34 Traumatic Injuries of the Colon, Rectum, and Anus
Abstract
Trauma is the leading cause of death for young people and the third overall for all age groups in the United States. In penetrating abdominal trauma, the colon and rectum are often injured. Blunt trauma as well as diagnostic and therapeutic endoscopic procedures may cause perforation. Management of battle injuries has been the driving force of surgical progress throughout history with a reducing mortality rate from colonic injuries.
Significant portions of this chapter were adopted from the third edition chapter written by Dr. Lee E. Smith.
34.1 Introduction
Trauma ranks as the number 1 cause of death for people in the age group of 1 to 46 years and the third overall for all age groups in the United States. 1 It accounts for more lost years of useful life than any other cause. With penetrating abdominal trauma, the colon and rectum are often injured because of the large area they occupy. Diagnostic and therapeutic endoscopic procedures may cause perforation from within the lumen, and external penetrating or blunt injury may cause perforation from without.
The desire to improve the results for traumatic injuries received in battle has been the driving force of surgical progress throughout history. The mortality rate from colonic injuries has decreased with each war from the Civil War to the Vietnam War (▶ Table 34.1).
War | Mortality rate (%) |
U.S. Civil War | 90 |
Spanish-American War | 90 |
World War I | 58 |
World War II | 37 |
Korean War | 15 |
Vietnam War | 9 |
34.2 Etiology
34.2.1 Penetrating Trauma
External penetrating trauma may result from a bullet, shotgun pellets, a knife, a piercing instrument, or impalement. 2 , 3 , 4 , 5 , 6 A bullet wound is the most frequent wound type, outnumbering knife wounds by a ratio of 10:1. 7 Inexpensive low-velocity weapons known as ‘‘Saturday night specials’’ have been the usual weapons used in criminal assault in the past. In recent years, high-velocity weapons (with bullets traveling at more than 2,000 ft/s) have become increasingly available and are now common throughout society. Velocity is the dominant factor in determining the amount of tissue damage within the body. 8 , 9 The other factor that determines wound ballistics (motion of the bullet within the tissues) is the mass of the bullet. Velocity (V) and mass (M) can be expressed in the formula for kinetic energy (KE):
The prime factor in kinetic energy is velocity, since it is expressed as the square. As the bullet travels through tissue, it creates a temporary high-pressure cavity around itself, resulting in secondary tissue damage away from the direct path of the bullet. The bullet may tumble (yaw) in its trajectory, also expanding the injury diameter (▶ Fig. 34.1).
Shotguns are smooth-bore weapons that discharge a number of small projectiles. The velocity of the pellets diminishes rapidly so that deep penetration in most instances does not occur if the weapon is fired more than 7 yards away from the person, but if a shotgun wound is inflicted at close range, extensive tissue loss occurs. Close-range shotgun wounds require extensive local debridement.
Large, bowel impalement injuries are caused by falling onto or running into an object that penetrates the abdomen or rectum. The rectal injury usually occurs after the individual falls with the legs astride the penetrating object such as a picket fence or a stake.
34.2.2 Blunt Trauma
Blunt trauma accounts for approximately 4% of colorectal injuries. Most injuries in this category result from motor vehicle accidents, with the steering wheel being the primary source of injury. Seat belts do save lives, but colonic or rectal injury can occur secondary to the use of seat belts, which cause pelvic fracture with a rectal tear or a compression of the colon between the anterior abdominal wall and the vertebral column, resulting in a ‘‘blow out’’ injury. 10 Direct force across the abdomen occurs when the belt either rides up from below the iliac crest or the person has slid down on the seat beneath the belt, creating free abdominal exposure. Shearing from rapid deceleration may cause an injury in which the fixed mesenteric peritoneum suspends the free-floating colon. In addition, hematoma and vascular injury may cause delayed perforation; thus, perforation after blunt trauma must be considered to avoid delay in treatment. 11 , 12 Automobiles striking pedestrians, motorcycle accidents, falls, being crushed under a heavy object, and athletic injuries result in similar damage. Also, blunt trauma to the perineum can disrupt the rectosigmoid and anal canal from the levator muscular sling. 11 , 12
34.2.3 Iatrogenic Injury
Few organ systems are as accessible for diagnosis and treatment as is the large bowel. This accessibility places it at risk for unintended injury. Diagnostic and therapeutic procedures performed for colon and rectal disease can result in injury if they are performed improperly or if the tissues investigated are weakened by disease.
