What is Rectal Trauma (Injury to the Rectum)?
The approach to treating injuries to the rectum has significantly developed over the past 80 years. A lot of these changes have been influenced by lessons learned during times of war. For instance, during World War II, Sir William H. Ogilvie, a military surgeon at the time, introduced the concept of managing all injuries to the colon and rectum by creating an opening to the outside of the body. This practice stuck around even in civilian medical treatments after the war. During the Vietnam War, the concept of draining the area before the tailbone (prehistoric drainage) and cleaning out the lower part of the rectum started to gain popularity. This completed the widely accepted four-step approach (cleaning out dead tissue, creating an opening, enabling draining and cleansing the lower rectum).
In 1979, a ground-breaking study by Stone and Fabian compared the traditional method of managing rectal injuries with direct repair. This sparked a series of changes in how such injuries were managed. Over the next twenty years, further research showed that directly repairing the injury or removing and reattaching the injured parts was much more beneficial for most injuries to the colorectum. Moreover, for injuries that occur outside the main body cavity, strategic control of fecal matter was preferred.
A study conducted in 1994 inspected previous cases involving serious colon injuries. They discovered a 14% complication rate with the direct reattachment approach. Upon further analysis, it was found that patients with pre-existing chronic diseases or those needing large amounts of red blood cell transfusions within 24 hours had a high complication rate of 42%, and out of these, a third died as a result of the complications.
What Causes Rectal Trauma (Injury to the Rectum)?
Most injuries to the rectum are due to sharp objects piercing the skin, if we set aside causes like medical procedures, sexual activity, and foreign objects. Specifically, 85 to 90% of these injuries come from gunshot wounds and around 5% are from stab wounds. Around 5 to 10% of rectal injuries happen because of blunt trauma or force, with 1 to 2% happening together with fractures in the pelvic area, usually caused by strong pressure applied from front to back.
Risk Factors and Frequency for Rectal Trauma (Injury to the Rectum)
Rectal trauma incidents account for 1 to 3% of cases in civilian trauma centers, and this figure increases to 5% in recent military conflicts. In military situations, the injuries are often more severe, involving high-speed weaponry, blast damage, fragmentations, and burns.
Signs and Symptoms of Rectal Trauma (Injury to the Rectum)
When treating a trauma patient, a systematic procedure must be followed according to the Advanced Trauma Life Support (ATLS) Program. It starts with a general assessment of the patient before focusing on distinct injuries. This approach involves a step-by-step evaluation, including an initial survey, resuscitation, comprehensive secondary survey and continuous reassessment during these steps.
The initial survey’s goal is to identify any immediate and life-threatening injuries. It follows a sequence defined by the ATLS, which involves safeguarding the airway, ensuring proper breathing and circulation (controlling any bleeding if necessary), assessing neurological status, and complete exposure of the patient. Securing a clear airway takes precedence over other steps, regardless of the injury’s nature or location. But it’s crucial to follow the protocol systemically.
- Airway assessment and management
- Ensure correct breathing or ventilation
- Check circulation, control bleeding if necessary
- Assess neurological status
- Patient’s full exposure to identify any injuries
During the initial assessment, the patient must be fully exposed and can be turned to both sides to not miss any hidden injuries. The inspection includes checking the perineum, buttocks, lower backside area, and any folds in the groin region. Back, flanks, and armpit areas must also be checked.
Finding rectal injuries requires a keen eye, especially in patients with penetrating wounds. The possibility of such injuries should increase if there are penetrating wounds to the lower abdomen, pelvis, perineum, buttocks, or thighs. Number and locations of these wounds should be noted to investigate the trajectory of the foreign object. An odd number of wounds should prompt suspicion that a foreign object might still be inside the patient.
For larger penetrating wounds like those caused by a knife or a spear, it is advised not to remove them until the patient is in a controlled environment like an operating room.
For patients who are stable and fully aware, it is important to take a detailed history of the events surrounding their injury. Questions about the event, distance of the projectile when fired, the weapon’s type, if known, should be asked. It’s essential to learn about previous medical and surgical history, current medications, and known drug allergies of the patients.
Testing for Rectal Trauma (Injury to the Rectum)
When diagnosing a trauma patient, doctors often use a procedure called the focused assessment with sonography for trauma (FAST) examination. This technique involves using bedside ultrasonography, which is a standard procedure. It enables them to conduct multiple evaluations at once during the initial patient assessment. One key aspect of this examination is looking at the suprapubic area (above the pubic bone) and the pelvic cul de sac (a pouch near the uterus).
If fluid is detected in this region, this could suggest several health issues, including internal bleeding in the abdomen, damage to the hollow organs of the digestive tract, or the presence of ascites (abnormal fluid buildup in the abdomen). However, it’s important to note that at least 200mL of fluid is needed for it to be detected within the abdominal cavity. The FAST examination has been found to correctly identify trauma 69.8% of the time (sensitivity) and accurately exclude trauma 92.1% of the time (specificity).
If the FAST result is positive (i.e., it shows an issue), the next steps will depend on the patient’s condition. In stable patients, the findings can be checked again using a computed tomography (CT) scan. On the other hand, an unstable patient showing positive results will need immediate surgery.
In the past, if doctors suspected penetrating rectal injury (damage caused by an object piercing the rectum), a digital rectal exam would conventionally be conducted as part of the damage assessment. Recently, however, the usefulness of this procedure has been disputed. The main reason is that it only detects injuries correctly about 51% of the time and it could potentially worsen rectal perforations. Instead, they may use a tool like a proctosigmoidoscope to visualize rectal damage more effectively, a procedure that should be conducted by an experienced senior physician.
