Intestinal injuries: causes, symptoms, diagnosis, treatment

The greatest number of traumatic injuries to the intestines occurred during wartime - these were mainly gunshot wounds and closed injuries due to the impact of a blast wave. During the Great Patriotic War, injuries to the colon accounted for 41.5% of all wounds to hollow organs. Of all closed injuries to abdominal organs, 36% were closed injuries to the intestines; in 80% of cases, the small intestine was damaged, and in 20%, the large intestine.

In peacetime, intestinal injuries are much less common.

Attempts have been made to classify traumatic bowel injuries. However, these classifications have not found application due to their complexity. In our opinion, the most acceptable for practical work is the classification proposed by A. M. Aminev (1965), which is based on the etiological principle and anatomical localization of injuries to the rectum and colon. The disadvantages of this classification include the lack of indications of damage to the small intestine.

Intestinal damage due to closed abdominal trauma in peacetime is observed in transport accidents, falls from height, strong compression, for example, between the buffers of carriages. The degree of intestinal damage may vary: contusion of the intestinal wall, multiple and single ruptures up to a complete transverse rupture of the intestine.

In cases where the force is applied non-perpendicular to the abdomen (oblique direction): the intestine may be torn away from the mesentery at the fixation points (proximal jejunum and distal ileum).

Since the injuries in closed abdominal trauma are usually combined, significant difficulties arise in diagnosis. Clinical signs of intestinal rupture include acute abdominal pain at the time of injury, rapid pulse, tenderness and tension of the abdominal wall muscles during abdominal palpation. Percussion reveals a decrease in the size of liver dullness due to gas accumulation in the subdiaphragmatic space. Obvious signs of peritonitis appear some time after the injury.

Open intestinal injuries occur as a result of abdominal wounds (gunshot, knife or any sharp object).

The clinical picture of acute injuries is dominated by abdominal pain of varying intensity, vomiting, increased pulse rate (over 100 per 1 min), abdominal muscle tension, and sharp pain on palpation. Percussion of the abdomen reveals dullness in the iliac regions due to fluid accumulation (spillage of blood, intestinal contents, or inflammatory effusion). Stool retention is noted. Gases do not pass. Abdominal distension and the absence of peristaltic noise on auscultation indicate the presence of intestinal paresis.

A significant place in the diagnosis of open and closed intestinal injuries is given to X-ray examination of the abdominal cavity, which makes it possible to identify the appearance of free gas, accumulation of fluid in the lateral parts of the abdomen, and paralytic intestinal obstruction.

Treatment of intestinal injuries is surgical. The method of surgical intervention is chosen depending on the nature of the damage.

In addition to the above-described intestinal injuries, there are injuries classified by A. M. Aminev (1965) and B. L. Kandelis (1980) as household injuries (intestinal damage during medical procedures, pelvic bone fractures, operations on other organs, intestinal damage by foreign bodies, intestinal burns, etc.).

A. M. Aminev divides intestinal damage during medical procedures into 3 groups:

1. minor injuries (excoriation, cracks, tears of the transitional fold of the anal ring and mucous membrane). Such types of injuries do not require treatment, they heal quickly;
2. moderate injuries (extraperitoneal dissection of the rectum, intestinal damage without disruption of the integrity of the peritoneum);
3. severe injuries with disruption of the integrity of the peritoneum or surrounding organs, complicated by infection of the abdominal cavity or cellular spaces.

Mechanical damage to the rectum can be observed during rectal thermometry, examination in mirrors, cleansing and therapeutic enemas. We often had to see during a rectoscope examination superficial traumatic damage to the intestinal wall caused by an enema tip when the procedure was performed insufficiently professionally. As a rule, this was a triangular-shaped defect of the mucous membrane located along the anterior wall of the rectum at a distance of 7-8 cm from the anus.

Despite the fact that rectoscopy is considered a routine examination and is widely used in clinical and outpatient practice, in some cases it can be accompanied by complications, the most severe of which is perforation of the rectum and sigmoid colon.

Perforation can be caused by several reasons: violation of the examination technique, pronounced pathological changes in the intestinal wall, restless behavior of the patient during the examination.

Clinical manifestations of complications depend on the size of the perforation, as well as on the virulence of the intestinal microflora and the degree of intestinal cleansing before the examination.

At the moment of damage to the intestinal wall during rectoscopy, the patient experiences mild pain in the lower abdomen, sometimes nausea. These symptoms soon disappear. Only after 2 hours do signs of a developed complication appear.

In the last decade, such a method as fibrocolonoscopy has become widely used in clinical practice. The importance of this method for diagnosing colon diseases is difficult to overestimate. However, there are reports of complications during colonoscopy, the most dangerous of which are perforation and bleeding.

Intestinal perforation may occur due to injury to the intestine by an endoscope, distension of the intestine by pumped air, or pathological changes in the intestinal wall (cancer, nonspecific ulcerative colitis, Crohn's disease, diverticular disease).

Bleeding is observed during biopsy of vascular formations (hemangiomas), after multiple biopsies in patients with ulcerative colitis and Crohn's disease, and also after electrocoagulation of polyps.

According to experts, any complication after colonoscopy is the result of a violation of the examination technique. Practice shows that the frequency of complications decreases as the endoscopist gains experience and the examination technique improves.

