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Bowel trauma

Background

Overview

Definition
Bowel trauma refers to any injury or damage to the gastrointestinal tract, which can occur due to various causes, such as blunt or penetrating abdominal trauma.
1
Pathophysiology
The pathophysiology of bowel trauma involves primary and secondary injury mechanisms. Primary injury results from direct tissue damage, while secondary injury can occur due to ischemia and inflammation. These processes can lead to tissue injury, increased oxidative stress, inflammatory cytokine release, and inflammatory cell infiltration and activation.
2
Epidemiology
The prevalence of bowel trauma is estimated at approximately 1% in blunt trauma and 17% in penetrating trauma.
3
Disease course
Clinically, patients with bowel trauma may present with a variety of symptoms, including abdominal pain, distension, and rectal bleeding. Depending on the severity and location of the injury, patients may also present with signs of peritonitis, such as rebound tenderness, guarding, and rigidity. Potential complications include abscess formation, bowel obstruction, and fistulae.
1
Prognosis and risk of recurrence
The prognosis of bowel trauma is largely dependent on the severity of the injury and the timeliness of intervention. Delay in the diagnosis and treatment of bowel injury is associated with increased morbidity and mortality.
1

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of bowel trauma are prepared by our editorial team based on guidelines from the World Society of Emergency Surgery (WSES 2022), the World Society of Emergency Surgery (WSES/AAST 2019), and the Eastern Association for the Surgery of Trauma (EAST 2012). ...
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Diagnostic investigations

Initial evaluation: as per WSES 2022 guidelines, obtain a primary survey, eFAST, perform a physical examination, obtain a secondary survey, blood chemistry, check for vital signs followed by contrast-enhanced abdominal CT in awake and oriented patients with blunt abdominal trauma.
A
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  • CT

Diagnostic procedures

Diagnostic peritoneal lavage: as per WSES 2022 guidelines, consider performing diagnostic peritoneal lavage as an adjunct to a negative laparoscopy to definitively exclude bowel injury, particularly in conjunction with the use of biomarkers.
C

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  • Diagnostic laparoscopy

Medical management

Nonoperative management: as per WSES 2022 guidelines, consider offering nonoperative management at specialized centers in patients with penetrating abdominal trauma if the patient is hemodynamically compensated and cooperative. Recognize that nonoperative management might be more suitable for stab wounds when compared to gunshot wounds.
C

Inpatient care

Serial clinical assessment
As per WSES 2022 guidelines:
Obtain at least 48 hours of serial clinical examinations, performed by consistent specialists or consultants, vital sign monitoring, and serial inflammatory markers testing during nonoperative management.
B
Admit patients with high-risk mechanisms (handlebar, seatbelt sign) and non-specific CT findings for observation including serial clinical examination.
B

Perioperative care

Perioperative prophylactic antibiotics: as per EAST 2012 guidelines, administer a single preoperative dose of prophylactic antibiotics with broad-spectrum aerobic and anaerobic coverage in all patients with penetrating abdominal trauma.
A
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Surgical interventions

Local wound exploration: as per WSES 2022 guidelines, perform local wound exploration or screening laparoscopy to investigate for peritoneal violation, when CT does not identify hard signs of bowel injury, to guide toward a laparotomy or nonoperative management. Discharge patients without peritoneal violation.
B

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  • Indications for laparotomy

  • Indications for bowel repair

Specific circumstances

Patients with duodenal injury, evaluation: as per AAST/WSES 2019 guidelines, obtain eFAST for detecting free fluid and solid organ injury.
A
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  • Patients with duodenal injury (nonoperative management)

  • Patients with duodenal injury (operative management)

Follow-up and surveillance

Follow-up: as per WSES 2022 guidelines, obtain long-term follow-up in patients with blunt abdominal trauma to identify the sequelae of mesenteric injuries.
B