Cir Cir 2012;80:482-487.

Preoperative leukocytosis as a predictor of

intraabdominal injury in penetrating
abdominal trauma
Juan de Dios Daz-Rosales, Lenin Enrquez-Domnguez, Jose Romeo Castillo-Moreno,
and Fernando Herrera-Ramrez

Abstract
Introduction: In Mexico, management of penetrating abdominal trauma does not follow algorithms of Trauma Center LevelI because
our limitations and laparotomies are inevitable in this context. Is it possible to use some degree of leukocytosis to suspect intraabdominal
injury?
Methods: We carried out a retrospective, descriptive and analytical study that included patients with penetrating abdominal trauma who
underwent exploratory laparotomy. We excluded patients with severe soft tissue damage to extremities, chest cavity, fractures, or central
nervous system damage. We divided patients into twogroups: groupI (therapeutic laparotomy) and groupII (nontherapeutic laparotomy).
Dependent variables were age, gender, type of injury, number of wounds, peripheral injuries, time lapse (between occurrence of injury
and taking of blood samples), mean grade of leukocytosis, percentage of neutrophils, leukocytosis 12,500/mm3, and hemoperitoneum.
We compared variables between groups using Pearson 2 test and Student t test, and percentages as summary of measures.
Results: We included 231patients: groupI159patients and groupII72patients. Overall leukocytosis was 13,200 mm3 and
neutrophils were in the range of 70.3%; 26% of patients did not have leukocytosis upon arrival and evaluation; however, they underwent
laparotomy due to peritoneal irritation. Leukocytosis 12,500/mm3 was statistically significant in patients with intraabdominal injuries
(74.2% vs. 27.7%, p<0.001).
Conclusions: Leukocytosis 12,500/mm3 may be an early serum marker in intraabdominal injuries due to penetrating abdominal trauma.
Key words: standard leukocyte count, predictive value, laboratory testing, leukocytosis, injuries.

Introduction
In Ciudad Juarez, penetrating trauma due to civil violence
and narcoviolence is a serious public health problem.1 This
condition is addressed in three referral hospitals. The most
influential is the Hospital General de Ciudad Juarez where
the majority of survivors of aggressions are admitted and
has become the point of referral in the city and throughout
the state.2-4

Servicio de Ciruga General, Hospital General de Ciudad Jurez, Divisin

de Posgrado, Universidad Autnoma de Ciudad Jurez, Ciudad Jurez,
Chihuahua, Mxico
Correspondence:
Juan de Dios Daz Rosales
Avenida del Charro 350
lamos de San Lorenzo
32310 Ciudad Jurez, Chihuahua, Mxico
E-mail: jdiaz.uacj@gmail.com
Received for publication: 2-24-2012
Accepted for publication: 9-7-2012

Abdominal trauma is a serious abdominal injury affecting all layers of the abdominal wall to the parietal peritoneum and is a common cause of significant disability and
mortality during productive ages.5-7 Currently, treatment of
abdominal trauma is twofold: surgical and conservative.
The category of patients where surgical intervention is imperative is clear (shock, evisceration, peritonitis), whereas
other patients can be treated conservatively and successfully.8-10
Algorithms of approach in trauma centers are established
in Level I Trauma Centers in countries with all the technological resources [computed tomography (CT], serial scans
such as Focused Assessment with Sonography in Trauma
(FAST), selective angiography and even laparoscopy) and
trained personnel.8-10 However, in second-level centers in
developing countries, there are shortages of these resources
for the appropriate approach to patients with doubtful diagnoses.
In our setting, the clinic is essential in the evaluation of
trauma patients, especially abdominal trauma. This assessment is useful in cooperative patients, those not under the
effects of toxic substances (drugs, alcohol), and patients
without other associated injuries (fractures, traumatic brain