Injury from Operative Procedures
Intraoperative injury to the colon and rectum can occur during any procedure in the pelvis or abdomen because the colorectum extends into every quadrant. By proximity, gynecologic procedures can lead to colorectal injury. Perforation may occur during routine dilatation and curettage of the uterus, and the adjacent colorectum is vulnerable to puncture. More complicated procedures that are performed frequently, such as total abdominal hysterectomy and vaginal hysterectomy, also may result in colorectal injury or fistulization. During laparoscopic sterilization, electrocoagulation may be used, possibly leading to bowel injury; deaths associated with this procedure have been reported. 13 Intrauterine devices have been known to erode into the peritoneal cavity and subsequently into the colon, creating a localized septic inflammatory process. 14
Anorectal injuries can result from simple anorectal surgery, including operations for hemorrhoids, fistulas, and fissure. Resulting complications may include anal stenosis, ectropion, or incontinence. Already there are several reports of leaks and sepsis following the new stapling procedures for hemorrhoids. 15 , 16 , 17 , 18 The surgical correction of these complications is specifically addressed in Chapters 6, 7, and 33.
Urologic surgery can cause colorectal trauma. Percutaneous nephrostomy is ordinarily a safe and reliable procedure for decompressing the urinary collecting system; however, LeRoy et al 19 reported on two perforations of the colon that occurred during nephrostomy. Perineal prostatectomy, suprapubic prostatectomy, or transurethral resection of the prostate can be associated with injury of the adjacent rectum. 20 , 21
During surgery in which electrocautery is used, explosions have occurred in the presence of combustible colonic gases, resulting in large perforations and deaths. 22 , 23 Both the hydrogen from a mannitol bowel preparation or unabsorbed carbohydrates and the methane sometimes naturally present within the colon are combustible.
Colorectal injury can occur with neurosurgical and orthopaedic operations. Inserting ventriculoperitoneal shunts in infants with hydrocephalus is a standard treatment to reduce intra-cerebral pressure, but on rare occasions the bowel has been perforated during placement of the peritoneal limb. 7 , 24 , 25 During internal fixation of a hip fracture, there have been instances of nails being too deep, causing injury to the rectum. 26
Colorectal stents have been employed in obstruction secondary to carcinoma for either palliation or as a bridge to surgery. Khot et al 27 reviewed the literature and found 29 case series covering 598 stent insertion attempts. Perforation occurred in 22 (4%) cases.
Endoscopically Induced Trauma
Injury associated with endoscopic procedures is uncommon. 28 Proctosigmoidoscopic perforation usually occurs near the peritoneal reflection, and in most instances the tear is in diseased bowel, with a mortality rate greater than 25%. Perforation is also associated with biopsy or snare polypectomy and if it is below the 10-cm level from the anal verge infrequently causes serious complications. In other studies, the mortality rate was only 8% if operation for the perforation was performed within 6 hours, but if the delay between perforation and operation was greater than 12 hours, death ensued in 20% of cases. 29 The major complications of colonoscopy are hemorrhage and perforation, 30 , 31 , 32 which were discussed in Chapter 4.
Injury from Rectal Thermometer
Obtaining rectal temperature is a routine procedure. Rectal thermometers are well-known causes of perforation during the first few days of a newborn’s life. In 1965, Fonkalsrud and Clatworthy 33 reported on 10 accidental perforations of the intestine in infants. The authors pointed out that the distance between the anus and the peritoneal cul-de-sac over the rectosigmoid in newborns is less than 3 cm and that half the perforations occur at this low level. Horwitz and Bennett 34 reported on an outbreak of peritonitis in a neonatal nursery that was caused by a nurse perforating the rectum with a thermometer while taking rectal temperatures (▶ Fig. 34.2).
Perforation by Therapeutic Enema
Even procedures such as giving a simple enema are subject to human error. Usually, perforation results from insertion of the enema tip by an unskilled or careless attendant or during self-insertion. A spectrum of anorectal injuries can occur during insertion of an enema tip. 35 , 36 Perforation from enemas can be classified into five types: (1) anal perforation, (2) submucosal perforation, (3) extraperitoneal perforation, (4) intraperitoneal perforation, and (5) perforation into adjacent organs. The majority of rectal perforations from enema tips are on the anterior wall. Extraperitoneal perforation can cause abscess, fistula, or severe hemorrhage. Gayer et al 37 reported 14 rectal perforations secondary to cleansing enemas. Abdominal pain and fever were the common symptoms. All had computed tomography (CT) with the findings of extraluminal air in the perianal and perirectal fat. No leak was seen on any CT. The CT was of help, because the physician did not suspect the etiology. Ten were subjected to surgery, but 5 died. The four who were treated conservatively all died.
