Penetrating Rectal Injuries

Posted by e-Medical PPT Tuesday, August 20, 2013
Introduction
Rectal injuries are rare and may not be readily apparent
Can result from blunt or penetrating trauma
82-94% in the civilian population are due to firearms
Stab wounds to the lower abdomen, pelvis, and buttocks rarely injure the rectum
Major pelvic fractures may be associated with blunt rectal trauma
Overall complication rate >50%

Clinical Examination
Intraperitoneal perforation may cause peritonitis
Anterior and lateral upper 2/3 of rectum
Extraperitoneal perforation may not cause immediate symptomatology
Posterior upper 2/3 and lower 1/3 of rectum
Careful digital exam to check for intraluminal blood or mucosal defect
Mental reconstruction of trajectory

Imaging
Plain films can help to reconstruct the trajectory
Helical CT has essentially substituted for plain films in rectal trauma
Should be routinely obtained for suspected rectal perforation
Rectal contrast may be helpful for both plain films and CT
Trajectory can be predicted with the CT
Must remember that bullets don’t always travel in a straight line

Sigmoidoscopy
Rigid sigmoidoscopy is an essential diagnostic tool that should be used if DRE and CT are suggestive of injury
Can help locate the injury more precisely and plan for operative strategy
Frequently reveals only intraluminal blood
Implies full thickness injury after penetrating trauma and should be a reason to operate
Can allow for transanal repair of low rectal injuries or removal of foreign bodies

Treatment
Diverting colostomy, rectal washout and presacral drainage defined the operative management of rectal injuries for many years
One by one, scientific evidence has doubted their necessity
Treatment also depends on location
Intraperitoneal: upper 2/3 anterior and lateral
Extraperitoneal: upper 2/3 posterior, lower 1/3
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