This document summarizes a study on using preoperative leukocytosis as a predictor of intraabdominal injury in patients with penetrating abdominal trauma. The study included 231 patients who underwent exploratory laparotomy for abdominal trauma. Patients were divided into two groups: those with therapeutic laparotomy who had intraabdominal injuries (Group I), and those with non-therapeutic laparotomy who did not have intraabdominal injuries (Group II). The study found that 74.2% of patients in Group I had leukocytosis levels over 12,500/mm3, compared to only 27.7% of patients in Group II, indicating leukocytosis over 12,500/mm3 may help predict which patients have intra

1. 482 Cirugía y Cirujanos
Cir Cir 2012;80:482-487.
Preoperative leukocytosis as a predictor of
intraabdominal injury in penetrating
abdominal trauma
Juan de Dios Díaz-Rosales, Lenin Enríquez-Domínguez, Jose Romeo Castillo-Moreno,
and Fernando Herrera-Ramírez
Servicio de Cirugía General, Hospital General de Ciudad Juárez, División
de Posgrado, Universidad Autónoma de Ciudad Juárez, Ciudad Juárez,
Chihuahua, México
Correspondence:
Juan de Dios Díaz Rosales
Avenida del Charro 350
Álamos de San Lorenzo
32310 Ciudad Juárez, Chihuahua, México
E-mail: jdiaz.uacj@gmail.com
Received for publication: 2-24-2012
Accepted for publication: 9-7-2012
Abstract
Introduction: In Mexico, management of penetrating abdominal trauma does not follow algorithms of Trauma Center Level I 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 two groups: group I (therapeutic laparotomy) and group II (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 χ2
test and Student t test, and percentages as summary of measures.
Results: We included 231 patients: group I—159 patients and group II—72 patients. 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
Abdominal trauma is a serious abdominal injury affect-
ing all layers of the abdominal wall to the parietal perito-
neum 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 im-
perative is clear (shock, evisceration, peritonitis), whereas
other patients can be treated conservatively and success-
fully.8-10
Algorithms of approach in trauma centers are established
in Level I Trauma Centers in countries with all the techno-
logical 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 di-
agnoses.
In our setting, the clinic is essential in the evaluation of
trauma patients, especially abdominal trauma. This assess-
ment is useful in cooperative patients, those not under the
effects of toxic substances (drugs, alcohol), and patients
without other associated injuries (fractures, traumatic brain

2. Volume 80, No. 6, November-December 2012 483
Preoperative leukocytosis in penetrating abdominal trauma
or spinal cord injuries) and, although initially intraabdomi-
nal 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 retro-
peritoneum 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 coexis-
tence of associated injuries are a frequent cause of confu-
sion 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 algo-
rithms, making them almost not feasible.
In the literature search we performed, early serum mark-
ers in penetrating abdominal trauma have not been exten-
sively 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 rea-
son, we evaluated the range of preoperative leukocytosis in
penetrating abdominal trauma. Its predictive character ac-
cording 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 exami-
nation. 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 Ciu-
dad Juarez, which is a teaching hospital center and trauma
center concentrated in the city. We evaluated patients ad-
mitted 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 ab-
dominal injury in the peritoneal cavity caused by firearm
and/or knife injury and who underwent emergency explor-
atory laparotomy for suspected intraabdominal organ in-
jury, 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 hemo-
dynamic 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 in-
jury, 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 hos-
pital 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 crite-
ria and local wound exploration. All patients with documen-
tation that the injury penetrated all layers of the abdominal
wall including the peritoneum and organ evisceration (or
both conditions) were considered positive. CBC was ob-
tained 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 non-
therapeutic laparotomy. Variables studied were age, gender,
type of trauma, number of wounds (point of entry), estimat-
ed time between injury and taking of blood count, hemato-
crit, 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 col-
lected was gathered in an Excel 2010 database. This data-
base was stripped and simple frequencies were corrected,
searching for inconsistencies. Subsequently, data were cap-
tured and processed using the statistical program STATA
v.10 (College Station, TX) and results were obtained. In-
formation is presented in frequency tables. Pearson χ2
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 accord-
ing to age group. Group I included 159 (68.8%) patients and

