Injury of the colon and rectum

　　One, Colon injury

　　It belongs to hollow viscus injury. After colon rupture, the intestinal contents overflow and stimulate the peritoneum, causing peritonitis, which is consistent with the clinical manifestations of other hollow viscus rupture. However, the stimulation of colon contents to the peritoneum is lighter, so the clinical symptoms and signs of colon injury develop slowly, often not receiving timely diagnosis and treatment, which deserves vigilance. The clinical manifestations of colon injury mainly depend on the degree, location, time of visit after injury, and whether there is injury to other organs at the same time.

　　Two, Penetrating colon injury

　　Mainly manifested as post-injury abdominal pain, with symptoms of peritonitis, or fecal-like intestinal contents flowing out from an open wound. Non-penetrating colon injury has complex clinical manifestations, with abdominal pain as a common symptom. A few patients with colon injury may not have abdominal pain symptoms at the time of injury, more common in left-sided colon injury, because the contents of the left colon are dry and solid, and it is not easy for the intestinal contents to enter the peritoneal cavity after rupture, with less stimulation to the peritoneum. In patients with delayed colon rupture, the symptoms of abdominal pain improve for a while and then reappear. In patients with combined injury to other organs, shock occurs early. In the early stage of extraperitoneal colon injury, neither abdominal pain nor peritonitis symptoms are prominent. When there is obvious infection in the retroperitoneal space, there is tenderness in the lateral abdominal wall or lower back, and sometimes subcutaneous emphysema can be palpated. Nausea and vomiting are also common symptoms. Low colon injury can cause hematochezia or jam-like stools. Elevated body temperature is a late manifestation of peritonitis.

　　Three, Colonoscopy

　　The colon injury caused is during the examination process, with sudden severe abdominal pain, followed by symptoms of peritonitis. In addition to severe abdominal pain, the patient's general condition is poor, and under fluoroscopy, barium enters the peritoneal cavity.

　　1. Injuries are divided into open and closed injuries based on whether there is a wound on the body surface.

　　(1) Open injury: There is a wound on the abdomen or lumbar region, more common in stab wounds and gunshot wounds.

　　(2) Closed injury: There is no wound on the body surface, mostly caused by blunt force, such as crush injuries.

　　2. Injuries are divided into intra-peritoneal and extra-peritoneal injuries based on whether the wound is connected with the peritoneal cavity.

　　(1) Intra-abdominal injury: The wound of the colon communicates with the peritoneal cavity, and the intestinal contents enter the peritoneal cavity, with symptoms of peritonitis. It is more common in rupture of the cecum, transverse colon, sigmoid colon, and intraperitoneal part of the ascending and descending colon.

　　(2) Peritoneal extrinsic injury: The ascending and descending colon are partially located outside the peritoneum. After injury, the intestinal contents enter the loose connective tissue spaces in the retroperitoneal space, and once infected, it is easy to spread, with no obvious peritonitis symptoms. It is more common in stab wounds in the lumbar and thoracolumbar region.

　　4. Open injury

　　Patients can easily make a diagnosis based on the location of the open wound, the direction of the ballot or stab wound, and the manifestations of peritonitis. Most abdominal open wounds are penetrating injuries, almost all with abdominal organ injury, and the vast majority of these patients require laparotomy. If there is a stab wound in the lower back with fecal-like intestinal contents flowing out of the wound, a diagnosis of colonic injury can be made. The diagnosis of closed colonic injury is difficult and often accompanied by injury to other organs. If there is a rapidly progressive diffuse peritonitis with septic shock after injury, or if indirect violence causes lower abdominal pain that progresses to peritonitis with free gas under the diaphragm, it should be considered that there is a colonic injury. The diagnosis of iatrogenic colonic injury is relatively easy, and a diagnosis of colonic injury can be made if the patient develops abdominal pain and peritonitis during colonoscopy.

　　5. Determine if there is a colonic injury

　　It is a difficult problem in clinical practice. If there are obvious signs of peritoneal irritation and rectal bleeding, early surgical exploration should be performed. Sometimes free gas can be seen on abdominal plain films, retroperitoneal gas accumulation, unilateral disappearance of the psoas muscle shadow, and paralytic ileus. Fractures of the pelvis and lumbar spine suggest the possibility of large bowel injury. Peritoneal lavage is a useful diagnostic method and should be performed after abdominal plain films to avoid gas entering the abdominal cavity and affecting X-ray diagnosis. The lavage fluid should be examined for blood cells, bacteria, or amylase, and if one or more abnormal conditions are found, surgical exploration should be considered.

