2 cases of colorectal trauma - one due to blunt trauma abdomen and one due to penetrating trauma to rectum are discussed in the light of colorectal trauma

1. COLORECTAL TRAUMA
 DR.ARKAPROVO ROY
 ASSOCIATE PROFESSOR,
 DR. DIBYASREE PAUL
 2ND YEAR RESIDENT
 DEPARTMENT OF SURGERY,
MEDICAL COLLEGE, KOLKATA

2. • an event, either witnessed or experienced, that represents a
fundamental threat to an individual’s physical safety and survival
• More than an event- it’s an EXPERIENCE, it has an EFFECT

3. Case:1
 45 year old male
 H/o blunt trauma to lower abdomen by a running vehicle
 Severe lower abdominal pain radiating to whole abdomen
 Inability to move both lower limbs

4. PRIMARY SURVEY & RESUSCITATION
 Conscious, alert, restless, GCS -15/15
 Pulse-120/minute, low volume; BP- 110/74 mm of Hg
 Pallor +
 Chest – B/L clear, SpO2- 97%
 Per abdomen- tense, generalised guarding, distended, diffuse
tenderness+, IPS-
 P/R- blood staining+, prostate palpable
 Urine- not passed
 Bruise over left iliac fossa, abrasions over pelvis and both
lower limbs
 Pelvic tenderness+, restriction of movement of B/L L/L

5.  Airway patency checked, Moist O2 inhalation
 Cervical spine support
 Two large bore I.V. cannula → 2 litres of crystalloid
solution infused in jet
• Ryle’s tube suction
• Foley’s catheterisation
• Blood requisition

6. Straight X-Ray Abdomen and
Pelvis-
 Chink of free gas underdiaphragm
 Ground glass appearance of
abdomen.
 Fracture of bilateral pubic rami,
 Fracture of left sacro-iliac joint *
*
*

7. eFAST - Fluid in peri-gall bladder area
CECT Whole Abdomen -

8. X-Ray Cervical Spine and Chest X-Ray - WNL
Blood Parameters -
Hb- 8 gm%
TLC- 12,800 /cu mm

9. URGENT EXPLORATORY LAPAROTOMY

10. Lacerated Perforation
with Devascularisation of
a portion of Sigmoid
Colon

11. Thorough Peritoneal Lavage with 5 litres of fluid
Resection of devascularised portion
Hartmann’s procedure
Drain placed in pelvis
Abdomen closed

12. POST-OPERATIVE PERIOD
 Uneventful recovery
 Stoma started functioning on POD 2
 Pelvic drain output ~50-60 ml/day(sero-sanguinous),
gradually reduced, omitted on POD 5
 No wound complications
 Orthopaedician’s opinion taken – left sided Upper Tibial
Skin Traction applied
 Discharged on POD 8

13. FOLLOW UP
 Surgery and Orthopaedics OPDs
 Rehabilitation
 A year later, the patient walked into the Surgery OPD with
a wish to have the colostomy reversed

14. CLINICAL EXAMINATION
 Stoma – functional, no prolapse or retraction
 Parastomal hernia
 Anal tone- high

15. INVESTIGATIONS
 CECT W/A - Parastomal herniation of small bowel loops
at colostomy site; no obvious leakage of contrast from
rectal stump; malunited fractures of left ilium and bilateral
pubic rami

16. • Distal Cologram

17. REVERSAL OF HARTMANN’S
PROCEDURE
Abdomen opened → stoma dismantled →
adhesiolysis done → distal stump identified →
margin refreshening done → end to end hand
sewn anastomosis done → parastomal hernia
repaired → abdomen closed.

18. POST-OPERATIVE PERIOD
 Patient recovered well
 Normal bowel habit resumed and oral diet
started on POD 3
 Discharged in a stable condition on POD 6

19. Case:2
 25 years old male
 Presented in ER with features of peritonitis
 X-ray – free gas under diaphragm
 Patient was in shock – resuscitated
 Patient did not give any history of trauma
 CECT abdomen – no intra-abdominal
injury/pathology
 Taken up for exploratory laparotomy
 Findings – beyond expectation- a small perforation at
lower part of rectum

20.  Perforation was repaired
 Sigmoid colostomy done
 Next day – on repeated enquiry – history of
instrumentation per rectum revealed
 Patient was discharged on 8th POD
 Patient lost to follow up

21. DISCUSSION

22. BLUNT ABDOMINAL TRAUMA
 Only 1% incidence of hollow viscus injury
 0.3% incidence of colo-rectal injury
MECHANISM:-
Direct rapid compression of bowel between the
blunt object and the vertebral column or pelvis →
tear or laceration (most common)
Sudden deceleration producing bowel-
mesenteric disruption and subsequent
devascularisation

23. MECHANISM :-
Direct rapid compression of bowel between the
blunt object and the vertebral column or pelvis
→ tear or laceration (most common)
Sudden deceleration producing bowel-
mesenteric disruption and subsequent
devascularisation

24. DIAGNOSIS
 Colorectal injury associated with blunt abdominal
trauma is especially treacherous and is uncommon
enough to worry even the most experienced surgeon
 Bleeding per rectum, features of peritonitis
 Proper inspection of perineum
 Per rectal examintion – important

25.  Penetrating trauma is the most common cause of
rectal trauma - accounting for at least 95% of rectal
injuries
 Iatrogenic injuries sometimes occur during diagnostic
procedures, such as endoscopy or barium enema.
 Iatrogenic perforations during pelvic operations such
as radical prostatectomy, prostatic biopsy, or
gynecologic procedures are uncommon, and their true
incidence is unknown. Perforation of the rectum
during internal fixation of a hip fracture has been
reported.

26.  Presence of urethral injuries or pelvic fractures should
arouse suspicion
 eFAST; Straight X-ray abdomen; CECT W/A and
Pelvis
 Sigmoidoscopy- preferred method, but often not
available
 Diagnosis is often made only at the time of
Laparotomy!

27. CLASSIFICATION OF COLORECTAL INJURIES
 AAST classification (AAST- The American
Association for the Surgery of Trauma)
 different for Colonic and Recto-sigmoid
injuries
 5 grades – I to V
 Grades IV and V are different for colonic and
recto-sigmoid injuries

28. AAST CLASSIFICATION OF INJURIES
COLON RECTO-SIGMOID
I - Contusion or Hematoma; partial
thickness Laceration
II - Small (<50% of circumference)
Laceration
III - Large (>50% of circumference)
Laceration
IV - Transection
V - Transection with tissue loss;
Devascularised segment
I - Contusion or Hematoma; partial-
thickness Laceration
II - Small (<50% of circumference)
Laceration
III - Large (>50% of circumference)
Laceration
IV - Full-thickness Laceration with
Perineal extension
V - Devascularised segment

29. MANAGEMENT OF COLO-RECTAL INJURIES
- according to Grade
Grades I or II : evaluate hematomas; close injuries primarily
Grade III : risk factors absent- close injuries primarily
risk factors present- treat like grade IV
Grade IV : colostomy or repair with proximal diversion;
for large grade IV cecal and right colon injuries-
resection and ileostomy
Grade V : colectomy and colostomy