Damage to the anal area and rectum by sharp and blunt objects is a type of injury that is quite rare. The term "fall on a stake" was used to describe such an injury in 19th century literature. Cases of falling on a mop handle, a ski pole, an umbrella handle are described. The injury results in acute pain in the anus, even to the point of pain shock, and bleeding. There is an urge to defecate, and the passage of feces and gases through the wound channel. Injuries of this type result in extensive and severe damage, such as rupture of the walls of the rectum and sphincter, perforation of the pelvic peritoneum, and damage to nearby organs.

Cases of damage to the rectum and sigmoid colon during gynecological and urological operations, medical abortions and obstetrics are described. Rectal injury leads to infection, resulting in numerous complications (cystitis, pyelitis, phlegmon, rectovaginal and other fistulas, peritonitis).

Intestinal damage by foreign bodies. As is known, foreign bodies enter the intestines when swallowed, introduced through the anus, penetrated from adjacent organs and formed in the intestinal lumen (fecal stones).

Small swallowed objects usually move through the digestive tract unhindered and are eliminated naturally. An emergency situation occurs when a foreign body damages the intestine or leads to the development of obstructive obstruction.

Sharp foreign bodies can cause perforation of any part of the intestine with the formation of an abscess, which during examination and even during surgery can be mistaken for a malignant tumor.

Foreign bodies sometimes enter the rectum through the anus during medical procedures (most often an enema tip), rectal masturbation, and are also the result of criminal acts. Foreign bodies can also penetrate the intestines from adjacent organs and tissues, for example, with gunshot wounds.

Casuistry includes cases when napkins and gauze tampons left in the abdominal cavity during surgery penetrated into the intestine through the resulting bedsore and exited naturally through the anus.

Finally, we should mention foreign bodies that form in the intestinal lumen - fecal stones. It is believed that with normal intestinal function, the formation of fecal stones is unlikely. Certain conditions are required for a stone to form and remain in the intestinal lumen for a long time. One of the main conditions is difficulty in evacuating intestinal contents, which occurs due to a number of reasons (scar strictures of the intestine, impaired innervation, intestinal atony).

In the center of the fecal stone there are dense indigestible particles. These include fruit pits, barium sulfate suspension, gallstones, etc. Gradually the stones are "enveloped" in feces, soaked in salts, and acquire significant density. Some types of long-term medications (sodium bicarbonate, bismuth nitrate, magnesium salts) can contribute to the compaction of stones. Such dense stones soaked in salts are called true coprolites, in contrast to false ones, which do not have time to soak in salts and remain softer. False coprolites can exit through the anus on their own after oil enemas or can be removed through the anus with a finger (completely or in parts). An example of false coprolites are fecal stones formed in elderly patients suffering from intestinal atony.

To remove true coprolites of a large size, it is necessary to resort to operations (laparotomy, proctotomy). Unrecognized fecal stones can cause intestinal perforation or lead to intestinal obstruction.

Spontaneous ruptures of the rectum. This includes traumatic ruptures of the rectum due to increased intra-abdominal pressure. The immediate cause of such trauma is usually a significant one-time increase in intra-abdominal pressure during lifting weights, defecation, urination, a blow to the abdomen, a coughing thrust, a fall, or during childbirth. A pathologically altered rectum is more susceptible to rupture. Therefore, spontaneous ruptures can most often be observed in people suffering from rectal prolapse, since with this pathology the intestinal wall becomes thinner and sclerotic.

Signs of a ruptured intestine include sharp pain in the lower abdomen and anus at the moment of rupture, bleeding from the anus. Often, loops of the small intestine fall out through the anus.

Chemical burns of the rectum and colon. Burns of the mucous membrane of the rectum and colon occur when ammonia, concentrated sulfuric acid, or certain substances are accidentally introduced into the rectum for therapeutic purposes.

The characteristic clinical symptoms of chemical burns of the rectum and colon include pain localized in the lower abdomen and along the colon, frequent urges, and the release of blood and bloody films from the anus. In severe cases, vomiting, chills, and fever are observed.

According to the data of V. I. Oskretov et al. (1977), the introduction of 50-100 ml of ammonia into the rectum in an experiment caused a burn of the rectum and distal sigmoid colon, 400 ml - a burn of the entire colon.

Treatment of patients with chemical lesions of the colon mucosa begins with rinsing the intestines with warm water (3-5 l) or a neutralizing solution (if the substance that caused the burn is known). In addition, analgesics, sedatives, and cardiovascular agents are administered. Then oil microclysters are prescribed (fish oil, sea buckthorn oil, rose hips, tampons with Vishnevsky ointment). In case of severe burns (intestinal wall necrosis), treatment is surgical.

Ruptures of the intestine from the effects of compressed air have been known in the literature since the beginning of the 20th century. This injury was first described by G. Stone in 1904. Most often, such damage is the result of careless handling of a hose from a cylinder with compressed air. A stream of air penetrates through the anus into the intestine, ruptures it and fills the abdominal cavity. In this case, the ampulla of the rectum, protected during inflation by the walls of the small pelvis, is usually not damaged. Ruptures occur in the supraampullar region, located above the pelvic diaphragm, and in various parts of the large intestine.

Most often, ruptures are localized in the area of flexures (rectosigmoid section, curvature of the sigmoid colon, splenic flexure). As a result of injury, fecal matter is sprayed across the abdominal cavity under the influence of compressed air. If the parietal peritoneum ruptures simultaneously with the intestine, intermuscular and subcutaneous emphysema occurs. The phenomena of extra- or intraperitoneal bleeding associated with vascular damage increase. Delay in surgery contributes to the development of pelvic peritonitis.

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