482 Ciruga y Cirujanos

Preoperative leukocytosis in penetrating abdominal trauma

or spinal cord injuries) and, although initially intraabdominal injury is not ruled out, it is helpful during primary and
secondary evaluation in the first 12-24 h.
Given the scenario of penetrating abdominal trauma
where it is verified that the peritoneal cavity or the retroperitoneum or both were penetrated, in patients with clear
data of hemodynamic instability and peritoneal irritation,
exploratory laparotomy is mandatory, without the need for
additional tests or serial scans. However, hemoperitoneum
arising from the abdominal wall is sufficient to irritate the
peritoneum. Pain at the site of injury entry and the coexistence of associated injuries are a frequent cause of confusion about the injury in an intraabdominal organ.11 With the
advent of CT12,13 and FAST in trauma cases,14 conservative
management has been established in penetrating injuries
with a high success rate; however, lack of availability of
these resources limits the application of treatment algorithms, making them almost not feasible.
In the literature search we performed, early serum markers in penetrating abdominal trauma have not been extensively studied,15-19 and the average leukocytosis related to
penetrating abdominal trauma is unknown and much less
if this measurement is related to the injury. For this reason, we evaluated the range of preoperative leukocytosis in
penetrating abdominal trauma. Its predictive character according to the severity of the intraabdominal damage was
found and we evaluated when correlating an early marker
of intraabdominal injury with data from the clinical examination. A prediction can be made whether or not there is
intraabdominal injury.

Methods
We carried out a retrospective and descriptive study in the
Department of General Surgery, General Hospital of Ciudad Juarez, which is a teaching hospital center and trauma
center concentrated in the city. We evaluated patients admitted with a diagnosis of penetrating abdominal trauma
and who underwent exploratory laparotomy for this reason
between April 1, 2008 and December 31, 2010. To obtain
information and selection of participants, we requested all
electronic records of hospital admissions and discharges
with a diagnosis of penetrating abdominal trauma. Prior
approval was obtained from the Bioethics and Research
Committee of the Autonomous University of Ciudad Juarez
and the Committee on Trauma of the General Hospital of
Ciudad Juarez. We included patients with penetrating abdominal injury in the peritoneal cavity caused by firearm
and/or knife injury and who underwent emergency exploratory laparotomy for suspected intraabdominal organ injury, with time between injury and the start of surgery <6

h and who were discharged in improved condition at the

end of their hospital stay. We excluded patients with hemodynamic instability in their initial assessment, with added
injury to the chest, limbs, head and neck, and who required
surgical intervention, traumatic brain and/or spinal cord injury, fractures at any site, major central vessel injury and/
or peripheral organs, absence of blood count on admission,
and death from trauma-related complications. Exclusion
criteria were patients with established treatment in the hospital and selected for the study but who were transferred to
another medical facility postoperatively, patients who were
pregnant or given birth, postmenopausal patients or patients
with seizures and death in the pre-, intra- and postoperative
period due to any cause.
Preoperative diagnosis was made based on clinical criteria and local wound exploration. All patients with documentation that the injury penetrated all layers of the abdominal
wall including the peritoneum and organ evisceration (or
both conditions) were considered positive. CBC was obtained in the emergency room during the primary evaluation
of the patient and was sent to the laboratory (processed with
a COULTER Ac. T5diff AL computer, Beckman Coulter,
Fullerton, CA). We compared two groups: group I patients
with therapeutic laparotomy vs. group II patients with nontherapeutic laparotomy. Variables studied were age, gender,
type of trauma, number of wounds (point of entry), estimated time between injury and taking of blood count, hematocrit, hemoglobin, number of leukocytes/mm3, percentage of
neutrophils, leukocytosis 12,500/mm3, hemoperitoneum
and length of hospital stay. Leukocyte values 5,120/mm3
were used to test the hypothesis of intraabdominal organ
injury.
To collect information, a sole instrument was made that
captured the recorded information. All information collected was gathered in an Excel 2010 database. This database was stripped and simple frequencies were corrected,
searching for inconsistencies. Subsequently, data were captured and processed using the statistical program STATA
v.10 (College Station, TX) and results were obtained. Information is presented in frequency tables. Pearson 2 test
and Student t test were used for statistical differences in
continuous and grouped data, respectively. Also included
were mean values, standard deviations (SD) and range of
continuous variables.