3. 484 Cirugía y Cirujanos
Díaz-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 af-
fected 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 pre-
sentation was abdominal pain in 219 (95%) patients. Other
less frequent data were evisceration, rectal bleeding, hema-
turia and palpable abdominal mass.
Hemoglobin and hematocrit in all patients were within
normal limits, and there were no significant differences sep-
arating 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 ad-
mission, 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
leukocyto-
sis with neutrophilia of 68%.
Leukocyte difference between groups was 2,700/mm3
and for neutrophils was 3% (both with a statistically sig-
nificant difference, p <0.001). Using the degree of leu-
kocytosis ≥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 leukocy-
tosis ≥12,500/mm3
, intraabdominal injuries were found that
required treatment, whereas in patients with leukocytosis
˂12,500/mm3
, 52% had a nontherapeutic laparotomy. Leu-
kocytosis ≥12,500/mm3
had a sensitivity of 74% and speci-
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 leu-
kocytosis 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 be-
tween 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 assess-
ment, 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 pa-
tients in this study were discharged due to improvement in
their condition.
14-19 20-29 30-39 40-49 ≥ 50
120
100
80
60
40
20
0
48
99
55
27
2
Age groups
Numberofpatients
Figure 1. Age groups affected. Source: Servicio de Cirugía, Hospital
General de Ciudad Juárez.
Table 1. Injuries per area (%)
Injury site %
Mesogastrium 16.9
Left flank 13.4
Right flank 12.5
Epigastrium 12.1
Right hypochondrium 10.4
Left hypochondrium 9.1
Right iliac fossa 6.1
Hypogastrium 5.2
Buttocks 5.2
Right dorsum 3.5
Left iliac fossa 3.0
Left dorsum 2.6
Source: Servicio de Cirugía, Hospital General de Ciudad Juárez.

4. Volume 80, No. 6, November-December 2012 485
Preoperative leukocytosis in penetrating abdominal trauma
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 simi-
lar to what occurs in the U.S.9
The reason is obvious—the
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 impor-
tant 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. Per-
centage 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 ki-
netics 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 in-
fluenced the results. Therefore, we excluded patients with
severe abdominal injuries and injuries to other areas. Leu-
kocytosis 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 cri-
teria, which filtered patients with more critical injuries and
conditions that caused higher morbidity. It stands to rea-
son 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.
Table 2. Laboratory results according to laparotomy carried out in patients with penetrating abdominal trauma
at the Hospital General de Ciudad Juárez
General Type of LAPE
Characteristic Mean (SD) Range Group I Group II *p
Leukocytes 13.2 ( 3.7) 5 - 23 14 ( 3.4) 11.3 ( 3.7) 0.001
Neutrophils 70.3 (10.3) 33 - 90 71.2 ( 9.9) 68.1 ( 10.6) < 0.001
Hemoglobin (g/dl) 13.6 ( 1.8) 8 - 19 13.6 ( 1.8) 13.8 ( 1.6) 0.273
Hematocrit (%) 40.9 ( 5.4) 25 - 62 40.5 ( 5.4) 41.5 ( 5.3) 0.583
Hemoperitoneum (ml) 641.6 (652.7) 185.4 (142.4) < 0.001
Leukocytosis
≥12,500/mm3
118 / 159 20 / 72 < 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 *p
Group Injury due to
knife wound
Firearm
injury
0.0001
Group I—therapeutic 55% 82%
Group II—nontherapeutic 45% 18%
Total 100%
(n=111)
100%
(n=120)
*χ2
.

