What is Intestinal Trauma (Gut Injury)?
Intestinal trauma, or damage to the intestines, can happen due to direct blows or piercing injuries to the abdomen. This can cause various degrees of harm, ranging from minor intestinal bruising to severe rotting of the intestines. Handling such injuries requires varied approaches, so healthcare providers need to be knowledgeable about assessing, diagnosing, and treating intestinal damage. If not identified and treated correctly, intestinal trauma can cause serious health complications and even death.
What Causes Intestinal Trauma (Gut Injury)?
Damage to the intestines can happen either from a hard impact (blunt trauma) or a wound that breaks the skin (penetrating trauma). Most of the time, blunt trauma to the abdomen doesn’t cause harm to the intestines. However, in about three percent of cases, it does cause injury, most commonly to the small intestine.
On the other hand, puncture wounds or cuts (penetrating trauma) are less common but are more likely to cause damage to the intestines. This type of trauma can be high-energy, like from a bullet, or low-energy, like from a stabbing incident.
Risk Factors and Frequency for Intestinal Trauma (Gut Injury)
Injury is a top reason for mortality in individuals under 44 years old. This issue predominantly affects males, who account for about 80% of cases. Intestinal damage is the third most frequent result of a blunt force to the abdomen, coming after spleen and liver injuries.
If the injury is caused by a penetrating object, the small intestine is usually injured the most, followed by the colon. With stab wounds, the likelihood of intestinal injury can range from 30% to 83%, depending on a person’s Body Mass Index (BMI). Interestingly, higher BMI seems to provide some protection in cases of abdominal stab wounds, resulting in less severe injuries and lesser need for surgery.
- Injury is a top reason for mortality in people aged 44 and under.
- About 80% of cases are men.
- Intestinal damage ranks third in injuries caused by blunt forces to the abdomen, after spleen and liver injuries.
- For penetrating injuries, the small intestine is usually the most affected, followed by the colon.
- In cases of stab wounds, the probability of intestinal injury is between 30% to 83%, based on the person’s BMI.
- People with higher BMIs have some degree of protection against stab wounds to the abdomen, leading to less severe injuries and lesser need for surgeries.
Signs and Symptoms of Intestinal Trauma (Gut Injury)
Patients with trauma should be evaluated in an orderly way, starting with a primary assessment. After this, medical teams should look for other injury signs during a secondary assessment, using other tests if needed. In this stage, they will look at the patient’s belly for visible signs of trauma and any pain, granted the patient can feel and respond to it. In situations of blunt trauma to the belly (like from a car crash), if a seatbelt mark is visible, the risk of a small intestine tear increases by almost five times. In the case of penetrating trauma (like stabbings), the number and location of wounds can help figure out likely injuries.
While physically examining the patient, doctors should also keep an eye on their vital signs and try to understand how the injury occurred. Knowing how the injury happened gives important clues about the type of injury the patient could have. If the situation allows and the patient is conscious, details about the patient’s medical and surgical history, lifestyle, allergies, and family health history should also be collected.
Testing for Intestinal Trauma (Gut Injury)
Alongside the initial personal history and physical examination, several methods can offer more insight into a trauma patient’s condition. These methods include x-rays of the chest and pelvis, a specialized form of ultrasonography for trauma known as FAST, a procedure known as diagnostic peritoneal lavage, CT scans, and laparoscopy.
Usually, x-rays of the chest and pelvis allow doctors to look for abnormalities like unusual chest profiles, bleeding in the chest, lung collapses, air under or anomalies of the diaphragm, and particularly unstable fractures in the pelvis. Additionally, radiographs can help in examining wounds from penetrating injuries to determine the type and path of the foreign object involved.
FAST, a type of ultrasonography used in trauma, helps identify the presence of fluid in specific areas that might suggest internal bleeding or damage to the intestine. However, FAST might not work as well in detecting bowel injuries.
Diagnostic peritoneal lavage is a technique used to decide if a surgical exploration of the abdomen, known as an exploratory laparotomy, might be beneficial for the patient. In this procedure, if the returned fluids after feeding warm saline into the abdomen show over 100,000 red blood cells or over 100 white blood cells per cubic millimeter, or evidence of food or bile, the patient is recommended for the exploratory laparotomy.
One of the most reliable imaging techniques for detecting intestinal damage is the CT scan. While it has high sensitivity and specificity, CT scans might still fail to identify intestinal damage in about 15% of patients suffering blunt abdominal trauma. These scans can pick up on free fluid, blood clots in the mesentery, presence of air in the peritoneal cavity, leakage of contrast material outside the intestines, and blunt injury to the vessel wall. For patients with penetrating injuries, the scans can also be useful in indicating foreign bodies and related visceral and bony injuries. Using intravenous contrast in CT scans can further enhance the evaluation of patients with abdominal trauma.