Results
We included 231 patients; 218 (94.4%) were male
(male:female ratio 17:1). Overall average age was 27 years
(8.9 years). Figure 1 shows the number of patients according to age group. Group I included 159 (68.8%) patients and

Volume 80, No. 6, November-December 2012 483

Daz-Rosales JD et al.

group II included 72 patients (31.2%). Of the total patients,

120 (52%) suffered gunshot wounds and 111 (48%) stab
wounds. The average time between injury and blood count
sample was 104 min. The average number of injuries per
location in both groups was 1.1/patient. The areas most affected were the mesogastrium, both flanks and epigastrium,
which constituted 55% of the injuries. Table 1 shows the
number of injuries per area. The most common clinical presentation was abdominal pain in 219 (95%) patients. Other
less frequent data were evisceration, rectal bleeding, hematuria and palpable abdominal mass.
Hemoglobin and hematocrit in all patients were within
normal limits, and there were no significant differences separating these according to type of laparotomy performed.
In both groups the average preoperative leukocytosis was
13,200 (3.7)/mm3 with 70% (10%) neutrophilia. Overall,
171 (74%) patients had leukocytosis (11,000/mm3) on admission, whereas 60 (26%) patients did not. The average
leukocytosis in group I was 14,000/mm3 with neutrophilia
of 71%, whereas in group II it was 11,300/mm3 leukocytosis with neutrophilia of 68%.
Leukocyte difference between groups was 2,700/mm3
and for neutrophils was 3% (both with a statistically significant difference, p <0.001). Using the degree of leukocytosis 5,120/mm3 as a reference value4 in predicting
whether or not the patient had intraabdominal injury, there
was a significant difference in favor of group I (p <0.001).
Leukocytosis 12,500/mm3 was found in 74.2% of cases in
group I and in 27.7% of cases in group II, with subsequent
leukocytosis 12,500/mm3 in 26% of cases in group I and
72% of cases in group II. In 85% of patients with leukocytosis 12,500/mm3, intraabdominal injuries were found that
required treatment, whereas in patients with leukocytosis
12,500/mm3, 52% had a nontherapeutic laparotomy. Leukocytosis 12,500/mm3 had a sensitivity of 74% and speci-

Number of patients

120
99

100
80
60

55

48

40

27

20
0

2
14-19

20-29

30-39

40-49

50

Age groups
Figure 1. Age groups affected. Source: Servicio de Ciruga, Hospital
General de Ciudad Jurez.

Table 1. Injuries per area (%)

Injury site
Mesogastrium
Left flank
Right flank
Epigastrium
Right hypochondrium
Left hypochondrium
Right iliac fossa
Hypogastrium
Buttocks
Right dorsum
Left iliac fossa
Left dorsum

%
16.9
13.4
12.5
12.1
10.4
9.1
6.1
5.2
5.2
3.5
3.0
2.6

Source: Servicio de Ciruga, Hospital General de Ciudad Jurez.

ficity of 72% for predicting intraabdominal injury in this

study (Table 2).
When the mechanisms of injury and type of laparotomy
were compared, a statistically significant difference was
found. Nontherapeutic laparotomies were more common
in the group of patients with stab wounds and therapeutic
laparotomy was more common in patients with gunshot
wounds (Table 3). There was virtually no difference in leukocytosis between the mechanism of action (stab wound vs.
gunshot wound) in the same group, but there was a marked
difference between the primary mechanism of action between groups, whose tendency towards stab wound (62%)
favored group I (p <0.001), whereas in group II the trend
was toward gunshot wound (69%) (p <0.001). As expected,
there was an important difference in the hemoperitoneum
between groups (600 mL), which was significant (p <0.001)
in the between-group comparison (Table 2).
In group II, 16 injuries were found (0.22/patient) in eight
different organs that did not require treatment, only assessment, triage and evacuation of hemoperitoneum (243 mL on
average). In group I, there were 263 injuries (1.6/patient) to
intraabdominal organs, most of which required treatment
(except for liver and spleen injuries that were not actively
bleeding) and evacuation of hemoperitoneum (641 mL on
average). The most common injuries occurred in the small
intestine, colon, stomach and liver. The remaining injuries
are shown in descending order in Table 4.
Average hospital stay was 6 days (5.5 days). The length
of stay for patients in group I was 7.3 days (6 days),
whereas in group II the average stay was 3 days (2 days)
with a statistically significant difference (p <0.001). All patients in this study were discharged due to improvement in
their condition.