5. 486 Cirugía y Cirujanos
Díaz-Rosales JD et al.
The clinical picture was always abdominal pain, which
occurred in patients undergoing therapeutic and nonthera-
peutic 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 genito-
urinary 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 leukocy-
tosis on admission were higher than in other similar stud-
ies22
(13.2 ± 3.7 vs. 11.6 ± 5 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 intraab-
dominal 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 be-
tween 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. Hemo-
peritoneum 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 se-
rum marker of intraabdominal injury in penetrating abdom-
inal trauma. As reported by Schnüriger et al.,15
leukocytosis
≤12,500/mL can exclude intraabdominal organ injury; how-
ever, 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 fre-
quently 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 hemoperi-
toneum with an average of 185 mL evacuated. It is impor-
tant 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 pa-
tients.
Table 4. Organs injured and degree of injury in patients with intraabdominal injuries at
the Hospital General de Ciudad Juárez
Degree of injury
Injured organ n I II III IV V
Small intestine 76 40% 25% 20% 15%
Colon 74 16% 62% 18% 4%
Liver 35 34% 37% 26% 3%
Stomach 24 4% 83% 13%
Kidney 21 5% 14% 19% 43% 19%
Bladder 17 6% 47% 29% 18%
Spleen 14 14% 7% 14% 29% 36%
Appendix 4 50% 50%
Pancreas 4 75% 25%
Diaphragm 4 100%
Gallbladder 3 100%
Duodenum 2 50% 50%
Ureter 1 100%
Source: Servicio de Cirugía/Hospital General de Ciudad Juárez.

6. Volume 80, No. 6, November-December 2012 487
Preoperative leukocytosis in penetrating abdominal trauma
5. Senado-Lara I, Castro-Mendoza A, Palacio-Vélez F, Vargas-
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10. Como JJ, Bokhari F, Chiu WC, Duane TM, Holevar MR,
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11. Thacker LK, Parks J, Thal ER. Diagnostic peritoneal lavage: is
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12. Shanmuganathan K, Mirvis SE, Chiu WC, Killeen KL, Hogan GJF,
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patients. Radiology 2004;231:775-784.
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15. Schnüriger B, Inaba K, Barmparas G, Eberle BM, Lustenberger T,
Lam L, et al. Serial white blood cell counts in trauma: do they predict
a hollow viscous injury? J Trauma 2010;69:302-307.
16. Abramson N, Melton B. Leukocytosis: basics of clinical assessment.
Am Fam Physician 2000;62:2053-2060.
17. Santucci CA, Purcell TB, Mejia C. Leukocytosis as a predictor of
severe injury in blunt trauma. West J Emerg Med 2008;9:81-85.
18. McCarthy DA, Grant M, Marbut M, Watling M, Wade AJ,
Macdonald I, et al. Brief exercise induces an immediate and delayed
leukocytosis. Br Sp Med 1991;25:191-195.
19. Cander B, Tosun M, Kalkan E. Morphologic and quantitative
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Ther 2007;24:119-122.
20. Casali M, Di Saverio S, Tugnoli G, Biscardi A, Villani S, Cancellieri
F, et al. Penetrating abdominal trauma: 20 years’ experience in a
Western European Trauma Center. Ann Ital Chir 2008;79:399-407.
21. Ertekin C, Yanar H, Taviloglu K, Güloglu R, Alimoglu O.
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Early leukocytosis in trauma patients: what difference does it make?
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Santucci et al.17
showed that, in blunt abdominal trau-
ma, 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 re-
lated 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 vol-
ume for resuscitation, need for transfusions, or surgery.
Length of hospital stay was consistent with expectations,
i.e., more days required for patients undergoing thera-
peutic laparotomy than for those who had a nonthera-
peutic laparotomy. This was probably due to the greater
inflammatory response in the former and also monitoring
for the appearance of complications in patients with or-
gan repair.
In conclusion, leukocytosis is a common finding in the
study of routine hospital laboratory examinations. There-
fore, 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 addi-
tion, fractures at any site may elevate the degree of leu-
kocytosis above the expected values in our study for both
groups.
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