　　6. Extra-peritoneal rectal injury

　　It is more difficult to diagnose, and severe pelvic fractures usually involve a large amount of soft tissue injury and rectal injury. Routine digital rectal examination is very important, and rectoscopy or sigmoidoscopy may be necessary if necessary, which can detect the flow of bloody fluid and the site of injury.

　　Abdominal infection and septic shock are the main complications of colonic injury:

　　1. Abdominal infection diseases:Including acute cholecystitis and biliary tract infection, bacterial liver abscess, acute peritonitis, and secondary bacterial infection of acute pancreatitis. It is usually a mixed infection of anaerobic bacteria such as Enterobacteriaceae, Enterococcus, and Bacteroides species.

　　2. Septic shock:Also known as septic shock, it is a type of shock commonly seen in surgery and difficult to treat. Sepsis is an acute organ dysfunction secondary to infection, characterized by fever, chills, tachycardia, altered consciousness, and elevated white blood cell count. Essentially, it is a systemic effect caused by the invasion of pathogenic microorganisms into the body, leading to the massive release of inflammatory mediators. The above clinical signs are also known as the systemic inflammatory response syndrome (SIRS). When severe sepsis continues to develop and is accompanied by circulatory failure, it is called septic shock, also known as toxic shock, endotoxin shock, or septic shock.

　　1. Symptoms

　　1. Abdominal pain and vomiting: Perforation or severe damage to the sigmoid colon or rectum, and after feces in the intestinal lumen overflow into the peritoneal cavity, abdominal pain and vomiting occur. The pain initially localized to the puncture site then spreads to the entire abdomen, forming a diffuse peritonitis with generalized abdominal pain.

　　2. Peritoneal irritation sign: abdominal tenderness, muscle tension, and rebound pain. The pain at the puncture or rupture site is most pronounced.

　　3. The bowel sounds are weakened or even disappear.

　　4. Rectal examination: In cases of low rectal injury, the injured site can be felt as a hollow sensation, and bloodstains may be found on the glove. In cases of colonic injury, only a few have bloodstains.

　　5. Colonic injury belongs to hollow viscus injury. After colonic rupture, the overflow of intestinal contents stimulates the peritoneum, causing peritonitis, which is consistent with the clinical manifestations of other hollow viscus rupture. However, the stimulation of colonic contents to the peritoneum is lighter, so the clinical symptoms and signs of colonic injury develop slowly and are often not diagnosed and treated in time, which deserves attention. The clinical manifestations of colonic injury mainly depend on the degree of injury, location, time of medical consultation after injury, and whether there are injuries to other organs at the same time.

　　6. Penetrating colonic injury is mainly manifested by post-injury abdominal pain, with symptoms of peritonitis, or fecal-like intestinal contents flowing out from the open wound. Non-penetrating colonic injury has complex clinical manifestations, with abdominal pain as a common symptom. A small number of colonic injury patients may not have abdominal pain symptoms at the time of injury, which is more common in left-sided colonic injury. Because the contents of the left colon are dry and solid, the intestinal contents are not easy to enter the peritoneal cavity after rupture, causing little stimulation to the peritoneum. In patients with delayed colonic rupture, the symptoms of abdominal pain may improve and then reappear. In patients with associated injuries to other organs, shock may occur early. In the early stage of extra-peritoneal colonic injury, neither abdominal pain nor peritonitis symptoms are obvious. When there is significant retroperitoneal space infection, there may be tenderness in the lateral abdominal wall or lower back, and sometimes subcutaneous emphysema can be palpated. Nausea and vomiting are also common symptoms. Low colonic injury can cause hematochezia or jam-like stools. An increased body temperature is a late manifestation of peritonitis.

　　Second, classification

　　1. Injuries are divided into open and closed injuries based on whether there is a wound on the body surface.

　　(1) Open injury: There is a wound on the abdomen or lumbar back, which is more common in stab wounds and gunshot wounds.

　　(2) Closed injury: There is no wound on the body surface, and it is mostly caused by blunt force, such as crush injuries.

　　2. Injuries are divided into intra-peritoneal and extra-peritoneal injuries based on whether the wound is connected with the peritoneal cavity.

　　(1) Intra-peritoneal injury: The colon wound is connected with the peritoneal cavity, and the intestinal contents enter the peritoneal cavity, showing symptoms of peritonitis. It is more common in the rupture of the cecum, transverse colon, sigmoid colon, and intra-peritoneal part of the ascending and descending colon injuries.

