July 7, 2009 | In: TRAUMA
RECTAL TRAUMA
9. How do rectal injuries occur?
Show answer
Similar to colon injuries, most rectal injuries result from penetrating trauma. Blunt pelvic fractures should be assessed with a strong suspicion for rectal (and urethral) injury.
10. How are rectal injuries diagnosed?
Show answer
A thorough examination is crucial, and the diagnosis is suggested by the course of the projectiles and the presence of blood on digital rectal examination. If rectal trauma is suspected, the patient should undergo proctoscopy to look for hematomas, contusions, lacerations, or gross blood. If the diagnosis is in question, radiographs with soluble-contrast enemas should be performed.
11. How are patients with intraperitoneal rectal injuries treated differently from those with
extraperitoneal injuries?
Show answer
The portion of the rectum proximal to the peritoneal reflection is called the intraperitoneal segment. Injuries of this portion are treated similar to colonic injuries.
12. What are the four basic principles for managing simple extraperitoneal rectal injuries?
Show answer
1. Diversion: either a loop or an end-sigmoid colostomy is appropriate.
2. Drainage: a retroanal incision should be used to place Penrose or closed-suction drains near the perforation site.
3. Repair: appropriate, when possible
4. Washout: irrigation of the distal rectum with isotonic solution until the effluent is clear. The role of washout remains controversial, but it may benefit patients whose rectum is full of feces.
13. How are complex extraperitoneal rectal injuries managed?
Show answer
In patients with massive pelvic trauma and an associated rectal injury, an abdominoperineal resection may be required for adequate debridement and hemostasis. An abdominoperineal resection is also required in rare instances in which anal sphincters have been destroyed.
14. What complications are associated with rectal trauma and its treatment?
Show answer
They are similar to those in colonic injuries. In addition, pelvic osteomyelitis may occur. In this case, debridement may be necessary, and culture-specific intravenous antibiotics should be administered for 2-3 months.
15. What is the role of antibiotics in colorectal trauma?
Show answer
Antibiotics are important. They should be initiated preoperatively (you need a good blood level at the time you make your incision) and ended quickly (12-24 hours postoperatively). Broad-spectrum, combination therapy is superior to single-agent therapy.
References
BIBLIOGRAPHY
1. Berne J, Velmahos G, Chan LS, et al: The high morbidity of colostomy closure after trauma: Further support for the primary repair of colon injuries. Surgery 123:157-164, 1998. Medline Similar articles
2. Burch J, Franciose R, Moore E: Trauma. In Schwartz S (ed): Principles of Surgery, 8th ed. New York, McGraw-Hill, 1999, pp 155-221.
3. Demetriades D, Murray J, Chan LS, et al: Handsewn versus stapled anastomosis in penetrating colon injuries requiring resection: A multicenter study. J Trauma 52:117-121, 2002.
4. Demetriades D, Murray J, Chan L, et al: Penetrating colon injuries requiring resection: Diversion or primary anastomosis? An AAST prospective multicenter study. J Trauma 50:765-775, 2001. Similar articles Full article
5. Velmahos G, Vassiliu P, Demetriades D, et al: Wound management after colon injury: Open or closed? A prospective randomized trial. Am Surg 68:795-801, 2002. Medline Similar articles
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