Installation of the wrong liquid, such as scalding water, can cause severe burns; the wrong solution, such as formaldehyde instead of paraldehyde, can cause sloughing and rectal bleeding.
Injury from Barium Enema
A variety of complications have been associated with barium enema studies. 38 Two of the most serious of these complications are mechanical perforation of the bowel, either intraperitoneally or extraperitoneally by direct penetration of the enema tip, and overinflation of the rectal balloon, causing pneumatic rupture of the rectum. 39 Other complications include the formation of barium granulomas within the rectal wall, necrotizing proctitis, and barium embolism.
Kiser et al 40 reported that one perforation of the colon occurred in 1,250 barium enemas administered at the Ellis Fischell State Cancer Center in Columbia, Missouri. Most perforations are ruptures through ulcers, neoplasms, diverticula, hernias, inflammatory bowel disease, or other areas of disease. Rosenklint et al 41 reported on six extraperitoneal perforations that occurred from barium extravasation during 20,000 barium enema examinations. Four of the six patients died, and the other two have permanent colostomies. None of the patients had disease in the colon or rectum. Obtaining tissue for a simple rectal biopsy weakens the bowel enough that a barium enema may complete a perforation. A 7-day wait allows sealing and helps protect against perforation. Biopsy specimens obtained through the rigid sigmoidoscope easily can be 5 mm in size; those taken through the colonoscope can be only 2 to 3 mm. 42 Thus, deeper biopsies afford greater risk to proceed to full-thickness perforation.
When small amounts of barium are injected submucosally, a simple barium granuloma results, which may be asymptomatic or cause pain. Sterile barium causes little inflammatory reaction when injected into the subcutaneous and retroperitoneal tissues, the wall of the rectum, or the peritoneal cavity. Several years later, it may present as isolated rectal nodules in a patient who has been asymptomatic. 43 , 44 Larger amounts of barium injected in the same manner can result in severe inflammatory reaction, abscess formation, or even necrotizing proctitis. Ultimately, retroperitoneal barium causes dense retroperitoneal fibrosis. Perforation above the peritoneal reflection results in intraperitoneal contamination by both barium and residual stool from the bowel. Even when perforation reaches into the free peritoneal cavity, the injury may not be suspected immediately because of the lack of symptoms suggesting that a free perforation has occurred. However, symptoms of peritoneal irritation occurring minutes or hours after the enema should be considered as possibly resulting from the barium enema study. During repeat abdominal radiograph, most of these cases show the presence of free air and/or evidence of barium outside the lumen of the bowel. Perforation also may be retroperitoneal.
Unlike the sometimes benign course of endoscopic biopsy perforation, the combination of barium and feces is a dreaded complication. 44 , 45 , 46 , 47 When barium is combined with significant bacterial contamination from the bowel, a massive, and often overwhelming, inflammatory response occurs. Sisel et al 48 experimented on rabbits, producing colonic rupture after a barium enema or an enema performed with a water-soluble contrast material. Without treatment, both types were uniformly fatal. Surgical repair of the rupture with concomitant peritoneal lavage resulted in only a 10% survival rate in animals with feces and barium contamination. Fifty percent of the animals with Gastrografin and feces contamination survived if surgery was performed promptly. Zheutlin et al 49 reported on a collected series of 53 patients in whom barium mixed with feces spilled into the peritoneal cavity. The mortality rate in this group was 51%. Nelson et al 50 reported a 100% mortality rate with this type of perforation. Based on these data, water-soluble contrast material is the preferred type for use in patients with suspected perforations, or suspected leaks in recent anastomoses.
Barium embolism is rare, but when it happens, a fatal outcome is likely. The pathophysiology begins with intravasation of barium into the veins of the rectum, resulting in pulmonary embolism and sudden death. 51 Not performing a barium enema on patients with acute inflammatory bowel disease or on patients who have had recent endoscopic procedures with biopsy or polypectomy will decrease the incidence of this rare occurrence.
