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Colon Trauma, Emergency Medicine

Basics

Description

  • Trauma that perforates the colon inflames the cavity in which it lies.
  • Peritoneal inflammation from hollow viscus perforation often requires hours to develop.
  • Mesenteric tears from blunt trauma cause hemorrhage and bowel ischemia.
  • Delayed perforation from ischemic or necrotic bowel may occur.
  • Peritonitis and sepsis may develop from the extravasated intraluminal flora.
  • Ascending and descending colon segments are retroperitoneal.
  • The left colon has a higher bacterial load than the right.
  • Morbidity and mortality increase if the diagnosis of colon injury is delayed.

Etiology

  • Penetrating abdominal trauma:The colon is the 2nd most commonly injured organ in penetrating trauma.Gunshot wounds have the highest incidence.Transverse colon is most commonly injured.Often presents with peritonitis
  • Blunt abdominal trauma:Colon rarely injured in blunt traumaBurst injury occurs from compression of a closed loop of bowel.Intestine may be squeezed between a blunt object (lap belt) and vertebral column or bony pelvis.Sudden deceleration may produce bowel-mesenteric disruption and consequent devascularization.With deceleration, the sigmoid and transverse colon are most vulnerable.
  • Transanal injury:Iatrogenic endoscopic or barium enema injuryForeign bodies used during sexual activities may reach and injure the colon.Compressed air under high pressure such as at automobile repair facilities can perforate the colon even if the compressor nozzle is not fully inserted anally.Swallowed sharp foreign bodies (toothpick) may penetrate the colon, particularly the cecum, appendix, and sigmoid:Most foreign bodies pass without complications.

Unlike adults, children have an equal frequency of blunt and penetrating colon injuries.

Diagnosis

Signs and Symptoms

  • Colon trauma is generally associated with other intra-abdominal and extra-abdominal injuries, commonly to the small intestine.
  • Injuries of significant severity may have minimal early findings.
  • It is uncommon to determine specific organ injury on physical exam.
  • Assess on exam:Abdomen for peritoneal signsEcchymosis or hematoma on lower abdomen from lap-belt compressionEcchymosis on epigastric region from steering-wheel compressionGrey Turner sign (flank hematomas) resulting from retroperitoneal bleeding.Foreign bodies or blood on digital rectal exam (be careful if sharp object suspected)Note: Abdominal wall ecchymosis or hematoma is not always present despite existing injury.Note: Bowel sounds are not helpful.

Essential Workup

  • Serial abdominal exam because inflammation takes time to develop
  • Abdominal CT with contrast is the best diagnostic study in stable patients.
  • US and diagnostic peritoneal lavage (DPL) are helpful in the potentially unstable patient.

Diagnosis Tests & Interpretation

  • No individual test or combination of currently available diagnostic modalities is adequate to exclude blunt colonic injury.
  • Signs of peritoneal irritation owing to intestinal injury typically develop hours after the event.

Lab

  • Electrolytes
  • Calcium, magnesium

Imaging

  • CT is more useful for detecting penetrating vs. blunt colon injury.
  • CT with triple contrast allows intraperitoneal and retroperitoneal visualization.
  • Oral contrast is not essential in blunt abdominal trauma CT evaluation.
  • Although CT may miss colon injuries, abnormal findings are typical.
  • CT is only moderately sensitive at identifying hollow viscus injury.
  • Hollow viscus injury-associated CT findings include extraluminal gas or contrast, mesenteric fat streaking, and free fluid without solid organ injury.
  • Water-soluble enema with fluoroscopy is useful if other test results are inconclusive.
  • Plain abdominal radiographs can show indirect signs such as intraperitoneal and retroperitoneal free air.
  • FAST US exam does not evaluate for enteric injury and retroperitoneal hemorrhage.
  • See "Abdominal Trauma, Blunt"; "Abdominal Trauma, Imaging."

