Damaged colon can be the consequence of blunt and sharp injuries and exposure to chemically active substances. Rupture of the rectum and colon may occur from a sudden raised intracolonic pressure, when intestinal lavage, enema, careless use of technical means, etc. are the Most common injuries of the colon occur in wartime. Basically, it is gunshot wounds (bullet and shrapnel), as well as injuries compression of the abdomen, falls from heights or bumps under the impact of the blast wave.
In peacetime, injuries of the colon occur most often due to blunt trauma in car accidents, some medical manipulations (enema, endoscopy), operations on adjacent organs or with endoscopic polypectomy. Describes the tearing of the rectum during sexual intercourse or Masturbation.
Chemical burns of the rectum and colon occurs, as a rule, the introduction into the rectum by mistake of the medical staff or the patient when the enema instead of water, any chemically active substances (ammonia, corrosive sublimate, formalin, etc.).
Damage to the colon can be as out-and intraperitoneal. The other important factor is the presence or absence of damage to the anal sphincter.
In addition to the direct injury of the colon wall possible partial tear or injury to the mesenteric without direct effects on the intestinal wall.
Like any injury, damage of the colon can be open and closed, single and multiple, mixed and combined.
Characteristic for all types of injuries of the colon is the rapid development of inflammatory complications. If penetrating injury is peritonitis, when extraperitoneal the subcutaneous or phlegmon adrectal fiber and perineal.
In chemical burns of the colon mucosa may Microtiterwells to a considerable extent, and the transition to other layers of the bowel wall may develop cellulitis or multiple perforations with spilled peritonitis.
In fractures of the pelvic bones damage is observed rectum in combination with injuries of adjacent organs (bladder, uterus, vagina, prostate). Therefore, in such situation it is necessary to produce x-rays of the pelvis, and to investigate not only the rectum, but these organs.
In cases of combined lesions of the colon can simultaneously be a rupture and injury of the small intestine, liver, stomach, kidney, spleen, hematoma of retroperitoneal fat. In combined injuries combined or isolated injuries of the colon occur on the background of injuries of the diaphragm, of the chest.
Damage rectal foreign bodies are usually observed in children, however, have a place among adults. Emergency situations arise when you want fast removal of foreign body with the elimination of complications. Foreign bodies can get into the rectum with trauma, to penetrate into the lumen of the intestine during medical manipulations, to be formed in the gut (fecal stones) in violation of the evacuation of intestinal contents. Sometimes foreign bodies introduced into the anus as a result of criminal or psychopathic actions.
Wounds of the rectum as sharp and blunt objects most often occur in time of peace. Most often it is associated with a drop crotch for sticking a hard object. Wounding object can damage the intestinal wall, getting directly through the anus or through the skin of the perineum. Thus patients feel great pain in the anus and perineum, you may experience heavy bleeding. Due to severe pain may be brief loss of consciousness and even shock.
Diagnosis of intraperitoneal injuries of the colon, especially in the case of its perforation, is based on the study of the mechanism of injury and the presence of peritoneal phenomena. Radiologically determined by the free gas in the abdominal cavity, and in the later stages and free fluid. In the analysis blood — leukocytosis, left shift in the formula of white blood, sometimes a decrease in hemoglobin. Often, the diagnosis of intraperitoneal wounds of the colon can be complicated. A set of diagnostic procedures for gunshot wounds of the abdomen consists of a series of successive stages of General clinical examination methods, primary surgical wound treatment, laparoscopic research.
The diagnosis of extraperitoneal injuries ascending, descending and rectum also presents certain difficulties, since the external damage can be minor and local and General symptoms of damage to the intestine some time can clearly not occur. A thorough history, the study of the mechanism of injury, careful inspection of the patient, identification of pelvic fractures contribute to the proper diagnosis. The presence of wounds in the perineum and the buttocks, especially when entering from deep wounds of the intestinal content, is the basis for the diagnosis of injury of the rectum. Last damaged and atomtime bone fracture of the pelvis. For a more detailed diagnosis of extraperitoneal wounds of the rectum is mandatory finger examination and anoscopy using anoscope or rectal mirror. While these studies can be detected defects of the rectal wall and the presence of blood in the lumen.
Differential diagnosis of intraperitoneal injuries and fractures should be non-penetrating in the intestine, injuries of the lumbar region, perineum and retroperitoneal hematomas. Some possible difficulties in the recognition of combined and isolated injuries of the urinary organs. Manual examination through the vagina in women and special urological research (urethra and cystography) often help to establish the correct diagnosis.
Treatment is always surgical. Damage to the colon and surgery for these injuries represent a high risk to the life of the patient. Therefore, it is necessary comprehensive treatment, beginning with preoperative preparation for the prevention and treatment of septic and hemorrhagic shock, including subsequent transfusion, antibacterial and stimulating therapy.
The amount of operation is determined by the nature of the damage to the gut and General condition of the patient. With an open injury required primary surgical processing of wounds with a further decision about the method of treatment of wounds or other damage of the colon. Defects in the intestinal wall is sutured only if stab and cut wounds early after injury in the absence of peritonitis and purulent inflammation during dermal wound. All this is done under the cover of colostomy.
When intraperitoneal injury most often output or resected the damaged area of the colon without anastomosis, a colostomy or Colo – ileostomy when removing damaged right half of the colon. The continuity of the colon recover after 2-4 months. after the inflammation subsided.
Often, the damage of the colon combined with damage to other abdominal organs (kidney, liver, spleen, stomach). Wounds of the colon can be associated with damage to the chest. Therefore, surgical intervention should first of all provide good access to the damaged organ, sufficient and complete overview of the abdominal cavity taking into account factors complicating access to some parts of the colon. All these requirements are met by median laparotomy, which is most often used in gunshot wounds of the colon.
During revision of the abdominal cavity, special attention should be paid to damage to other organs, the sources of bleeding and extraperitoneal parts of the colon that has not gone unnoticed bruises and other injuries.
Resection is performed when extensive wounds, partial or complete ruptures of the intestinal loop with damage to the vessels of the mesentery. This operation is performed, basically, if the damage is transverse, descending and sigmoid colon.
When damaged, the right half colon resection type hemicolectomy produced infrequently — extended operation is very difficult the wounded were transferred. However, recent reports based on experience of treating the wounded in Afghanistan and Chechnya suggests that a frequent use of this procedure with quite satisfactory results.
In extraperitoneal injuries of the rectum thoroughly sanitize the wound and sutured it in layers from the lumen. If it damaged the outer sphincter and an extensive wound of the perineum, it is necessary to impose fasting colostomy, sanitize the wound and the distal section of the colon, to drain them with the expectation of the application of delayed suture.
Also dvuhetapnyh treat retroperitoneal injuries of the colon: first, cut off the damaged part overlay separate colostomy or ileostomy, and after healing of the damaged intestine or formation of fistula to produce recovery operations. In some cases, the issue of colostomy or ileostomy is controversial. Some surgeons think it is possible to do without disabling the intestine in small isolated injuries of the colon and rectum.
Absolute indications to disable intestine are:
- different types of intra-abdominal penetrating injury of the rectal wall;
- different types of extraperitoneal penetrating injury of the rectal wall above the level of the levator.