Diagnostic laparoscopy can avoid the need for surgical exploration of the abdomen in trauma patients who are stable. It’s used for assessing potential penetration of the peritoneum in tangential penetrating wounds, as well as suspected damage to the diaphragm and intestines in trauma affecting the chest and abdomen. Its reported accuracy, sensitivity, and specificity are all quite high.
Treatment Options for Intestinal Trauma (Gut Injury)
Treatment methods for intestinal injuries depend on the patient’s condition post-injury.
In cases of blunt injury where the patient is stable, management differs depending on their ability to undergo a physical exam. If the patient can have a physical exam, and there are no complicating factors like brain trauma, spinal cord injury or intoxication, they might not need further imaging. Instead, doctors monitor the patient with repeated abdominal exams for the next 24 hours. If a physical exam isn’t reliable, the patient needs a CT scan. The scan results could lead to hospitalization for monitoring or surgery if an injury is found.
Stable patients with penetrating injuries might avoid surgery if they meet certain criteria. However, a CT scan is still recommended regardless of whether a physical exam can be conducted. There’s an ongoing push towards treating more abdominal penetrating injuries without surgery, due to the high rate of unwarranted surgeries and associated complications.
Patients who are unstable require immediate attention. Those with blunt injuries would undergo a diagnostic or ultrasound examination. Positive results would lead directly to surgery. Meanwhile, unstable patients with penetrating injuries should be taken swiftly to the operating room for exploratory surgery.
During surgery, antibiotics are administered. The choice of antibiotic depends on the specifics of the injury—when unknown, broad-spectrum antibiotics are administered. Currently, guidelines suggest 24 hours of preventative antibiotics post-intestinal trauma repair and four days following infection control.
The surgery process itself is systematic, focusing first on stopping hemorrhage, then controlling contamination, diagnosing all injuries, and finally reconstruction. The surgeon must evaluate the extent, location, and patient’s status to decide on the correct approach, including primary repair, resection, or a damage control approach that defers definitive repair.
Certain injuries, like those involving the duodenum or the extraperitoneal rectum, require special consideration given their complex surrounding anatomy. In such cases, treatment would be tailored to the specifics of the injury. For instance, if only a specific segment of duodenum is injured, it could be repaired primarily, while significant damage may warrant complicated reconstruction procedures.
What else can Intestinal Trauma (Gut Injury) be?
When medical professionals evaluate injuries within the body, particularly the abdominal area, they break them down into different categories based on the parts of the body affected. These categories and types of injuries may include:
Hollow Organ Injury: This refers to injuries to organs that have a hollow space inside of them, such as:
- The esophagus: The tube that connects your throat to your stomach.
- The stomach: The organ where food is broken down.
- The small bowel: The part of the digestive system where most food is absorbed.
- The colon and rectum: Parts of your large intestine, where stools are formed.
Intra-abdominal Vascular Injury: This deals with injuries that affect blood vessels within the abdomen. This could lead to a rapid loss of blood resulting in acute blood loss anemia, a condition where your body doesn’t have enough red blood cells to deliver oxygen to your tissues.
Bowel Ischemia: This refers to a condition where the bowl doesn’t get enough blood, often due to an injury.
Mesenteric Hematoma: This is a blood-filled swelling in the tissues that hold the small intestines in place within your abdomen.
Bowel Wall Hematoma: This is a bruise that occurs within the wall of the bowel.
Solid-organ Injury: These are injuries affecting solid organs such as:
- The liver: The organ that processes the food and liquid you consume and filters harmful substances from your blood.
- The spleen: The organ that helps your body fight infection and filter old and damaged cells out of your bloodstream.
- The bladder: The organ that holds urine.
Retroperitoneal Injury: This term refers to injuries in the area at the back of your abdomen. This might include:
- A retroperitoneal hematoma: A blood-filled swelling in the area at the back of your abdomen.
- Pancreas injury: This refers to damage to the organ that helps in the digestion and regulates blood sugar.
- Kidney injury: This term refers to damage to the organ that filters waste products out of your blood.
What to expect with Intestinal Trauma (Gut Injury)
A patient’s outlook significantly depends on their overall health and the specific injury they have sustained. Patients who decide against treatment, perhaps due to their age or other factors, typically have a less favorable prognosis. Similarly, those who require a life-saving surgery but are not ideally suited for surgical procedures generally have a poorer prognosis, particularly if they have other existing health conditions.
The mortality rate for traumatic intestinal injury varies significantly, ranging from 8% to 87%, with an average rate of around 25%. The higher mortality rates were notably associated with instability in the patient’s blood circulation.
Possible Complications When Diagnosed with Intestinal Trauma (Gut Injury)
If an injury to the intestine isn’t picked up right away, such as in the case of a trauma, it can lead to worse outcomes for the patient. This is why doctors try to quickly diagnose this type of injury – even a delay of 1 to 1.5 hours can raise the risk of patients dying.
