bowel injury
DESCRIPTION
BOWEL INJURY. F. Al-Mashat Dep of Surgery Kauh. TYPES :. 1. Blunt 2. Penetrating: Stab, Gunshot 3. Operative. Mechanism:. Crushing: Compression Shearing: Sudden Deceleration Bursting: Abdominal Pressure. Causes:. Motor – Vehicle: 75% High – Speed Vehicular - PowerPoint PPT PresentationTRANSCRIPT
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F. Al-Mashat
Dep of Surgery
Kauh
BOWEL INJURY
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TYPES :
1. Blunt
2. Penetrating: Stab, Gunshot
3. Operative
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Mechanism:
1. Crushing: Compression 2. Shearing: Sudden Deceleration 3. Bursting: Abdominal Pressure
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Causes:
1. Motor – Vehicle: 75%
2. High – Speed Vehicular
3. Fall from Heights
4. Seat Belt
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Unrecognized : frequent cause of preventable death
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Symptoms and Signs:
Unreliable
Often Masked:1. Head Injury 2. Major Fractures3. Alcohol
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Signs:
1. Echymosis & Abrasions 2. Tender ribs
3. Peritonitis
a. Tenderness and Guarding : 75%
b. Rebound and Rigidity: 28%
4. Pelvic Fracture
5. DRE
6. Urethral blood
7. Tests, Perineum , Vagina
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Investigations:1. CBC
2. U&E’s
3. LFT’s
4. Amylase
5. Clotting Profile
6. ABG
7. Urinalysis
8. CXR : A-P
9. KUB
10. DPL : 95 % Accurate
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11. Contrast
12. CT
13. U/S
14. IVU /Contrast CT
15. Double – Contrast CT
16. Aortography : Embolization
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The most frequently involved in penetrating (90%)
The 3rd in blunt
Penetrating: Gunshot: > 80%
Stab: 30%
Occurs in 5-15% of blunt
Small Bowel Injuries
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Penetrating:
1. History 2. Examination
Not Sufficient
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Blunt :“High Index of Suspicion”
Physical signs: Non Specific 1. associated injury2. Alcohol 3. Neutral PH & bacteria – minimal
inflammation
Delay
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Laparotomy: 1. Four: Quadrant Survey
2. Control Enteric Contamination
3. Exploration ??
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1. Haematoma & Laceration : Lembent, Transverse
2. Mural haematoma <1cm: Inversion
3. Small perforation : Close transverse
4. Adjacent perforations:divide, close transverse
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5. Resection: A. Enterroraphy ½ diameter
B. Multiple injuries
C. Devascularized
Single, Double, Stapler
High Bacteria in terminal S. Bowel: repair in a distal to proximal fashion
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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
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Injury distal SMA
Bowel Resection +
Enteroenterostomy
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Colon Injuries
• Majority: Penetrating
• Mortality: < 5%
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Risk Factors :
• Shock: Sustained hypotensionmortality significantly
• Duration from injury to surgery morbidity not up to 12 H
• Faecal Contamination Quantity ? Major: > one Quadrant Class II & III: Major -- Sepsis
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• Associated injuries:Class I, II, & III: > 2 organs -- Sepsis PATI > 25, FSS > 25 , Flint >11Class I: Greater # of associated organ
injury
Mortality & Sepsis
But : NO Contraindication to 1º repair of non destructive
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• Anatomic Location: – Class I , II , & III: NO Significant
difference in complications between right & Left for 1º repair
• Blood Transfusion: 4 units critical > 4 → ↑ morbidity
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Flint Severity Score:
• Isolated colon injury, minimal contamination, no shock, minimal delay.
• Perforation, lacerations, moderate contamination
• Severe tissue loss, devascularization, heavy contamination
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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
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Exteriorization:
a. Healing: 5 – 10 days
b. Colostomy
Abandoned: Failure & Complications
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1. Drains : NO W. Infection Sepsis
2. Peritoneal Irrigation3. Wound:
Definitiona: Open: Significant
Contamination b: Delayed primary closure: 7 days
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1. Class I & II: Single Pre - OP
aerobic & Anaerobic
2.Class I & II: 24 H hollow viscus
3. Shock : dose 2 – 3 folds
Prophylactic Antibiotics
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Type: Single = Combination Aminoglycocide + Clindamycin
orAminoglycocide + metroindazole
Duration:Class I & II: 24 H
Optimal Dose: Fluid Shift High Dose Aminoglycocide: 3mg/Kg
Loading
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Recommendations:
1. Class I & II: Non Destructive: 1º repair (Peritonitis º)
2. Destructive: 1º repair if:1 – Haemodynamic stable 2 – Shock °3 – Significant underlying disease º4 – Minimal associated injuries 5 - Peritonitis º
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3. Complex: Shock + substantial contamination or trauma to other organs
Resection + proximal diversion
Colostomy/ Ileostomy
Mucous Fistula
Hartmann’s
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Pregnancy
1. Blood Volume 2. Lax Abdominal Muscles
3. Enlarged Uterus
4. Pulse, BP, Haematocril, WBC, HCO3
5. Compressed Uterus: peripheral venous Pressure
6. GIT motility
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Diagnostic Procedures: Same
1. Limit Radiation/ Shielding
2. Avoid Anaesthesia
3. DPL: Open
4. IVU: Single exposure
5. DIC
6. Early Mobilization of fracture
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Special
1. Fetal Heart: Doppler (12w)2. U/S3. Placental Separation: Fetal cells in maternal blood
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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
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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
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Maternal death
Immediate Delivery
Poor infant survival if maternal death >15 minutes
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