484 Ciruga y Cirujanos

Preoperative leukocytosis in penetrating abdominal trauma

Table 2. Laboratory results according to laparotomy carried out in patients with penetrating abdominal trauma
at the Hospital General de Ciudad Jurez
General

Type of LAPE

Characteristic

Mean (SD)

Range

Group I

Group II

*p

Leukocytes
Neutrophils
Hemoglobin (g/dl)
Hematocrit (%)
Hemoperitoneum (ml)
Leukocytosis
12,500/mm3

13.2 ( 3.7)
70.3 (10.3)
13.6 ( 1.8)
40.9 ( 5.4)

5 - 23
33 - 90
8 - 19
25 - 62

14 ( 3.4)
71.2 ( 9.9)
13.6 ( 1.8)
40.5 ( 5.4)
641.6 (652.7)
118 / 159

11.3 ( 3.7)
68.1 ( 10.6)
13.8 ( 1.6)
41.5 ( 5.3)
185.4 (142.4)
20 / 72

0.001
< 0.001
0.273
0.583
< 0.001
< 0.001

LAPE, laparotomy; SD, standard deviation.

*Student t test.

Table 3. Type of laparotomy carried out according to

the mechanism of injury of patients with penetrating
abdominal trauma
Mechanism of injury
Group

Injury due to
knife wound

Group Itherapeutic

55%

82%

Group IInontherapeutic

45%

18%

100%
(n=111)

100%
(n=120)

Total

*p

Firearm
injury
0.0001

*2.

Discussion
As observed in Mexican studies in regard to trauma, males
in the third decade of life are the most affected.1-7 It was
observed that, in Ciudad Juarez, low sociocultural level is
a risk factor for this type of injury. The activities related to
organized crime are also considered high risk for suffering
from this type of injury. The average time from injury to
blood sampling was considered reasonable.
In our center we have a higher rate of penetrating trauma
by firearm (52 vs. 48% in this study), contrary to what is
reported by the major European trauma centers20 and similar to what occurs in the U.S.9 The reason is obviousthe
high rate of drug-related crime along our border is known
worldwide.
Of patients with abdominal trauma included in this study,
31.2% underwent nontherapeutic laparotomy. It is important to mention that patients had injuries spanning all layers

of the abdominal wall, verified by escape of fluid from the

omentum or digital exploration of the wound, despite being
a limited universal study due to the inclusion criteria. Percentage of nontherapeutic laparotomies is within average
limits, as with other studies.20,21
This is despite not having advanced imaging studies
and is based on clinical and scarce paraclinical evidence
to corroborate our diagnosis. The highest percentage of
patients with nontherapeutic laparotomy came from the
group of patients with stab wounds. Obviously, the kinetics and type of trauma directly influence the risk of
injury requiring corrective surgery which, as has been
observed, is higher for gunshot wounds than for stab
wounds.
This study avoided the variables that may have been
related with increased leukocytosis and that may have influenced the results. Therefore, we excluded patients with
severe abdominal injuries and injuries to other areas. Leukocytosis increases considerably when abdominal trauma is
accompanied by a fracture, but that will be the subject of a
future study. Associated injuries in this study were only soft
tissue injuries.
Although patients with gunshot wounds were slightly
higher in number, the average injury per patient was low.
This is due to the inclusion, exclusion and elimination criteria, which filtered patients with more critical injuries and
conditions that caused higher morbidity. It stands to reason that the greater the number of injuries, the poorer the
condition of the patient. The central and upper areas of the
abdomen are the most commonly affected, but it should be
noted that a percentage of patients had abdominal injuries
caused by points of entry in the pelvis, back and buttocks.
Therefore, patients with such injuries are not exempt from
having intraabdominal injury.

Volume 80, No. 6, November-December 2012 485

Daz-Rosales JD et al.

Table 4. Organs injured and degree of injury in patients with intraabdominal injuries at
the Hospital General de Ciudad Jurez

Injured organ

Small intestine
Colon
Liver
Stomach
Kidney
Bladder
Spleen
Appendix
Pancreas
Diaphragm
Gallbladder
Duodenum
Ureter

76
74
35
24
21
17
14
4
4
4
3
2
1

I
16%
34%
4%
5%
6%
14%
50%

II

Degree of injury
III

40%
62%
37%
83%
14%
47%
7%
50%
75%
100%
100%
50%
100%

25%
18%
26%
13%
19%
29%
14%

IV

20%
4%
3%

15%

43%
18%
29%

19%
36%

25%

50%

Source: Servicio de Ciruga/Hospital General de Ciudad Jurez.

