BOWEL INJURY

F. Al-Mashat
Dep of Surgery
Kauh

TYPES :
1. Blunt
2. Penetrating: Stab, Gunshot
3. Operative

Mechanism:
1. Crushing: Compression
2. Shearing: Sudden Deceleration
3. Bursting: Abdominal Pressure

Causes:
1.
2.
3.
4.

Motor Vehicle: 75%

High Speed Vehicular
Fall from Heights
Seat Belt

Unrecognized : frequent
cause of preventable death

Symptoms and Signs:

Unreliable
Often1.Masked:
Head Injury
2. Major Fractures
3. Alcohol

Signs:
1.
2.
3.

4.
5.
6.
7.

Echymosis & Abrasions

Tender ribs
Peritonitis
a. Tenderness and Guarding : 75%
b. Rebound and Rigidity: 28%
Pelvic Fracture
DRE
Urethral blood
Tests, Perineum , Vagina

Investigations:
1.

CBC

2.

U&Es

3.

LFTs

4.

Amylase

5.

Clotting Profile

6.

ABG

7.

Urinalysis

8.

CXR : A-P

9.

KUB

10. DPL : 95 % Accurate

11. Contrast
12. CT
13. U/S
14. IVU /Contrast CT
15. Double Contrast CT
16. Aortography : Embolization

Small Bowel Injuries

The most frequently involved
in penetrating (90%)
The 3rd in blunt
Penetrating: Gunshot: > 80%
Stab: 30%
Occurs in 5-15% of blunt

Penetrating:
1. History
2. Examination

Not Sufficient

Blunt :
High Index of Suspicion
Physical signs: Non Specific
1. associated injury
2. Alcohol
3. Neutral PH & bacteria minimal
inflammation
Delay

Laparotomy:
1. Four: Quadrant Survey
2. Control Enteric Contamination
3. Exploration ??

1. Haematoma & Laceration : Lembent,

Transverse
2. Mural haematoma <1cm: Inversion
3. Small perforation : Close transverse
4. Adjacent perforations:divide, close
transverse

5. Resection: A. Enterroraphy diameter

B. Multiple injuries
C. Devascularized
Single, Double, Stapler
High Bacteria in terminal S. Bowel: repair in a distal
to proximal fashion

Mesentry
Haematoma & Lacerations: >2cm, expanding, uncontained, near
root mesentomy

Lesser Sac
Proximal Control
Root Mesentry
Mattox

Evacuation

Ligation/SMA repair saphenous vein/ graft

Second look 24H

Injury distal SMA

Bowel Resection
+
Enteroenterostomy

Colon Injuries
Majority: Penetrating
Mortality: < 5%

Risk Factors :
Shock: Sustained hypotension
mortality significantly
Duration from injury to surgery
morbidity not up to 12 H
Faecal Contamination
Quantity ?
Major: > one Quadrant
Class II & III: Major -- Sepsis

 Associated injuries:
Class I, II, & III: > 2 organs -- Sepsis
PATI > 25, FSS > 25 , Flint >11
Class I: Greater # of associated organ

injury

Mortality & Sepsis

But : NO Contraindication to 1 repair of non
destructive

 Anatomic Location:
Class I , II , & III: NO Significant
difference in complications
between right & Left for 1 repair
Blood Transfusion:
4 units critical
> 4 morbidity

Flint Severity Score:

Isolated colon injury, minimal
contamination, no shock, minimal delay.
Perforation, lacerations, moderate
contamination
Severe tissue loss, devascularization,
heavy contamination

Methods of Repair:
Primary Repair: The Standard
Safe Right & Left (I, II, III)
Prospective
Colostomy : Safe, conservative, acceptable
Closure: 10% Morbidity
W. Infection
I. Obstruction
Fistula
Incisional Hernia

Exteriorization:
a. Healing: 5 10 days
b. Colostomy
Abandoned: Failure &
Complications

1. Drains : NO
W. Infection
Sepsis
2. Peritoneal Irrigation
3. Wound:
Definition
a: Open: Significant
Contamination
b: Delayed primary closure: 7 days

Prophylactic Antibiotics
1. Class I & II: Single Pre - OP
aerobic & Anaerobic
2.Class I & II: 24 H hollow
viscus
3. Shock : dose 2 3 folds

Type: Single = Combination

Aminoglycocide + Clindamycin
or
Aminoglycocide + metroindazole
Duration:
Class I & II: 24 H
Optimal Dose: Fluid Shift
High Dose
Aminoglycocide: 3mg/Kg Loading

Recommendations:
1. Class I & II:
Non Destructive: 1 repair
(Peritonitis )
2. Destructive: 1 repair if:
1 Haemodynamic stable
2 Shock
3 Significant underlying disease
4 Minimal associated injuries
5 - Peritonitis

3. Complex: Shock + substantial

contamination or trauma to other
organs
Resection + proximal diversion
Colostomy/ Ileostomy
Mucous Fistula
Hartmanns

1. Blood Volume

Pregnancy

2. Lax Abdominal Muscles

3. Enlarged Uterus
4. Pulse, BP, Haematocril, WBC, HCO3

5. Compressed Uterus: peripheral

venous Pressure

6. GIT motility

Diagnostic Procedures:

Same
1. Limit Radiation/ Shielding
2. Avoid Anaesthesia
3. DPL: Open
4. IVU: Single exposure
5. DIC
6. Early Mobilization of fracture

Special
1. Fetal Heart: Doppler (12w)
2. U/S
3. Placental Separation: Fetal
cells in maternal blood

Treatment: Vigilant
Mother must be saved first
Options: as non pregnant
1. Uterine Injuries
2. Termination

In Majority: non injured uterus

V. Delivery at term
Injured uterus repair

Indicators for C Section :

1. Uterine rupture
2. Worseness fetal distress
3. Exposure of rectum, great vessels
4. Maternal Thoracolumbar spine
fracture
5. DIC
6. MOF

Maternal death

Immediate Delivery
Poor infant survival if maternal
death >15 minutes

THANK YOU