Diagnostic Procedures/Surgery

  • DPL or ultrasound in addition to CT will increase sensitivity.
  • In blunt trauma, DPL will often not detect retroperitoneal injuries and enteric injury as intra-abdominal bleeding is limited.
  • Fecal or vegetable material on DPL analysis indicates hollow viscus injury.
  • Lavage white cell response may be negative secondary to delayed peritoneal inflammation.
  • In hollow viscus injury, lavage WBC count: RBC ratio is higher than that seen with solid organ injuries.

Differential Diagnosis

  • Other intra-abdominal injuries
  • A fractured pelvis may present similarly to intraperitoneal injuries in children.

Treatment

Pre-Hospital

  • Cautions:Follow standard pre-hospital guidelines for trauma management (ABCs).Do not remove penetrating foreign bodies.Do not attempt to replace eviscerated bowel; cover with moist saline dressings.Obtain history regarding mechanism of injury, vehicular damage, and seat belt use.
  • Controversies:Use of intravenous crystalloid resuscitation is still considered the standard of care.

Initial Stabilization/Therapy

  • Refer to topic on abdominal trauma.
  • ABCs should precede abdominal evaluation.
  • Aggressive management with IV crystalloid resuscitation and blood replacement as needed.

Ed Treatment/Procedures

  • Early surgical consultation; surgery is definitive treatment.
  • Cover eviscerated bowel in moist saline gauze, in a nondependent position.
  • Administer broad-spectrum antibiotics to cover gram-negative aerobic and anaerobic bacteria.
  • The efficacy of multiple-agent and single-agent antibiotic regimens is similar.
  • Ensure tetanus prophylaxis.

Medication

  • Ampicillin: 2 g (peds: 50 mg/kg) IV q6h + gentamicin 2 mg/kg (peds: 2.5 mg/kg) IV q8h + metronidazole 500 mg IV q6h (peds: Use clindamycin 25-40 mg/kg IV q24h div. q6-q8h)
  • Aztreonam: 2 g IV q8h (peds: 90-120 mg/kg IV q24h div. q6-q8h) + clindamycin 900 mg IV q8h (peds: Use clindamycin 25-40 mg/kg IV q24h div. q6-q8h)
  • Cefoxitin: 2 g IV q8h (peds: 40 mg/kg IV q6h)
  • Piperacillin/tazobactam: 4.5 g (peds: 75 mg/kg) IV q8h

Follow-Up

Disposition

Admission Criteria

  • Colon injuries require admission for surgical repair or monitoring.
  • All penetrating foreign bodies must be removed to prevent sepsis.
  • Patients with abdominal ecchymosis require hospital admission and observation because of potential for undiagnosed hollow viscus injury.

Discharge Criteria

  • Patients in whom serious abdominal injury is not suspected and with completely normal abdominal exam, normal hemodynamic status, and no other injury may be considered for discharge with appropriate precautions.
  • If there is any doubt about the possibility of colon injury, the patient should be admitted and observed.

Pearls and Pitfalls

Patients may initially present with paucity of symptoms:

  • Observation and serial exams are indicated if mechanism suggests significant blunt abdominal trauma.

Additional Reading

  • Cleary RK, Pomerantz RA, Lampman RM. Colon and rectal injuries. Dis Colon Rectum. 2006;49(8):1203-1222.
  • Goldberg JE, Steele SR. Rectal foreign bodies. Surg Clin North Am. 2010;90(1):173-184.
  • Greer LT, Gillern SM, Vertrees AE. Evolving colon injury management: A review. Am Surg. 2013;79(2):119-127.
  • Steele SR, Maykel JA, Johnson EK. Traumatic injury of the colon and rectum: The evidence vs dogma. Dis Colon Rectum. 2011;54(9):1184-1201.
  • Williams MD, Watts D, Fakhry S. Colon injury after blunt abdominal trauma: Results of the EAST Multi-Institutional Hollow Viscus Injury Study. J Trauma. 2003;55(5):906-912.

