rectal injury
Introduction
Introduction to rectal injury Because the position of the rectum is deep, concealed, and there is good protection of the pelvis, it is rarely damaged. Once the injury is due to the stenosis of the rectum or the stool is formed, it is not easy to overflow from the perforation. The inflammation progresses slowly, and the symptoms are concealed. be ignored. However, there are many kinds of bacteria in the feces of the wounds, and the density is large, 1016/L, which is easy to cause serious intra-abdominal or rectal infections, complicated complications and high mortality. Therefore, early diagnosis and treatment of rectal rupture should be highly valued. Once the rectal rupture is diagnosed, emergency surgery is required, and the fatality rate will increase by 15% for every 4 hours of delay. basic knowledge The proportion of illness: 0.003% Susceptible people: no specific population Mode of infection: non-infectious Complications: septic shock
Cause
Cause of rectal injury
Open injury (30%):
More common in wartime, especially in the lower abdomen and perineal firearm injuries, and often multiple internal organs, often combined with perineal soft tissue injury and defects, usually seen in knife stab wounds or high places falling hips riding or falling Sitting on a sharp foreign object, the sharp object is injured by the perineum or anus penetrating into the rectum, and there is also a perforation of the rectum caused by perverted sex or anal foreign body prank.
Sometimes the lower limbs are stretched by a strong external force and stretched out, abducting, tearing the perineum while rotating and involving the anal canal and rectum. This injury is characterized by a large wound in the perineum and a urethral or vaginal laceration.
Closed injury (30%):
Mostly caused by traffic accidents, falling, squeezing, collision, rolling, etc., one of which is due to the displacement of the pelvic fracture, the levator ani muscle contraction and tearing the rectum or the fracture piece piercing the rectum, and the second is the blunt violence, instantly squeezing the abdomen The sigmoid gas is flushed into the rectum. Because the anus is closed, the rectum is closed. Rosenberg's experiment proves that the pressure of 20.5kg/cm2 can cause the intestinal wall to rupture to the rectal space without peritoneal coverage. The former is seriously injured and merged. Urethral injury and traumatic hemorrhagic shock, the latter rupture mouth, serious pollution.
Iatrogenic injury (20%):
Pelvic surgery, perineal surgery and intravaginal surgery can be accidentally injured in the rectum, cleansing enema, barium enema, proctoscopy or sigmoidoscopy or treatment (such as high frequency electrocautery, laser, etc.) can also occur rectal perforation.
Pathogenesis
Pathological changes vary with the degree of injury, the nature of the injury and the method of action, location, extent, time and presence or absence of other organ injuries. Light is only mucosal tears and myometrial rupture, heavy full-thickness intestinal wall rupture and extensive Sphincter injury, if accompanied by large blood vessels and anterior venous plexus injury, can cause hemorrhage and shock, rectal, middle and third of the injury often accompanied by suppurative peritonitis, the lower third of the injury is likely to cause infection around the rectum and anal canal Such as pelvic cellulitis, rectal posterior space and ischial rectal fossa infection, due to these large gaps, combined with anaerobic mixed infection and intestinal fecal contamination, can cause extensive necrosis, severe toxemia and sepsis, and even death , rectal injury can also be complicated by rectal bladder spasm, rectal vaginal fistula and rectal fistula, anal canal injury can cause anal canal stenosis and anal incontinence.
Prevention
Rectal injury prevention
No specific precautions, pay attention to avoid trauma.
Complication
Rectal injury complications Complications septic shock
Excretion of feces after rupture of the rectum is prone to infection in adjacent areas.
Symptom
Symptoms of rectal injury Common symptoms Rectal crisis Abdominal pain Peritoneal irritation Rectal duplication Deformity Trauma Pelvic injury Vascular injury Shock
Due to the location of the injury, the degree of injury, the length of the perforation, the size of the perforation and the degree of fecal contamination of the feces, the clinical manifestations are different. Common manifestations are:
1. Shock: Hemorrhagic shock caused by rectal injury is more common. This type of bleeding is often difficult to control. The incidence of shock in rectal injury is 11%, and the incidence of concomitant injury is 31.7%, especially It is more serious when combined with pelvic injuries.
2. Peritonitis: Intraperitoneal rectal injury is inevitably accompanied by signs of peritonitis, the severity of which is clearly related to the extent of injury, the amount of intestinal contents and the combined injury, single perforation of rectal injury, emptiness of the rectum The symptoms are not obvious.
3. Abdominal cellulitis: There is no peritonitis in the extraperitoneal rectal injury, abdominal pain is not heavy, but the infection easily spreads along the periorbital space of the rectum, causing pelvic cellulitis, posterior rectal infection, sciatic rectal fossa infection, etc. The symptoms are serious.
3. Combined injury: Due to the difference of combined injuries, the clinical manifestations of rectal injuries may be very different, even the performance of combined injuries is the main cause of rectal injury but missed diagnosis, such as combined bladder, urethral injury, can be expressed as blood And/or urine mixed with feces.
Precautions
(1) Taboo enema: Regardless of the type of examination, it is absolutely forbidden to inject air, water, tincture or other substances into the anal canal to prevent the infection from accelerating.
(2) Pay attention to the characteristics of penetrating injury: In the rectal penetrating injury, the number of perforations is usually double number, that is, there is a perforation on one side and a perforation on the opposite side, which cannot be ignored.
