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Rectal Trauma

Rectal trauma occurs due to various injuries, like anorectal avulsion, automobile, gunshot or stab wounds, foreign body ingestion, drug trafficking, or erotic activity. Diagnosis may be difficult, especially in patients who cannot or will not offer a detailed description of their injury.


Presentation

Patients may present with isolated rectal trauma or associated injuries like pelvic fractures or penetrating abdominal, buttock or thigh injuries that are potentially life threatening. If severe, these lesions have a 50% mortality rate. Bone fragments may induce rectal wall laceration. While inquiring about the history of the disease, the physician must obtain information about any pain, tenesmus, incontinence and associated genitourinary and abdominal symptoms [1]. In military injuries, type, trajectory, and velocity of the penetrating foreign body must be known in order to understand potential lesions [2].

In selected cases, careful clinical examination (inspection, sphincter tonus assessment) followed by digital evaluation should be performed, although controversy exists regarding the utility of the latter method [3] [4]. However, it can detect gross rectal blood loss and laceration [5] [6]. In sexual assault, the physician should keep in mind that disruption of the rectal wall is likely and document evidence if the patient is stable. Prostate evaluation in men is useful if concomitant lesions of the urethra are suspected. Examination should also assess vital signs according to the Advanced Trauma Life Support protocol defined by the American College of Surgeons. Peritonitis and pelvic fracture signs should be looked for. If a perineal penetration wound is noticed, entry and exit signs should be documented. Women should also undergo vaginal bimanual and speculum examination with focus on the posterior wall.

Perineal Pain
  • Some women chose not to speak with their doctors because they believed that anal incontinence was a normal consequence of childbirth. 6, 12 The scope of life-disrupting morbidities Perineal pain and dyspareunia may persist for years Perineal pain can[mdedge.com]
  • Available from: A 38-year-old male presented to emergency department complaining of rectal bleeding accompanied by dull pelvic and perineal pain.[onlinejets.org]
Weight Gain
  • At the moment defecation takes place 2-3 times a day, growth and weight gain are quite normal.[ncbi.nlm.nih.gov]
Recurrent Pulmonary Embolism
  • Two of the 20 patients (10 percent) died, one after a prolonged septic course and one from recurrent pulmonary embolism. Rectal trauma continues to be a challenging injury.[ncbi.nlm.nih.gov]
Fecal Incontinence
  • The management of fecal incontinence is a struggle to maintain patient hygiene and limit the transmission of nosocomial infections. Intrarectal devices that cause diversion and collection of the fecal stream have been used with increasing frequency.[ncbi.nlm.nih.gov]
  • The safety and efficacy of the artificial bowel sphincter for fecal incontinence: results from a multicenter cohort study. Dis Colon Rectum 2002; 45 (9) 1139-1153 33 Wexner SD, Baeten C, Bailey R, et al.[thieme-connect.com]
  • incontinence NOS, Gallstones, GERD, Germ cell tumor, Hemangioma, Hiatal hernia, Hirschsprung's disease, Hydrocele, Hyperhidrosis NOS, Idiopathic thrombocytopenic purpura, Inguinal hernia, Intestinal obstruction, Irritable bowel syndrome, Neuroblastoma[mayoclinic.org]
  • She goes on to discuss the various surgical and non-surgical treatments for fecal incontinence and other complications. Dr.[patientpower.info]
  • incontinence had ever discussed the problem with a physician. 11 Wood et al 10 reported that most women with anal sphincter injury were either unaware that they had the injury, or felt they did not receive an adequate explanation of their injury.[mdedge.com]
Rectal Pain
  • Both result in gastrointestinal inflammation and rectal pain.[verywell.com]
  • Rectal pain is the symptom of pain in the area of the rectum.[en.wikipedia.org]
  • An unexpected source of acute onset rectal pain One of my patients called our office, and insisted on making an appointment for her 14-year-old daughter for evaluation of a rectal tear.[clinicaladvisor.com]
  • Other symptoms include abdominal and /or rectal pain , dizziness , fainting , low blood pressure , vomiting , rapid heartbeat, and confusion.[emedicinehealth.com]
  • He had never complained of any rectal pain or bleeding. Examination at the trauma centre included digital rectal examination and rigid sigmoidoscopy/proctoscopy, revealing some blood and pus and an injury to the lateral rectal wall.[trauma.org]
Tenesmus
  • While inquiring about the history of the disease, the physician must obtain information about any pain, tenesmus, incontinence and associated genitourinary and abdominal symptoms.[symptoma.com]
  • A common symptom of proctitis is called tenesmus. Tenesmus is a frequent urge to have a bowel movement. Inflammation and irritation of the rectum and rectal lining cause tenesmus.[healthline.com]
  • Epidural anesthesia Anesthesia: epidural may be necessary to reduce peristalsis and tenesmus. This can be achieved using lidocaine Lidocaine, but xylazine Xylazine may be preferred as it causes less ataxia and weakness.[vetstream.com]
  • Despite tenesmus and the urge to stimulate herself digitally, she was unable to produce stool. The patient reported no recent vomiting, diarrhea, weight loss, or history of rectal instrumentation or trauma.[mdmag.com]
Anal or Rectal Pain
  • If you have anal or rectal pain, don't let embarrassment prevent you from getting it looked at. In the end, your rectal health is every bit as important as your heart, lungs, brain, and bones. Thanks for your feedback![verywell.com]
Blood in Stool
  • Blood in stool after car accidents is one of the colon trauma symptoms. Diagnosis of Colon and Rectal Trauma The diagnosis of trauma to the colon and rectum is usually found at the time of surgery.[autoaccident.com]
Neglect
  • We fear in this narrow perspective, other and possibly more effective hepatitis C prevention messages could be neglected.”[aidsmap.com]
Homonymous Hemianopsia
  • He had right homonymous hemianopsia and hemiplegia. Cardiac examination was positive for a pansystolic murmur in the apical area. The abdominal examination was unremarkable.[bmcinfectdis.biomedcentral.com]