A barium enema sometimes is used therapeutically to reduce intussusceptions in infants. Unfortunately, the hydrostatic force introduced into the colon perforated 6 of 1,000 colons in one series. 52
Obstetric Trauma
Cephalopelvic disproportion and the stretching of local anatomy that takes place during childbirth result in trauma to some degree in almost every vaginal delivery. 53 , 54 A deep laceration may occur in the perineum after parturition that involves not only the vagina, but also the perineal body, the rectum, and the anal canal, including the anal sphincter mechanism. An episiotomy during delivery will decrease the tendency for third-degree lacerations involving the anal sphincter. If the episiotomy is performed in the posterior midline of the vagina, harm to the sphincteric mechanism is more likely than if it is directed laterally. The size of the infant, the flexibility of the pelvic tissues, the parity of the patient, the weight of the patient, the skill of the obstetrician, and the decision whether or not to use instrumentation are factors that influence incidence of anorectal trauma during childbirth. 54
Precise repair of a third-degree tear is a necessary skill for those who practice obstetrics; a colorectal surgeon seldom is needed to repair such an injury on an emergency basis. Most repairs will heal uneventfully; however, if incontinence is a postdelivery problem, a secondary repair by sphincteroplasty is indicated. See Chapter 14 for details of repair.
Rectovaginal fistulas may also result from difficult parturition, and laceration. Pressure necrosis of the rectovaginal wall, forceps delivery, and midline episiotomies are often associated factors. See Chapter 15 for repair details.
Irradiation-Induced Proctitis
Irradiation of neoplasms of the pelvis may cause both immediate and delayed complications. Irradiation proctitis is an anticipated sequela after radiation of common neoplasms that originate from the uterus, ovary, bladder, prostate, anus, or rectum. Quan 55 reviewed 65 patients who underwent irradiation therapy for pelvic malignancy, 52 of whom had carcinoma of the cervix. Often, radiation damages both the bladder and the intestine simultaneously. The acute findings are edema, inflammation, erythema, and friability of the rectal mucosa, which may progress to ulceration or necrosis. 56 As the rectum heals, granulation tissue, fibrosis, and telangiectasia may result. Full rectal wall necrosis may develop, and in women a rectovaginal fistula may occur if necrosis is severe anteriorly. The radiation injury site may form a stricture as part of the healing phase. Microscopic examination of these tissues reveals underlying irradiation-induced endarteritis leading to tissue hypoxia, resulting in the above sequence of macroscopic events. Likewise, lymphatic channels are destroyed.
The onset of symptoms after radiotherapy varies from immediately to years after treatment, with rectal bleeding as the most common symptom. The anterior rectal wall usually demonstrates the most severe radiation-induced changes. The extent of damage depends on the size of the area treated, the total dose delivered, overall treatment time, and fractionation of the dosage. Individual techniques affect the outcome as well.
Mild proctitis usually requires no treatment. Sherman et al 57 reported good results from using corticosteroid enemas in the management of patients with acute and chronic irradiation proctitis. Henriksson et al 58 performed a double-blind, placebo-controlled trial using oral sucralfate, an aluminum hydroxide complex of sulfonated sucrose, for 2 weeks after onset of radiation and continued for 6 weeks. Bowel movements were significantly improved with treatment and fewer patients required antidiarrheal medications. Colonic obstruction caused by irradiation colitis or proctitis is rare, but if such complications do occur, colostomy is indicated. 59 When bleeding becomes incessant oozing from the injured surface, the laser, the argon plasma coagulator, or topical formalin have been effectively used over the entire surface to stop the hemorrhage. 60 , 61 , 62
van Nagell et al 63 reported on rectal injury in a series of patients with uterine carcinoma requiring irradiation. An increasing incidence of proctitis was noted in patients who had preexisting hypertensive vascular disease or diabetes mellitus. No rectal injuries occurred when the total dose to the rectum was less than 4,000 rad. The authors also stressed that severe proctitis often preceded bladder or other bowel complications. Fractionation of the remaining irradiation dosage over longer periods of time prevented much of the later irradiation changes. A 2-week rest period in the middle of the treatment course using topical steroids and cleansing enemas lessened acute injury symptoms.