The clinical picture was always abdominal pain, which

occurred in patients undergoing therapeutic and nontherapeutic laparotomy. The ability to discern between intensity
and type of pain between these groups may be the subject
of another study. Abdominal pain is not a decisive factor
for differentiating patients with suspected intraabdominal
injury from those patients in whom this has been ruled out.
Evisceration is also not necessarily an indicative factor for
intraabdominal injury. Hematuria can occur with genitourinary injuries ranging from contusions (not requiring
surgery) to injuries requiring emergency surgery. Rectal
bleeding may be the only data that when present along with
penetrating abdominal trauma, prompts us to search for an
intraabdominal injury (specifically of the gastrointestinal
system) and, therefore, to perform laparotomy.
Average leukocytosis values and patients with leukocytosis on admission were higher than in other similar studies22 (13.23.7 vs. 11.65 and 70 vs. 59%, respectively),
perhaps because of the higher incidence of gunshot wounds.
In our study, patients with intraabdominal injuries had
higher leukocyte counts on admission than those without
injuries. Average leukocyte count in patients with intraabdominal injury due to gunshot wounds was almost equal to
leukocyte count in patients with stab wounds.
There was also no difference in the leukocyte count between the same group and mechanism of action, suggesting
that leukocytosis is in proportion to the presence or absence
of intraabdominal injuries and, therefore, we may expect
similar ranges of leukocytosis between mechanisms in one
or the other group. Gunshot wounds are more often associ-

ated with intraabdominal injuries than stab wounds. This

shows that the risk of intraabdominal injury is greater if
the injury is due to a gunshot than to a stab wound. Hemoperitoneum found was as expected, significantly higher in
patients with intraabdominal injury than in those without.
Preoperative hemoglobin and hematocrit were within the
normal range and do not predict or discern acute bleeding
in patients with penetrating abdominal trauma, as seen in
our results. Leukocytosis 12,500/mL between groups had
a significant difference (p = 0.001), with a sensitivity of
74% and specificity of 72%. This suggests that preoperative
leukocytosis 12,500/mL may be an indicator or early serum marker of intraabdominal injury in penetrating abdominal trauma. As reported by Schnriger et al.,15 leukocytosis
12,500/mL can exclude intraabdominal organ injury; however, we believe that the leukocytosis values in the first 24 h
has limited predictive value. We use it as a reference value
to distinguish those patients with intraabdominal injury
from those without intraabdominal injury with the results
reported here.
Our study coincides with other trauma studies5-7 in frequently affected intraabdominal organs. In group II, one
nontherapeutic laparotomy was carried out. There were also
minor injuries found, most grade I, as well as one hemoperitoneum with an average of 185 mL evacuated. It is important to mention that, even in nontherapeutic laparotomies,
we also found a significant degree of injury (22%). This
shows the importance of having advanced imaging studies
to facilitate the monitoring of injury evolution in these patients.

486 Ciruga y Cirujanos

Preoperative leukocytosis in penetrating abdominal trauma

Santucci et al.17 showed that, in blunt abdominal trauma, leukocytosis is associated with severe damage. The
same results were reproduced by this study in the setting
of penetrating abdominal trauma. Chang et al.22 found
that the level of leukocytosis in trauma patients is not related to the mechanism of injury or to the affected organ,
but with the severity of damage with results similar to
ours. Furthermore, these authors concluded that the level
of leukocytosis in these patients does not predict the volume for resuscitation, need for transfusions, or surgery.
Length of hospital stay was consistent with expectations,
i.e., more days required for patients undergoing therapeutic laparotomy than for those who had a nontherapeutic laparotomy. This was probably due to the greater
inflammatory response in the former and also monitoring
for the appearance of complications in patients with organ repair.
In conclusion, leukocytosis is a common finding in the
study of routine hospital laboratory examinations. Therefore, level of leukocytosis may be an early serum marker
for intraabdominal injury in penetrating abdominal trauma.
This information in no way changes the algorithm study of
these patients. We should always be cautious and examine
the patient from a holistic standpoint, taking into account
serious injuries to soft tissues, injuries to blood vessels, and
thoracic and central nervous system involvement. In addition, fractures at any site may elevate the degree of leukocytosis above the expected values in our study for both
groups.
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