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 trauma
- Burst 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 injury
- Foreign 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 signs
- Ecchymosis or hematoma on lower abdomen from lap-belt compression
- Ecchymosis on epigastric region from steering-wheel compression
- Grey 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)