(3) Prevention of missed diagnosis: rectal injury is easily missed in the following cases:
1 When there are a large number of wounded or wounded patients with multiple perforation injuries, rectal injuries are easily missed, especially when there are only small perforation injuries in the perineum.
2 In the case of shock and multiple fractures and misplacement, the diagnosis of rectal injury is easily affected. A few cases often require sigmoidoscopy to be found.
3 below the peritoneal reentry, the damage above the levator ani muscle, because the early symptoms are light, easy to ignore, but if there is a history of obvious trauma, the diagnosis is not difficult.
(4) Pay attention to rectal injury information:
1 closed injury, if you can carefully analyze and examine the history of trauma and clinical manifestations, most can be diagnosed, the clinical manifestations vary depending on the location of the injury, the degree and the morning and evening of the visit. After the patient is admitted to the hospital, the patient's condition is quickly estimated, not only the abdomen and the pelvis. Also pay attention to whether there are combined injuries in other parts of the body.
2 firearm injuries, should be from the entrance, exit, size, direction, route and injury time of the firearm, posture and posture when injured, often indicate whether there is a rectal injury, blood loss from the anal canal after injury is a rectal injury Strong evidence, such as abdominal pain and peritoneal irritation, indicates that there is an intraperitoneal rectal injury. If you can not urinate after the injury or have blood and feces in the urine, or have urine from the anal canal, it indicates a bladder or urinary tract injury. Any open injury of the genitals, appendix, buttocks, thighs, and lower abdomen. If there is fecal self-mouth overflow, rectal injuries should be considered. For example, traumatic injury occurs during rectal injury, and other organ injuries, such as pelvic fractures. , large vascular injury, retroperitoneal hemorrhage and extensive soft tissue injury.
Examine
Examination of rectal injury
1. Digital rectal examination: The following conditions should be routinely used for digital rectal examination:
1 Anal canal injury caused by violence, such as a bruise or a fall injury.
2 anal stab wound.
3 pelvic crush injury, lower abdominal kick.
4 After the injury, there is anal bleeding, rectal examination can not only find the size and quantity of the wound, but also determine the anal sphincter injury, provide a reference for treatment, the rectal examination is often stained with blood or urine, such as the injury site Low, can be broken, the swelling area and swelling can be diagnosed, the positive rate can reach 80%.
Negative finger test, still suspected of rectal injury, can be used for rectal examination if the injury is allowed, but not as a routine, abdominal X-ray film and anterior, posterior and lateral pelvis, which is helpful for diagnosis.
2. Vaginal digital examination: vaginal diagnosis of married women suspected of rectal injury, also helpful for diagnosis, can touch the rupture of the anterior wall of the rectum, and whether the vaginal rupture is combined.
3. Endoscopy: For patients with negative digital examination, rectal or sigmoidoscopy can be found in rectal rupture that has not been reached or missed. Because it can visually damage the location, extent and severity, it can often provide a basis for treatment.
4. X-ray examination: It is also an indispensable means to diagnose rectal rupture. It is found that the free gas under the armula indicates the rupture of the intraperitoneal rectum. Through the pelvic phase, the pelvic fracture condition and the metal foreign body can be understood. When the pelvic wall soft tissue sees bubbles, Tips for rupture of the extraperitoneal rectum.
Although rectal angiography is helpful for diagnosis, it can aggravate the pollution and spread the infection. The disadvantages are greater than the benefits, so it should be classified as a contraindication.
5. Blood routine examination: white blood cell count and neutrophilia.
Diagnosis
Diagnosis and identification of rectal injury
diagnosis
(1) Injury: According to the direction and path of the injury, it is often possible to determine whether there is a rectal injury. Any wound in the lower abdomen, perineum or buttocks may damage the rectum. Intraperitoneal rectal injury is accompanied by peritonitis. Abdominal pain is more severe than extraperitoneal rectal injury.
Closed injury across the pelvis, although there is no injury, but according to the pelvic fracture, the possibility of rectal injury should also be considered. Because the rectum is inactive, the front is the force of action, and the back has the tibia, which is easy to damage the rectum.
(2) anal bleeding: rectal or anal canal injury often causes anal bleeding hemorrhagic fluid, which is an important marker for the diagnosis of rectal or anal canal injury.
(3) Visceral prolapse: In some serious rectal injuries, there may be a large omentum or small intestine in the perineal or anal canal.
(4) with bladder combined injury: dysuria or blood or feces in the urine, or urine from the anus and wounds.
(5) Rectal examination: When the anal canal or rectum is injured, the rectal examination can find the injury site, the size and number of the wound. When the injury position is high, the diagnosis can not be achieved and the finger infection is a clear indication. The rectal examination can still determine the damage of the anal sphincter to provide a reference for treatment.
(6) Anorectal microscopy: The location, extent and severity of the injury can be clearly seen.
(7) X-ray examination: intra-abdominal rectal injury sometimes has intra-abdominal free gas, especially underarm, but no free gas can not rule out the existence of rectal injury, pelvic X-ray film, pelvic fracture misalignment helps Judging the diagnosis of rectal injury, it is reported that about 21% of rectal warfare is accompanied by the retention of foreign bodies, which is helpful for the diagnosis of rectal injury according to the location of the wound and foreign body.
Differential diagnosis
Mainly should be identified with peritonitis and colon injury.
