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

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

3. Mechanism: 1.Crushing: Compression 2.Shearing: Sudden Deceleration 3.Bursting:  Abdominal Pressure

5. Causes: 1.Motor – Vehicle: 75% 2.High – Speed Vehicular 3.Fall from Heights 4.Seat Belt

6. Unrecognized : frequent cause of preventable death

7. Symptoms and Signs: Unreliable Often Masked: 1. Head Injury 2. Major Fractures 3. Alcohol

8. Signs: 1.Echymosis & Abrasions 2.Tender ribs 3.Peritonitis a.Tenderness and Guarding : 75% b.Rebound and Rigidity: 28% 4.Pelvic Fracture 5.DRE 6.Urethral blood 7.Tests, Perineum, Vagina

9. Investigations: 1.CBC 2.U&E’s 3.LFT’s 4.Amylase 5.Clotting Profile 6.ABG 7.Urinalysis 8.CXR : A-P 9.KUB 10.DPL : 95 % Accurate

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

14. The most frequently involved in penetrating (90%) The 3 rd in blunt Penetrating: Gunshot: > 80% Stab: 30% Occurs in 5-15% of blunt Small Bowel Injuries

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

17. Blunt : “High Index of Suspicion” Physical signs: Non Specific 1.associated injury 2.Alcohol 3.Neutral PH &  bacteria – minimal inflammation Delay

18. Laparotomy: 1.Four: Quadrant Survey 2.Control Enteric Contamination 3.Exploration ??

19. 1.Haematoma & Laceration : Lembent, Transverse 2.Mural haematoma <1cm: Inversion 3.Small perforation : Close transverse 4.Adjacent perforations:divide, close transverse

20. 5.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

26. 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

27. Injury distal SMA  Bowel Resection + Enteroenterostomy

30. Colon Injuries Majority: Penetrating Mortality: < 5%

31. 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

32. 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

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

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

35. 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

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

37. 1.Drains : NO W. Infection Sepsis 2.Peritoneal Irrigation 3.Wound: Definition a: Open: Significant Contamination b: Delayed primary closure: 7 days

38. 1. Class I & II: Single Pre - OP aerobic & Anaerobic 2.Class I & II: 24 H hollow viscus 3. Shock :  dose 2 – 3 folds Prophylactic Antibiotics

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

40. Recommendations: 1.Class I & II: Non Destructive: 1º repair (Peritonitis º) 2.Destructive: 1º repair if: 1 – Haemodynamic stable 2 – Shock ° 3 – Significant underlying disease º 4 – Minimal associated injuries 5 - Peritonitis º

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

42. 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

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

44. Special 1. Fetal Heart: Doppler (12w) 2. U/S 3. Placental Separation: Fetal cells in maternal blood

45. Treatment: Vigilant Mother must be saved first Options: as non pregnant 1.Uterine Injuries 2.Termination In Majority: non injured uterus – V. Delivery at term Injured uterus – repair

46. Indicators for C –Section : 1.Uterine rupture 2.Worseness fetal distress 3.Exposure of rectum, great vessels 4.Maternal Thoracolumbar spine fracture 5.DIC 6.MOF

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

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