　　(2) Extra-peritoneal injury: The ascending and descending colon are partially located outside the peritoneum, and after injury, the intestinal contents enter the loose connective tissue spaces in the retroperitoneal space, which are easily infected and can spread rapidly without obvious peritonitis symptoms. It is more common in stab wounds in the lumbar and thoracolumbar region.

　　3. Open abdominal injuries can be easily diagnosed based on the location of the wound, the direction of the bullet or stab wound, and the symptoms of peritonitis. Most abdominal open injuries are penetrating injuries, almost all of which have intra-abdominal organ injuries, and the vast majority of these patients require laparotomy. For example, a stab wound in the lower back with fecal-like intestinal contents flowing out of the wound can be diagnosed as a colonic injury. The diagnosis of closed colonic injury is difficult and often accompanied by injuries to other organs. If there is a rapid progression of diffuse peritonitis with toxic shock after the injury, or if indirect violence causes lower abdominal pain to progress to peritonitis with free intraperitoneal gas, it should be considered that there is a colonic injury. The diagnosis of iatrogenic colonic injury is relatively easy, as abdominal pain and symptoms of peritonitis can be diagnosed during colonoscopy.

　　4、判断是否有结肠损伤是临床上的一个难题，如有明显的腹膜刺激征和直肠出血，应尽早手术探查。在腹部平片上有时可看到游离气体，腹膜后积气，单侧腰大肌影像消失，以及麻痹性肠梗阻。骨盆和腰椎骨折提示有大肠损伤的可能。腹腔灌洗是一个有用的诊断方法，应在拍完腹部平片后再作灌洗，以免气体进入腹腔，影响X线诊断。抽出的灌洗液应作血细胞、细菌或淀粉酶的检查，出现1项以上异常情况可考虑手术探查。

　　5、腹膜外直肠损伤在诊断上更困难，较严重的骨盆损伤通常合并大量软组织损伤和直肠损伤，常规作肛门指诊是很重要的，必要时作直肠镜或乙状结肠镜检查，可发现血性液体流出和损伤部位。

　　4

　　How to prevent colorectal injury:

　　How to prevent postoperative complications of colorectal injury:

　　Because the position of the colon at the stoma is not properly placed, torsion occurs, postoperative difficulty in defecation causes obstruction. Prevention:

　　1. During the operation for colorectal injury, the colon mesentery must be placed on the lateral side of the abdominal wall;

　　2. The colon loop of the stoma must be fully freed, and the external fixation should be tension-free. Treatment: Mild torsion, the stoma can be expanded with fingers and a thick soft rubber tube placed at the proximal end to support and promote defecation; severe torsion leading to circulatory obstruction, necrosis of the colon, or peritonitis should be treated by reoperation and re-making the stoma immediately.

　　1. The upper and lower ends of the stoma or the colon to be treated are not sufficiently free.

　　2. The stoma is shorter than 3 cm outside the skin.

　　3. Although the stoma is exposed for a long time, the blood circulation is poor, and necrosis and shrinkage occur postoperatively.

　　4. The suture and fixation of the stoma with the layers of the abdominal wall are not firm, and the sutures have fallen out.

　　5. Use the intestinal loop stoma, the colon has not formed adhesions with the surrounding area and the supporting glass rod was removed prematurely, causing the stoma to shrink. Treatment: Mild shrinkage, adhesions have formed around, feces may contaminate the wound, initial observation can be made; if shrinkage into the abdominal cavity causes peritonitis, emergency surgery should be performed, and another stoma should be made on the proximal active segment of the colon after resection of the necrotic intestinal loop.

　　3. Intestinal prolapse next to the stoma

　　If the separation of the surrounding muscle at the stoma is too much, and the colon cannot be sutured tightly with the peritoneum and the aponeurosis of the external oblique muscle layer by layer, after the recovery of intestinal function postoperatively, the irregular peristalsis of the small intestine may sometimes protrude from the side of the stoma, which is more common in the external fixation of the sigmoid colon or stoma. After the occurrence, the small intestine should be immediately returned to the abdominal cavity and the colon re-sutured and fixed.