If an injury is not directly visible, detecting blood using this tool can indicate rectal injury with a 90% success rate. With a CT scan, doctors can also evaluate the path of the penetrating object and any other injuries present. If doctors notice blood in the patient’s urine during catheter insertion, they may also use a CT cystogram to check for potential bladder injury.
Treatment Options for Rectal Trauma (Injury to the Rectum)
The management of rectal trauma is dependent on the patient’s physiological condition and the details of their injury. If the patient is physically unstable with extensive blood loss, it’s often necessary to take them to the operating room for immediate surgery, since the injury often results from gunshot wounds or severe pelvic fractures.
If the patient is stable, the plan for treating the rectal injury depends on where and how severe the wound is. The rectum is partially inside and partially outside the abdomen, which determines the type of treatment. For wounds that are inside the abdomen, like colon injuries, broad-spectrum antibiotics are given and the wound is repaired. If the wound is minor (involving less than 50% of the rectum), repair is done. If it’s severe (more than 50%) the affected part of the rectum is removed and the healthy tissue is reconnected.
The necessity of diverting feces away from the wound site has been a topic of debate. In the past, doctors thought it was necessary to decrease the risk of infection after surgery. However, numerous studies have compared primary repair (repairing the wound immediately) with fecal diversion, and found that primary repair often has lower mortality rates and fewer wound complications. Importantly, creating a fecal diversion (also called an ostomy) can lead to its own complications, like hernias and wound infections.
There are some specific situations where fecal diversion is still employed. If the wound is extensive, or involves fractured pelvis bones or disrupted blood supply to the rectum, fecal diversion may be safer. For wounds on the outside portion of the rectum, there’s ongoing debate about whether to use fecal diversion, drain the area above the tailbone, or wash out the rectum.
However, in severe cases, such as war-related injuries that result in massive damage to the area in front of the lower part of the spine and large tissue damage, fecal diversion is usually necessary. Lastly, in rectal trauma cases where the bladder has also been injured, fecal diversion isn’t necessary and doesn’t seem to affect the patient’s outcome.
What else can Rectal Trauma (Injury to the Rectum) be?
Doctors should be highly alert to the possibility of rectal injury if a penetrating wound is found in areas such as the lower abdomen, pelvis, buttocks, or thighs. When treating injuries in these areas, doctors must also consider and rule out the possibility of other conditions that may also result from the trauma – including injuries to the portion of the rectum that’s either inside or outside the peritoneal cavity (the space within the abdomen that contains the intestines, stomach, and liver), damage to blood vessels, or harm to the bladder. In case of a penetrating injury, doctors need to check for any damage to other major organs or blood vessels since these could also be affected by the impact.
What to expect with Rectal Trauma (Injury to the Rectum)
The overall outcome for patients who experience rectal trauma depends on various factors. These include patient’s age, co-existing health conditions, the stability of their vital signs, additional injuries, and the location of the injury within the abdomen. Despite improvements in trauma treatment guidelines, the death rate still ranges between 3% and 10%, with a further 18% to 21% of patients experiencing other health complications.
A study conducted between 2004 and 2015 reviewed patients who suffered from a traumatic rectal injury treated at 22 major trauma centers. This study found that patients with injuries located within the abdomen, who then underwent a specific type of diversion procedure, experienced more abdominal complications than those who did not undergo this procedure (22% vs. 10%). The study also identified other risk factors contributing to abdominal complications, including severe injuries or injuries resulting from penetrative trauma. However, the death rate remained the same for all patients (3% vs. 2%), excluding those who passed away in the first 48 hours upon hospital arrival.
Regarding injuries located outside the abdomen, the prognosis was similar. This same study found no difference in mortality rate, even with the performance of a diversion procedure (2% vs. 1%), when excluding those who died within the first 48 hours of hospital admission. Further analysis showed that independent risk factors for complications with these types of injuries were those who received a specific rectal washout and those who had a drain placed in the area in front of the tailbone.
In cases of severe injuries located outside the abdomen, while a diversion procedure and creation of an ostomy (a new way for waste to leave the body) is only selectively indicated, it’s important to mention. This is because the procedure itself can lead to complications in 25% to 55% of cases.
Possible Complications When Diagnosed with Rectal Trauma (Injury to the Rectum)
Bowel injuries can lead to an increase in the risk of infection and complications with rectal repair or rejoining of the intestine’s ends. Factors that contribute to these complications include fecal contamination, high blood loss, or unstable blood flow. Serious complications can also arise directly from rectal injuries. These might include:
- Infections of the wound
- Abdominal or pelvic abscesses
- The development of a fistula or an abnormal connection between two parts of the body
- Fascial dehiscence, which is the breaking open of a surgical wound
- Bacteremia, or bacteria presence in the blood
- Necrotizing fasciitis, a severe bacterial skin infection
Non-life-threatening conditions that can affect a person’s lifestyle can include ostomy maintenance and fecal incontinence or lack of control over bowel movements.
There is plenty of research that cautions against unnecessary ostomy creation, despite this, some studies still show a high rate of ostomy creation in rectal trauma cases. Ostomy complications might include:
- Parastomal hernias, or hernias that develop around the stoma
- Stenosis or narrowing of the stoma
- Retraction or pulling in of the stoma
- Metabolic imbalances
Lastly, reversing an ostomy also carries an infection risk for the local wound, which can range from 3 to 20%.
Preventing Rectal Trauma (Injury to the Rectum)
Some experts suggest that removing hard stool from the rectum by hand might aid in the early stages of healing. Similarly, it’s important for patients to consume a high-fiber diet and begin taking stool softeners early on during their recovery period. These steps can help improve the health and function of their bowels.