Workup

Clinical evaluation should be followed by blood workup and imaging studies. The complete blood cell count may show acute posthemorrhagic anemia. Rigid or flexible proctoscopy or sigmoidoscopy offer valuable information [7] in penetrating and blunt injuries [8] [9], but they should be performed carefully and gently by an experienced doctor in order to prevent further injury. Despite the fact that they are the gold standard in detecting rectal damage [5], if other imaging methods offer reliable information, they can be excluded from the workup. However, sigmoidoscopy can sometimes fail to identify wounds and may have up to 31% false negative results [10].

Computer tomography can be used in rectal trauma, but if associated bowel injury is suspected, evaluation can prove difficult [11] and oral, intravenous or rectal contrast should be used, if appropriate, in order to increase sensitivity and specificity [12]. Bladder lesions can also be evaluated by this method. Triple-contrast helical computed tomography has higher accuracy if combined with contrast enema [13] [14]. This latter method can also be applied by itself.

Guaiac testing is another complementary diagnosis method. It has acceptable sensitivity (69%), but low specificity (33%) [15].

Rectal Ulceration
  • Injury is most likely to occur because of traumatic removal or rectal ulceration secondary to pressure necrosis.[ncbi.nlm.nih.gov]
  • ulcer syndrome, Ulcerative colitis, Umbilical hernia, Wilms' tumor more see full list in profile[mayoclinic.org]
  • Karger AG, Basel Introduction Solitary rectal ulcer syndrome (SRUS) is a chronic, benign disorder of defecation.[karger.com]