Codes

ICD9

  • 863.40 Injury to colon, unspecified site, without mention of open wound into cavity
  • 863.42 Injury to transverse colon, without mention of open wound into cavity
  • 863.50 Injury to colon, unspecified site, with open wound into cavity
  • 863.52 Injury to transverse colon, with open wound into cavity
  • 863.41 Injury to ascending [right] colon, without mention of open wound into cavity
  • 863.43 Injury to descending [left] colon, without mention of open wound into cavity
  • 863.44 Injury to sigmoid colon, without mention of open wound into cavity
  • 863.45 Injury to rectum, without mention of open wound into cavity
  • 863.46 Injury to multiple sites in colon and rectum, without mention of open wound into cavity
  • 863.49 Other injury to colon or rectum, without mention of open wound into cavity
  • 863.4 Injury to colon or rectum without mention of open wound into cavity
  • 863.51 Injury to ascending [right] colon, with open wound into cavity
  • 863.53 Injury to descending [left] colon, with open wound into cavity
  • 863.54 Injury to sigmoid colon, with open wound into cavity
  • 863.55 Injury to rectum, with open wound into cavity
  • 863.56 Injury to multiple sites in colon and rectum, with open wound into cavity
  • 863.59 Other injury to colon or rectum, with open wound into cavity
  • 863.5 Injury to colon or rectum with open wound into cavity

ICD10

  • S36.501A Unspecified injury of transverse colon, initial encounter
  • S36.509A Unspecified injury of unspecified part of colon, initial encounter
  • S36.539A Laceration of unspecified part of colon, initial encounter
  • S36.519A Primary blast injury of unspecified part of colon, initial encounter
  • S36.500A Unspecified injury of ascending [right] colon, initial encounter
  • S36.502A Unspecified injury of descending [left] colon, initial encounter
  • S36.503A Unspecified injury of sigmoid colon, initial encounter
  • S36.508A Unspecified injury of other part of colon, initial encounter
  • S36.510A Primary blast injury of ascending [right] colon, initial encounter
  • S36.511A Primary blast injury of transverse colon, initial encounter
  • S36.512A Primary blast injury of descending [left] colon, initial encounter
  • S36.513A Primary blast injury of sigmoid colon, initial encounter
  • S36.518A Primary blast injury of other part of colon, initial encounter
  • S36.520A Contusion of ascending [right] colon, initial encounter
  • S36.521A Contusion of transverse colon, initial encounter
  • S36.522A Contusion of descending [left] colon, initial encounter
  • S36.523A Contusion of sigmoid colon, initial encounter
  • S36.528A Contusion of other part of colon, initial encounter
  • S36.529A Contusion of unspecified part of colon, initial encounter
  • S36.530A Laceration of ascending [right] colon, initial encounter
  • S36.531A Laceration of transverse colon, initial encounter
  • S36.532A Laceration of descending [left] colon, initial encounter
  • S36.533A Laceration of sigmoid colon, initial encounter
  • S36.538A Laceration of other part of colon, initial encounter
  • S36.590A Other injury of ascending [right] colon, initial encounter
  • S36.591A Other injury of transverse colon, initial encounter
  • S36.592A Other injury of descending [left] colon, initial encounter
  • S36.593A Other injury of sigmoid colon, initial encounter
  • S36.598A Other injury of other part of colon, initial encounter
  • S36.599A Other injury of unspecified part of colon, initial encounter

SNOMED

  • 125629006 Injury of colon (disorder)
  • 18147000 Injury of colon with open wound into abdominal cavity (disorder)
  • 125632009 Injury of transverse colon (disorder)
  • 262871004 Contusion of colon (disorder)
  • 125631002 Injury of ascending colon (disorder)
  • 125633004 Injury of descending colon (disorder)
  • 125634005 Injury of sigmoid colon (disorder)
  • 25110002 Injury of multiple sites in colon AND/OR rectum with open wound into abdominal cavity (disorder)
  • 287101003 Injury to colon/rectum (disorder)
  • 658009 Injury of colon without open wound into abdominal cavity (disorder)