OVERVIEW
The diagnosis and management of colonic injury is relatively complex. Colon wall is thin, blood supply is poor, healing is not good; colon accumulates a large number of bacteria and feces, easy to be infected; peristalsis and contraction of colon are strong, intestinal lumen pressure is large, intestinal contents are easy to be leaked into the abdominal cavity through the injury site or anastomosis; ascending and descending colon belong to the peritoneal interlaminar organs, relatively fixed, posteriorly there is no peritoneum, when the peritoneal part of the colon injury can cause serious and extensive retroperitoneal infections, and it is not easy to diagnose and find out in early stage. After the rupture of the colon, the irritation of intestinal contents on the peritoneum is less than that of small intestinal contents, and the early symptoms may not be obvious, but the infection and poisoning are serious. Most colonic injuries occur in the transverse colon, followed by the cecum, ascending colon and descending colon. The danger of colonic injury is that the intestinal content flows into the abdominal cavity after the injury, causing serious abdominal infection and systemic poisoning symptoms.
Causes
1. Blunt injury
The abdomen is crushed or hit violently, such as car accidents, falling, boxing, fighting and so on. There is no wound in the abdomen, and it is a closed injury.
2. Puncture injury
Wartime stab wounds, usually for murder, robbery, etc. caused by stabbing, more common than blunt injuries.
3. Firearm injury
Mostly seen in wartime gunshot wounds, usually seen in western countries, often combined with abdominal organ injury.
4. Medical injury
Sigmoidoscopy, fiber colonoscopy to colon perforation, endoscopic colon electrocautery polyp removal, biopsy. Also seen in the original pathologic basis of the colon and take inappropriate enema, anal tube insertion, etc. caused by medical injury.
Classification and grading
1.Classification
(1) Contusion Intestinal wall contusion without perforation, no blood flow obstruction, or bleeding from colonic mesenteric contusion to form hematoma, but does not affect blood flow.
(2) Laceration ① the intestinal wall is not perforated, non-complete tear or plasma membrane tear; ② the intestinal wall has been perforated, the whole layer of the tear, but the scope of the damage is not large, not completely transected; ③ the intestinal wall of the large tear, transected, defective, the abdominal cavity is completely contaminated, or damage to the main blood vessels of the mesentery, blood flow obstruction and necrosis of the intestinal wall.
2.Grading
Flint et al. divided colonic injury into three levels: the first level is limited to colonic injury, no contamination of the abdominal cavity, no systemic shock manifestations or no delay in diagnosis and treatment; the second level is the perforation of the entire intestinal wall; the third level is a serious tissue defect, the abdominal cavity is heavily contaminated with shock symptoms or delay in diagnosis and treatment.
Symptoms
1. Abdominal pain, abdominal distension, nausea and vomiting: after perforation of colon injury, the feces in the intestinal lumen overflows into the abdominal cavity with abdominal pain, and abdominal distension, nausea, vomiting, or intestinal obstruction appear gradually.
2. Peritoneal irritation: abdominal pressure, abdominal muscle tension and rebound pain.
3. Bowel sounds: weakening or disappearance.
4. Systemic symptoms: systemic symptoms such as shock.
5. Rectal finger test examination: there is tenderness in the rectum, and a hematoma or blood on the finger cuff is felt.
Examination
1. Laboratory examination
Routine blood test may have decreased hematocrit, decreased hemoglobin and red blood cell count, and increased white blood cell and neutrophil count.
2. Auxiliary examination
X-ray abdominal plain film can find free gas under the diaphragm or intestinal obstruction.
3. Diagnostic abdominal lavage
Lavage fluid can be seen in the bloody fluid or feces and other intestinal contents.
4. Cesarean section
There are a lot of intra-abdominal organ injuries that can only be diagnosed qualitatively before surgery, and the localization of diagnosis requires caesarean section. Colon injury is also so, do not be satisfied to find an injury on the end of the exploration, should be systematic and comprehensive careful exploration. When only the intestinal wall contusion or mesenteric hematoma injury should be found to determine whether the intestinal wall hemodynamic disorders, necrosis, do not miss the hepatic flexure, splenic flexure and other hidden fixed parts of the exploration, ascending and descending colon retroperitoneal perforation injuries should be examined to check the wound channel, and through the exploration of retroperitoneal hematoma to determine, and does not require all the colonic free.
Diagnosis
A colonic injury can be identified based on the presence of abdominal pain, nausea, vomiting, and signs of peritonitis following abdominal trauma, the visible pneumoperitoneum sign on X-ray, and the extraction of fecal-like fluid by diagnostic puncture.
Treatment
The only treatment for colonic injuries is surgery, which should be performed as soon as the diagnosis is confirmed. A median incision is preferred to facilitate exploration during surgery. After entering the abdomen, the first step is to control active bleeding; the second step is to control the leakage of intestinal contents into the abdominal cavity, and then to carry out exploration of the abdominal cavity to clarify the location and number of injuries. There are various surgical methods, based on the degree of trauma, abdominal contamination, the presence of combined injuries, delayed treatment and systemic conditions, such as taking different surgery.
1. Simple repair or resection anastomosis
The first method of surgery for colon injury is simple repair or resection anastomosis. However, the mortality rate of the operation was as high as 90% at that time, so that it was gradually replaced by external placement or stoma.
2. Colostomy
Ostomy includes: intestinal repair plus proximal stoma; intestinal resection, both ends of the stoma; damage to the intestines external stoma 3 kinds.
3. Intestinal externalization
Intestinal externalization is to repair the damaged intestinal segment in one stage, and temporarily place it on the abdominal wall after repair.