34.2.4 Ingested Foreign Bodies
Perforation of the gastrointestinal tract from ingestion of foreign bodies is rare. Natural foods, such as pits, thorns, seeds, or soft bones, undergo significant digestion by the time they reach the colon. However, hard particulate matter, such as chicken and other animal bones, toothpicks, portions of glass, shells, or other sharp objects, may pass through the intestinal tract into the colon and cause injury to the rectum and anus. Infants, children, and mentally deranged adults are at higher risk because of objects they may put in their mouths and subsequently swallow. Of course, anyone could inadvertently swallow an object that enters the mouth; parts of dentures sometimes break off and are swallowed. To prevent such injuries, potentially dangerous objects should be kept out of the reach of infants, children, and mentally incompetent adults.
The complications secondary to ingested foreign bodies include perforation, hemorrhage, abscess formation, bowel obstruction, and death. 64 , 65 Less than 1% of foreign bodies that become entrapped cause perforation. Observation and expeditious gastrointestinal endoscopy are the two best forms of therapy. The physician must decide if it is preferable to watch the foreign body pass spontaneously or to perform endoscopic removal within 1 or 2 hours of ingestion. Surgical intervention is required for the 1% of patients who experience perforation or obstruction because of these objects. Seventy-five percent of gastrointestinal perforations occur at the ileocecal valve and the appendix. Sequential abdominal roentgenograms show that most objects exit the gastrointestinal tract within 1 week. Failure of the foreign body to exit is another indication for surgery. Close observation for the development of the rare complication is a safe approach. Early endoscopic removal of selected easily reached objects may be an acceptable approach.
Illegal drug traffic has led drug dealers to develop multiple ways to import their product secretly. A health hazard is created if a packet of a pure narcotic is placed into a body orifice (▶ Fig. 34.3). If swallowed, large packets of the drug may obstruct the gastrointestinal tract. During the attempt to remove them endoscopically or surgically, special care should be exercised to avoid rupturing the packets because if they open in the gut, the patient may suffer overdose.
34.2.5 Foreign Bodies and Sexual Trauma
An amazing variety of objects have been inserted into the rectum and have become entrapped above the anal sphincter musculature. Practically any object that can be contemplated as fitting into the rectum has been used for sexual stimulation. Some of the more ‘‘fashionable’’ rectal foreign bodies include vibrators, plastic phalluses, cucumbers, baby powder cans, balls, bottles of all shapes and sizes, glasses, flashlight batteries, flashlights, test tubes, screwdrivers, ballpoint pens, paperweights, and thermometers (▶ Fig. 34.4). The entrapment of the object causes the patient not only social embarrassment, but also significant physical pain.
Serious injuries to the rectum, rectosigmoid, and other intraperitoneal structures can occur. Death resulting from placement of foreign bodies in the rectum has been reported by numerous authors. 66 , 67 , 68 , 69 , 70 Eftaiha et al 69 found it useful to classify the level of entrapment of the foreign body. Most objects lying in the rectum at the low or middle level (up to 10 cm) can be removed transanally, but celiotomy may be needed to remove objects that become lodged in the upper rectum or lower sigmoid.
Sohn et al, 70 Beall and DeBakey, 71 and Barone et al 67 have reported independently on rectosigmoid perforation caused by insertion of foreign bodies. Such injury may be incurred by the patient in an attempt at autoeroticism or may be delivered by a sexual partner or during a criminal assault. Splitting of the rectosigmoid results in peritoneal contamination and peritonitis. Presenting with an acute abdomen, the patient may hide the history of sexual or assaultive action. Plain radiographs should be part of the emergency evaluation when such injuries are reported or suspected. Anteroposterior and lateral abdominal and pelvic views should be used to determine the type, number, and location of the foreign bodies; however, radiolucent objects may not be visualized.
34.2.6 Sexual Assault
Sexual assault is a common violent crime. Over 300,000 adults over the age of 12 years report being assaulted each year. 72 The assault may be criminal and intended to harm, or it may be the result of a vigorous sexual act that was intended to be enjoyed by both partners. Whatever the motive, sexual assault can cause significant injury to the extraperitoneal or intraperitoneal rectum or rectosigmoid.
Sohn et al 70 reported on an act termed ‘‘fist fornication’’ or ‘‘fisting’’ in 11 patients over a 4-year interval. Fist fornicators force a closed clenched fist through the intact anus into the rectum for sexual gratification. The rectum or sigmoid colon was the site of injury. Six patients had mucosal lacerations in the rectum that bled, but no sphincteric laceration was noted. Only simple suturing of the mucosal laceration was necessary for these patients. Four patients developed an acute abdomen requiring celiotomy, resection, and a Hartmann pouch. One patient had complete anal sphincteric incontinence from severe sphincteric laceration.
