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BOWEL INJURY

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

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  1. BOWEL INJURY F. Al-Mashat Dep of Surgery Kauh

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

  3. Mechanism: • Crushing: Compression • Shearing: Sudden Deceleration • Bursting:  Abdominal Pressure

  4. Causes: • Motor – Vehicle: 75% • High – Speed Vehicular • Fall from Heights • Seat Belt

  5. Unrecognized : frequent cause of preventable death

  6. Symptoms and Signs:UnreliableOften Masked: 1. Head Injury 2. Major Fractures 3. Alcohol

  7. Signs: • Echymosis & Abrasions • Tender ribs • Peritonitis • Tenderness and Guarding : 75% • Rebound and Rigidity: 28% • Pelvic Fracture • DRE • Urethral blood • Tests, Perineum , Vagina

  8. Investigations: • CBC • U&E’s • LFT’s • Amylase • Clotting Profile • ABG • Urinalysis • CXR : A-P • KUB • DPL : 95 % Accurate

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

  10. 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

  11. Penetrating: 1. History 2. Examination Not Sufficient

  12. Blunt : “High Index of Suspicion” Physical signs: Non Specific • associated injury • Alcohol • Neutral PH &  bacteria – minimal inflammation Delay

  13. Laparotomy: • Four: Quadrant Survey • Control Enteric Contamination • Exploration ??

  14. Haematoma & Laceration : Lembent, Transverse • Mural haematoma <1cm: Inversion • Small perforation : Close transverse • Adjacent perforations:divide, close transverse

  15. 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

  16. 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

  17. Injury distal SMA  Bowel Resection + Enteroenterostomy

  18. Colon Injuries • Majority: Penetrating • Mortality: < 5%

  19. 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

  20. 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

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

  22. Flint Severity Score: • Isolated colon injury, minimal contamination, no shock, minimal delay. • Perforation, lacerations, moderate contamination • Severe tissue loss, devascularization, heavy contamination

  23. 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

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

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

  26. 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

  27. Type: Single = Combination Aminoglycocide + Clindamycin or Aminoglycocide + metroindazole Duration: Class I & II: 24 H Optimal Dose: Fluid Shift High Dose Aminoglycocide: 3mg/Kg Loading

  28. 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

  29. Complex: Shock + substantial contamination or trauma to other organs Resection + proximal diversion Colostomy/ Ileostomy Mucous Fistula Hartmann’s

  30. 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

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

  32. Special • Fetal Heart: Doppler (12w) • U/S • Placental Separation: Fetal cells in maternal blood

  33. 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

  34. Indicators for C –Section : • Uterine rupture • Worseness fetal distress • Exposure of rectum, great vessels • Maternal Thoracolumbar spine fracture • DIC • MOF

  35. Maternal death  Immediate Delivery Poor infant survival if maternal death >15 minutes

  36. THANK YOU

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