Another situation that can complicate things is what is known as a delayed presentation. This happens when patients are treated without surgery after an injury, and they have no signs of intestinal damage at first. But later on, symptoms start to show, leading doctors to realize that the intestine was injured. Usually, this happens when patients are treated for other injuries they got in the same incident but not operated upon. However, the safety of delaying surgery in these situations is a subject of debate.
There can also be complications when the intestine is injured and starts bleeding. This can make it harder for doctors to put the intestine back together as it should be. Patients who need more blood products because of their injuries are more likely to have problems with their intestines not being correctly connected. Signs of bleeding in the intestine can be seen on a CT scan. If a doctor sees signs of bleeding during a surgery, they will likely do a thorough inspection and handling of the structures inside and behind the abdomen. If they see the source of the bleeding, they will likely repair it or tie it off. If they can’t find a specific source, they may attempt to pack the area.
There’s also a risk of contents from the intestine leaking out after it’s been repaired. This can be a serious problem and even cause death. The rate of this happening is around 5% to 8%. Factors that seem to raise the risk are a higher Injury Severity Score, needing more fluids during surgery, and needing more blood products. It doesn’t seem to make a difference whether the repair is done with hand-sewing or with staples.
Recovery from Intestinal Trauma (Gut Injury)
Doctors used to wait for the patient’s digestive system to start working again before they’d begin feeding them, particularly after an injury that required intestinal repair. However, recent studies suggest that it’s both safe and effective to start feeding them earlier. This early feeding does not increase the risks of leaks or blockages. It has been found that starting nutrition within 24 to 48 hours after the repair is safe and can actually speed up recovery. Also, it’s unnecessary to use specific drugs like metoclopramide or erythromycin after this kind of surgery. But doctors should monitor patients closely for symptoms like bloatedness, and nausea and vomiting.
While there aren’t specific guidelines for patients who’ve undergone intestinal trauma, the recommendations for critical care and surgery patients can be used. These guidelines suggest enteral nutrition, or feeding directly into the gut, in seriously ill and mechanically ventilated patients. If patients are on stable doses of medications that narrow blood vessels (vasopressors), enteral feeding can continue. But for patients with low blood pressure or needing more vasopressors, enteral feeding should be put on hold until they’re stable. During enteral feeding, the patients should be watched for signs of lack of blood supply to the gut, such as distension, pain, and worsening acidosis.
The ASPEN recommends enteral nutrition for the critically ill who can tolerate it. This can be done in one big dose, which causes fewer interruptions, or through continuous feeding, with no difference in survival rates. Some measures that help prevent lung infection due to food or liquid entering the airways include keeping the patient’s head elevated at a 30 to 45-degree angle and using a mouthwash called chlorhexidine twice daily for those on a breathing machine. While it’s still disputed whether small or full-strength tube feeds are best, especially for intestinal trauma patients, the guidelines suggest stepping it up for those who had poor nutrition before hospitalization. On the other hand, patients who weren’t malnourished didn’t benefit from full-strength feeding compared to small doses. But those at high risk, as determined by a specific nutrition risk score, did better when 80% or more of their target feed was reached.
The ASPEN recommends against measuring how much feed is left in the stomach (gastric residual volumes). It doesn’t help prevent lung infection due to food or liquid entering the airways. Monitoring physical exams and x-rays for signs of distension are a better idea. However, if gastric residuals are used, feeding should not be stopped unless there’s more than 500 ml left, or if there are other worrying signs. If the patient can’t tolerate enteral nutrition, they should be fed through a vein (parenteral nutrition) after about seven days, but doctors should check each day whether enteral feeding can be started.
The best way to treat patients with an intestinal injury who also have low blood pressure isn’t clear. Both medications that narrow blood vessels and large fluid resuscitation have been linked with anastomotic leaks, or leaks from the surgical junction in the intestine. A review in 2017 found higher death rates with vasopressor use but recommended more research as most studies were retrospective. For now, it might be better to avoid vasopressors and use fluid resuscitation instead.
If there’s no injury to the urinary or genital tract, there’s no need to keep a catheter in and it should be removed early after surgery. There’s no definitive guideline on when to remove it after an intestinal injury, but it’s usually removed the day after surgery unless the surgery was on the middle to lower part of the rectum. In this case, it’s better to remove it between three to six days after surgery to reduce the risk of being unable to urinate.
Preventing Intestinal Trauma (Gut Injury)
Intestinal injuries can happen in many different ways. This means that in order to prevent such injuries, we need to address all the most common causes. The main sources of these injuries are car accidents, gunshot wounds, and stabbings. It is suggested that education programs in communities that focus on safe driving could help lower the number of car accidents. Similarly, teaching about how to safely handle and store firearms could reduce accidental injuries. Additional partnerships with local groups might be necessary to tackle the risk of community violence, which leads to the remaining injury cases.