　　IV. Sigmoid colon intussusception

　　If the sigmoid colon is externalized or stoma is created, if the sigmoid colon is not sutured and fixed with the parietal peritoneum adjacent to it, a cavity is left behind. After the recovery of small intestinal peristalsis after surgery, the small intestine can prolapse into the pelvic cavity from the lateral space of the sigmoid colon, causing internal hernia, and even intestinal obstruction or strangulated intestinal necrosis. After clear diagnosis, surgery should be performed as soon as possible to realign the small intestine. If the small intestine is incarcerated and necrotic, an intestinal resection and anastomosis should be performed. During the operation, the interspace adjacent to the colon should be sutured to prevent the formation of internal hernia again.

　　V. Stoma mucosal prolapse

　　2. Stenosis of the stoma site, partial obstruction after surgery, or constipation after surgery, often requiring forceful defecation, which can lead to mucosal relaxation and prolapse after a long time, with a few prolapses longer than 10 cm.

　　1. The colon stoma is too long outside the abdominal wall.

　　Examine the lavage fluid for white blood cells, bacteria, or amylase. If one or more abnormalities are found, consider surgical exploration:

　　1. Diagnostic peritoneal puncture:It is simple and easy to perform. If there is organ injury, the positive rate is generally over 90%. According to the nature of the puncture material, it can be judged whether there is a rupture of hollow organs, but it has no specificity in diagnosing colonic injury, and if the peritoneal perforation is negative, it cannot exclude abdominal organ injury.

　　2. Diagnostic peritoneal lavage:It has a high diagnostic value for closed abdominal trauma, with a diagnostic rate of up to 95%, and like diagnostic peritoneal puncture, it still has no specificity in judging whether there is a colonic injury.

　　3. Abdominal X-ray examination:Some patients may find free gas under the diaphragm, which is helpful for diagnosing colonic injury and can help locate foreign bodies in cases.

　　4. Laparoscopic examination:It can directly detect the condition of abdominal organ injury, can find the location, degree, and relationship with surrounding organs of colonic injury, with an accuracy of over 90%, which is valuable for early diagnosis.

　　Eat less or no food rich in saturated fat and cholesterol
　　(1) Eat less or no food rich in saturated fat and cholesterol. Including: lard, beef fat, chicken fat, mutton fat, fatty meat, animal internal organs, fish roe, squid, octopus, egg yolk, and palm oil and coconut oil, etc.
　　(2) Limit the intake of vegetable oils such as peanut oil, soybean oil, sesame oil, and rapeseed oil to about 20 to 30 grams per person per day, which is approximately 2 to 3 tablespoons.
　　(3) Do not eat or eat less fried food.
　　(4) Eat foods rich in monounsaturated fatty acids in moderation, such as olive oil, tuna, etc.
　　(5) Avoid overheating animal foods and vegetable oils during cooking.
　　(6) Increase dietary fiber intake. Increasing dietary fiber intake, the main force in preventing colorectal cancer, can reduce the incidence of colorectal cancer. The reason may be that dietary fiber has strong water absorption, which can increase the volume of feces, make the feces form, facilitate defecation, reduce the concentration of carcinogenic substances in the intestines, and thus reduce the risk of developing colorectal cancer.

　　Conventional methods of Western medicine for treating colorectal injuries

　　1. Primary suture repair: This operation is simple, does not require a second operation, has a short hospital stay, causes less psychological trauma to the injured, has fewer complications, and is also economically beneficial. However, colonic repair without intestinal preparation may lead to fistula, so strict selection of patients is required.

　　2. Primary resection and anastomosis: The indications for this operation are basically the same as those for primary suture repair, but the wound of the colon is larger, and suture repair is difficult. If there is a possibility of leakage or intestinal stricture after suture repair, or if there are multiple lacerations in the colon close together, primary resection and anastomosis should be performed, especially suitable for the right half colon without other visceral injuries.

　　3. Resection of intestinal segment, double-side fistula or proximal fistula, distal closure, especially in cases with injury, local intestinal segment ischemia and necrosis, and obvious abdominal contamination, this method is the best. After resection of the injured intestinal segment, enterostomy is performed at both ends. If the distal end cannot be brought out of the peritoneum to perform fistula, the residual end can be closed (Hartmann operation).

　　4. Treatment of colonic perforation after colonoscopy: If there is obvious peritonitis in clinical practice, emergency laparotomy should be performed, and delayed surgery increases complications. Since most cases are colon clean, in the case of perforation of the intestinal segment at the lesion or close to the lesion, if the patient's general condition is good, the intestinal segment can be excised and anastomosed in one stage. If primary suture repair is performed on the normal intestinal perforation.