Treatment

  • In all these patients we believe the standard treatment would have included fecal diversion. Four patients sustained blunt trauma and five sustained penetrating trauma.[ncbi.nlm.nih.gov]
  • Diagnosis and management of rectal blunt trauma is still a matter of debate and no definitive recommendation treatments are available.[ncbi.nlm.nih.gov]
  • The mainstay of treatment for civilian rectal trauma remains diverting sigmoid loop colostomy, despite its morbidity, and peri-operative antibiotics.[ncbi.nlm.nih.gov]
  • Proper treatment plans, including the management of the rectal injury, the use of intravenous antibiotics and drains, rectal washout, and careful closure of surgical wounds, will usually lead to a favorable outcome.[ncbi.nlm.nih.gov]
  • […] and surgical treatments.[books.google.ro]

Prognosis

  • Management and prognosis depend on the severity of the trauma. The American Association for the Surgery of Trauma attempted to quantify the severity of anal trauma and proposed the Rectal Injury Scaling System comprising five degrees of severity.[abdominalkey.com]
  • Equis ISSN 2398-2977 Synonym(s): Rectal liner Contributor(s): Prof Gary M Baxter, Timothy Mair, Graham Munroe Introduction Initial management First aid and prompt referral/treatment is of paramount importance to prognosis.[vetstream.com]
  • […] mesenteric vessels 4, 7 abrupt termination of the mesenteric vessels 7 accumulation ('pooling') of contrast on multiphase imaging suggestive signs 7 mesenteric infilatration: haziness and fat stranding mesenteric hematoma bowel wall thickening Treatment and prognosis[radiopaedia.org]
  • What Is the Prognosis for Rectal Bleeding? The majority of people with significant rectal bleeding are elderly. Members of this population commonly have many other medical problems.[emedicinehealth.com]

Etiology

  • We report a case of CCP in a patient with a history of anal masturbation, supporting an acquired traumatic etiology. Diagnosis was assisted by transrectal ultrasound. The patient was successfully treated by local excision. 1994 S.[karger.com]
  • Etiology• Blunt trauma• This is rare due to the protected situation of the anus and rectum and it is usually associated with fracture pelvis. The commonest cause is motor vehicle accidents followed by falls and crush injuries. 4.[slideshare.net]
  • This chapter describes the most frequent etiologies of anal/rectal trauma and the basic clinical and instrumental investigations necessary to provide the most appropriate treatment, particularly in emergencies, when saving patient’s life is a surgeon’[link.springer.com]
  • Etiology Gunshot wounds ( 75%) and stabbings ( 20%) are the leading causes of bowel and mesenteric injury from penetrating trauma 8.[radiopaedia.org]
  • The etiology of SRUS remains uncertain; however, in addition to mechanical injury, local ischemia from pressure of impacted stool and prolapse may be an important contributing factor.[karger.com]

Epidemiology

  • It remains to be emphasized that in case of delayed presentation and an inconsistent history regarding the trauma mechanism, sexual abuse has to be excluded. [5] Kadish et al . described differences in epidemiology and presentation of accidental and non-accidental[afrjpaedsurg.org]
  • He has since completed further training in emergency medicine, clinical toxicology, clinical epidemiology and health professional education.[lifeinthefastlane.com]
  • Epidemiology of modern battlefield colorectal trauma: a review of 977 coalition casualties . J Trauma Acute Care Surg 2012; 73 (06) (Suppl. 05) S503-S508 4 Cho SD, Kiraly LN, Flaherty SF, Herzig DO, Lu KC, Schreiber MA.[thieme-connect.de]
  • Google Scholar Crossref Medline ISI Grotz, MR, Allami, MK, Harwood, P. ( 2005 ) Open pelvic fractures: epidemiology, current concepts of management and outcome . Injury 36(1): 1 – 13 .[journals.sagepub.com]
  • Poppers: epidemiology and clinical management of inhaled nitrite abuse. Pharmacotherapy 2004 ; 24 : 69 –78. Lee SJ , Galanter M, Dermatis H. et al Circuit parties and patterns of drug use in a subset of gay men. J Addict Dis 2003 ; 22 : 47 –60.[sti.bmj.com]
Sex distribution
Age distribution

