The document discusses colorectal trauma management with detailed case studies illustrating blunt abdominal injuries, their diagnosis, surgical interventions, and post-operative care. It highlights the low incidence of colorectal injuries in blunt trauma, classifies such injuries according to the AAST criteria, and outlines management strategies based on injury grades. Two specific cases demonstrate the intricacies of diagnosis and treatment, emphasizing the potential complexities of colorectal injuries in trauma patients.

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