34.2.7 Child Abuse
Anorectal trauma in children is rare, but when found, it is usually due to abuse. 73 Sexually abused boys experience anorectal trauma in 7 to 16% of cases of this type of abuse, and they are abused at a younger age than girls. Anal sexual acts account for injury in 54.5% of abused boys. Only 3.7% of abused girls suffer anal injury. 74
Black et al 74 reported on 617 rape victims. Twenty-four percent were younger than 16 years, and 33% had anal trauma. The medical community must be alert to recognize these criminal acts and report them to prevent more physical and emotional morbidity to the child and his or her siblings. 75 The examiner should keep accurate records as legal evidence, and a one-on-one interview should take place.
Signs of trauma around the anus or elsewhere on the body should be noted. Anal trauma may be the only visible trauma site because no resistance is offered if the assailant is known to the victim. Sperm and acid phosphatase should be sought in any material retrieved. 76 Venereal disease testing should be performed if the circumstances make the physician suspicious.
Sedation may be necessary to perform an anal or rectal examination if there is pain or great distress. Obtaining abdominal films to look for free air is warranted if the abdomen is tender.
34.2.8 Unusual Perforations
Hard impacted stool sometimes perforates the rectum, or the rectosigmoid colon by ischemic necrosis, a condition termed ‘‘stercoral perforation.’’ The blood supply to a site in the colorectum is impaired by pressure of the hard bolus of stool pressed against an unyielding organ. 77 , 78
Rarely, spontaneous perforation will occur in the rectosigmoid or cecum from either distention or spasm. The possibility of perforation is well recognized in preexisting disease such as inflammatory bowel disease, diverticulitis, or carcinoma, but sometimes spontaneous perforation occurs in the absence of pathologic disease. 79
Cain et al 80 reported on five bizarre cases of trauma resulting from children sitting on a swimming pool drain. Suction caused perforation of the rectosigmoid, followed by small bowel evisceration and loss of much small bowel.
Electrocution may immediately or subsequently perforate the bowel but most often the colon. If celiotomy is performed as part of therapy, careful exploration for burned bowel is mandatory. 81 During sexual antics, people have directed compressed air toward and into the anus so that a hole is blown in the proximal colon. 82 Thermal injury of the gastrointestinal tract is rare, but there has been a report of instillation of hot water into a stoma, causing a mucosal burn that subsequently formed a stenosis. 83 Improper insertion of a stomal irrigation tube or forceful insertion of a catheter to empty a continent reservoir pouch (Kock’s pouch) may cause perforation, which may be unrecognized initially since little or no pain may occur. The design of cone tips for ostomy irrigation prevents deep insertion and bowel injury.
34.3 Management
Progress continues in the management of the traumatized patient. The Advanced Trauma Life Support (ATLS) courses promote a systematic approach, which is divided into four phases: primary survey, resuscitation, secondary survey, and definitive care (▶ Table 34.2). 84 These principles can be applied to both the military combat situation and civilian trauma.
The primary survey comprises rapid clinical diagnosis of life-threatening conditions such as an occluded airway, inadequate respirations, cardiac failure, arrhythmias, and hemorrhage. The resuscitation phase involves using procedures immediately to save lives. Chest tube placement, pericardiocentesis, intubation of the airway, control of obvious severe hemorrhage, and placement of lines must be performed without delay before time-consuming laboratory examinations are begun.
During the secondary survey, the colorectal injuries are identified, leading to the final phase, definitive care. These two phases are dealt with in depth in the following sections. Without the secondary survey, more subtle perineal and rectal wounds may be overlooked, and delay in diagnosis and late treatment lead to increased morbidity and mortality. 85
34.3.1 Diagnosis of Trauma (Secondary Survey Phase)
History
An alert and cooperative patient may be questioned about the circumstances of the trauma. However, the patient with a head injury or multiple trauma may be unable to communicate. At times, the trauma is obvious, but a history from someone at the scene (if available) may prove helpful. The observer—a paramedic, ambulance driver, litter bearer, helicopter pilot, corpsman, or a relative—may be able to relate important details of the trauma, specifically the type of trauma, the wounding agent, and the interval of time that has elapsed. For example, knowing whether the injury was caused by an ice pick or a bayonet, a low-velocity 22-caliber pistol or a high-velocity M16 rifle, a fall from 5 or 50 feet, or a fall from a golf cart or a motorcycle traveling at high speed, or whether it occurred 20 minutes or 20 hours previously would aid in making the decisions about appropriate diagnostic tests and the extent of treatment.