Pathophysiology

  • Google Scholar Medline ISI Horrocks, CL . ( 2001 ) Blast injuries: biophysics, pathophysiology and management principles . Journal of the Royal Army Medical Corps 147(1): 28 – 40 .[journals.sagepub.com]
  • Zhu QC, Shen RR, Quin HL, Wang Y: Solitary rectal ulcer syndrome: clinical features, pathophysiology, diagnosis and treatment strategies. World J Gastroenterol 2014; 20: 738–744. Author Contacts M. Gruber St.[karger.com]

Prevention

  • Prevention efforts are needed to communicate sexual or sex-associated routes of transmission for hepatitis C that cannot be prevented by condoms alone”, conclude the investigators. Reference Schmidt AJ et al.[aidsmap.com]
  • Demographics, injury severity, and preventive antibiotics (24-hour) were similar between groups.[ncbi.nlm.nih.gov]
  • The detection, diagnosis, management and prevention of effects are all considered in detail, and prognostic outcomes are discussed. Radiation risk factors and interactions with chemotherapy effects are clearly presented.[books.google.ro]
  • To prevent this from happening, many surgeons place a piece of the fatty tissue in the abdomen between the two organs so they cannot connect with one another. Antibiotics should be used to prevent infection in these kinds of injuries.[autoaccident.com]

References

Article

  1. Hellinger M. Anal trauma and foreign bodies. Surg Clin North Am. 2002; 82(6):1253–1260.
  2. Burch J, Feliciano D, Mattox K. Colostomy and drainage for civilian rectal injuries: is that all? Ann Surg. 1989;209(5):600-610.
  3. Esposito T, Ingraham A, Luchette F, et al. Reasons to omit digital rectal exam in trauma patients: no fingers, no rectum, no useful additional information. J Trauma. 2005;59(6):1314–1319.
  4. Porter J, Ursic C. Digital rectal examination for trauma: does every patient need one? Am Surg. 2001;67(5):438–441.
  5. Morken J, Kraatz J, Balcos E, et al. Civilian rectal trauma: a changing perspective. Surgery. 1999;126:693-700.
  6. Mangiante E, Graham A, Fabian T. Rectal gunshot wounds: management of civilian injuries. Am Surg. 1986;52:37-40.
  7. Fry R. Anorectal trauma and foreign bodies. Surg Clin North Am. 1994; 74(6):1491–1505.
  8. Ferraro F, Livingston D, Odom J, et al. The role of sigmoidoscopy in the management of gunshot wounds to the buttocks. Am Surg. 1993;59(6):350–352.
  9. Ross G, Dodd O, Lipham J, et al. Rectal perforation in unstable pelvic fractures: the use of flexible sigmoidoscopy. Injury. 2001;32(1):67–68.
  10. Grasberger RC, Hirsch EF. Rectal trauma: a retrospective analysis and guidelines for therapy. Am J Surg. 1983;145:795-798.
  11. Butela S, Federle M, Chang P, et al. Performance of CT in detection of bowel injury. AJR Am J Roentgenol. 2001;176(1):129–135.
  12. Anderson S, Soto J. Anorectal trauma: the use of computed tomography scan in diagnosis. Semin Ultrasound CT MR. 2008;29(6):472–482.
  13. Rubesin S, Levine M. Radiologic diagnosis of gastrointestinal perforation. Radiol Clin North Am. 2003;41:1095-1115.
  14. Shanmuganathan K, Mirvis S, Chiu W. Triple-contrast helical CT in penetrating torso trauma: a prospective study to determine peritoneal violation and the need for laparotomy. Am J Roentgenol. 2001;177:1247-1256.
  15. Levine H, Simon R, Smith T, et al. Guaiac testing in the diagnosis of rectal trauma: what is its value. J Trauma. 1992 Feb; 32 (2):210-212.

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Last updated: 2017-08-09 17:15