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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
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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 • Fall from Heights • Seat Belt
Symptoms and Signs:UnreliableOften Masked: 1. Head Injury 2. Major Fractures 3. Alcohol
Signs: • Echymosis & Abrasions • Tender ribs • Peritonitis • Tenderness and Guarding : 75% • Rebound and Rigidity: 28% • Pelvic Fracture • DRE • Urethral blood • Tests, Perineum , Vagina
Investigations: • CBC • U&E’s • LFT’s • Amylase • Clotting Profile • ABG • Urinalysis • CXR : A-P • KUB • 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 • associated injury • Alcohol • Neutral PH & bacteria – minimal inflammation Delay
Laparotomy: • Four: Quadrant Survey • Control Enteric Contamination • Exploration ??
Haematoma & Laceration : Lembent, Transverse • Mural haematoma <1cm: Inversion • Small perforation : Close transverse • Adjacent perforations:divide, close transverse
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
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 1º repair of non destructive
Anatomic Location: • Class I , II , & III: NO Significant difference in complications between right & Left for 1º 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
Drains : NO W. Infection Sepsis • Peritoneal Irrigation • 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: • Class I & II: Non Destructive: 1º repair (Peritonitis º) • Destructive: 1º repair if: 1 – Haemodynamic stable 2 – Shock ° 3 – Significant underlying disease º 4 – Minimal associated injuries 5 - Peritonitis º
Complex: Shock + substantial contamination or trauma to other organs Resection + proximal diversion Colostomy/ Ileostomy Mucous Fistula Hartmann’s
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
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 • Fetal Heart: Doppler (12w) • U/S • Placental Separation: Fetal cells in maternal blood
Treatment: Vigilant Mother must be saved first Options: as non pregnant • Uterine Injuries • Termination In Majority: non injured uterus – V. Delivery at term Injured uterus – repair
Indicators for C –Section : • Uterine rupture • Worseness fetal distress • Exposure of rectum, great vessels • Maternal Thoracolumbar spine fracture • DIC • MOF
Maternal death Immediate Delivery Poor infant survival if maternal death >15 minutes