Trauma and Critical Care—Colon and Rectal Trauma
Concept
Likely to be seen in the context of multiple other injuries for example, GSW to abdomen with small bowel and colon injury or in the setting of a pelvic fracture with an obvious rectal injury. Again, go through the ABCs in all these questions to avoid missing an injury.
Way Question May be Asked?
“36 y/o male is being evaluated for a pelvic fracture in the ED and, on rectal examination, there is gross blood. What do you want to do?” This may be in the setting of a pelvic fracture in the OR after an exploratory laparotomy was performed, in the setting of a GSW to the pelvis or thigh, or from direct rectal trauma. Remember to deal with life- threatening injuries first.
How to Answer?
In trauma setting, always the ABCs:
Airway and C-spine control (intubate with C-spine control if necessary)
Breathing and Ventilation (does pt need chest tube—
place before CXR) Circulation and IV access Disability (Neuro status)
Don’t skip secondary survey either, or you will miss some key finding!
History
Pelvic fracture
Penetrating abdominal injury (remember abdomen stretches from nipples to groin)
Physical Exam
Rectal exam
Rigid sigmoidoscope
Diagnostic Studies
DPL CT scan
Surgical Treatment
Resuscitate the pt
Rule out other life-threatening injuries Colon injuries:
(1) Primary repair if:
Pt stable
Small laceration (< 1 cm) Contamination minimal Not on anti-mesenteric border Debride to healthy tissue
Close in one or two layers
(2) Colostomy for left sided injuries in:
Pt in shock
Multiple other injuries Peritonitis
(3) Resection and anastomosis for right sided injuries in:
Destructive wounds but pt stable with minimal injuries
Rectal injuries:
Diverting stoma Presacral drainage:
3 cm curvilinear incision b/w coccyx and rectum and
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Posterior dissection carried up to level of injury Distal rectal washout
2 liters of GU irrigant following an anal stretch
Common Curveballs
Pt will have other associated injuries (intra- and extraabdominal)
Missed bowel injury Pt will be unstable intra-op
Pt will develop abdominal compartment syndrome post-op
Pt will leak for primarily repaired colon wound Pt will have open pelvic fracture (gets diverting sigmoid
colostomy regardless of whether rectal injury or not) Pelvic fracture will have coincident bladder injury
Strikeouts
Not knowing how to treat rectal injury with diversion, drains, and washout
Not knowing to primarily repair small colon injuries Not looking for other injuries
Not looking for rectal injury in pelvic fracture Not looking for bladder injury in pelvic fracture
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