Patients with isolated anorectal trauma may complain of perineal, anorectal, or abdominal pain. Usually pain begins precisely at the time of injury. Less often, the pain may be delayed in a patient with small extraperitoneal perforations of the rectum or after a foreign body cannot be removed from the rectum. Dull lower abdominal pain may be the only manifestation of an upper rectal or rectosigmoid tear with perforation. Rectal bleeding denotes rectal trauma, and its presence warrants a thorough examination. 67 , 69 , 86 Wounds of the colon and rectum may be lethal if not recognized promptly. The patient who is hemodynamically stable may deteriorate 1 or 2 days later if sepsis results from an overlooked rectal or colonic injury, which may be recognized only when such a patient becomes septic and hypotensive. Crepitus and soft-tissue manifestations may denote gas gangrene. When sepsis is not recognized until it is in its late stages, patient survival is less likely.
Physical Examination
During resuscitation, a nasogastric tube and transurethral catheter are inserted as part of the ‘‘place a tube in every orifice’’ dictum. Blood in the nasogastric aspirate directs the examiner to look for intra-abdominal injury. Blood in the urine calls attention to the retroperitoneum and the pelvis. The bladder may be penetrated via the rectum in patients with impalement or other penetrating injuries, so examination of the urine is imperative. 87 In the patient with multiple trauma, anorectal and other pelvic organ injuries may be overlooked because of preoccupation of the resuscitation team with cranial and thoracic injury or massive hemorrhage. Thus, looking at the back and perineum should be part of the routine assessment. Furthermore, a wound below the nipple line on the chest or just below the scapular tips represents abdominal entry in 15% of stab wounds and 50% of gunshot wounds. 88 Abdominal injury is considered with any thoracoabdominal penetration. This area extends from the nipples to the inguinal ligaments and from the scapular tips to the buttocks.
Multiple trauma from high-speed vehicle injuries or major blunt injuries on the battleground is a prime example of a situation in which less obvious wounds may be overlooked. A conscious patient can indicate whether or not abdominal pain is present. Thorough examination includes inspection of the abdominal wall and palpation for crepitus and hematoma formation. In a patient with penetrating trauma, both the entry and exit wounds should be sought. The surmised track of the penetration provides clues as to organs that may be injured and directs the exploration at laparotomy.
Anal examination can be performed with the patient in the supine or lateral position. It should be noted whether the anus is in its normal position, for blunt trauma sometimes detaches it from muscular sling. 89 Even with no observable evidence of perineal trauma, a digital examination should be performed in the usual fashion. In a series by Mangiante et al, 90 blood was evident on rectal examination in 80% of patients with rectal gunshot wounds. A loose sphincteric tone might suggest a central nervous system injury. Specifically, in patients with blunt trauma the levator attachments should be palpated to verify that they are intact. Hematoma may create bogginess around the prostate, or the prostate may be dislocated by severe blunt trauma. In female patients, a vaginal examination should be performed to be certain that the injury does not involve the genital tract. If rectal injury is suspected because bright red blood is present, anoscopy and sigmoidoscopy should be performed to attempt visualization of the lower part of the rectum and anal canal. Positioning of the multiply traumatized patient is difficult, but before operation it is necessary to know whether and where the rectum is injured. Irrigation and suction may allow clearance of stool and blood to at least the peritoneal reflection level (15 cm). The injured site can be specifically identified in 91% of rectal injuries. 84 The insufflation of large volumes of air should be avoided when the rectum is filled with blood, because stool and contaminated blood can be forced into the peritoneal cavity or extraperitoneal soft tissues if a perforation is present.
Pelvic and rectal trauma also should direct the examiner to evaluate for neurologic integrity. The sciatic nerve is at risk, and appropriate neurologic assessment should be performed. Impotence may be a neurologic sequela of pelvic trauma that is not noted until later. 4
Related posts:
36 Unexpected Intraoperative Findings and Complex Preoperative Decisions
37 Miscellaneous Conditions of the Colon and Rectum
35 Colorectal Complications of Colonic Disease and Complication Management
Diagnosis of Colorectal and Anal Disorders
19 Benign Neoplasms of the Colon and Rectum
32 Intestinal Stomas
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