viscus injury on a timely fashion. Both works were almost similar in sample size and included only blunt traumatic abdominal injuries. The BIPS scoring relied on only three criteria (abdominal tenderness, leukocytosis, and computed tomography [CT] Grade 4 in the emergency department) in the decision-making process. The first two criteria are nonspecific and frequently seen in most of trauma patients regardless of the severity or the presence of internal organ injury. The range of BIPS was very narrow (0Y3), and the cutoff score of 2 or greater with a large 95% confidence interval (6.79Y54.36) may prevent the generalizability of the scoring system. Therefore, a scoring system like the z score may be more reliable since it includes more criteria and has a wide range from 0 to 14. The scoring criteria included abdominal pain/tenderness (0Y3), external abdominal signs (0Y3), abdominal CT scan free intra-abdominal fluid (0Y4), and CT scan signs of bowel/mesenteric injury (0Y4). The diagnostic weight of these criteria was based on its clinical implications from other previous studies. The cutoff z score of greater than 9 was found to be highly sensitive (96.7%) and specific (97.4%) for the presence of bowel and mesenteric injuries. The positive predictive value was 93.5%, and the negative predictive value was 98.7%. However, the sensitivity, specificity, positive predictive value, and negative predictive value of BIPS of 2 or greater to predict a surgically significant bowel injury were 85.7%, 76.2%, 70.6%, and 88.9%, respectively. In each study, there were four deaths; four were reported in the operative arm in the study of McNutt et al., whereas in the study of Zarour et al., the four deaths occurred in the nonoperative arm characterized by a z score of lower than 9 but with head injuries. McNutt et al. did not mention head injuries in their article; however, the Glasgow Coma Scale (GCS) score was given as greater than 12. Moreover, in the study of McNutt et al., we could not know whether solid organ injury was excluded. In contrast, the exact surgical intervention timing was not clear in the study of Zarour et al. Prospective validation for both studies is warranted to assess the accuracy of their scores. However, we can say that the z score is the first one that combined clinical presentation, external abdominal marks, and CT scan findings to diagnose early and manage traumatic bowel and mesenteric injury.