SHORT BOWEL SYNDROME

SHORT BOWEL SYNDROME

Q. 1

A man comes to emergency with stab injury to left flank. He has stable vitals. What would be the next

step in management.

 A CECT
 B

Diagnostic peritoneal lavage

 C

Laprotomy

 D Laproscopy
Q. 1

A man comes to emergency with stab injury to left flank. He has stable vitals. What would be the next

step in management.

 A CECT
 B

Diagnostic peritoneal lavage

 C

Laprotomy

 D Laproscopy
Ans. A

Explanation:

CECT [Ref. Washington Manual of Surgery,5/ep373; Trauma by David V Feliciano 6/e p622;Last Minute Emergency Medicine by Mary Jo Wagner 2007/e; Schwartz 9/e p1.51 (8/e pI41)]

  • The main decision in an abdominal injury is to decide whether an exploratory laparotomy is necessary or not. Physical examination though may help sometimes, has significant limitations and may be unreliable.
  • The diagnostic approach to penetrating (Gunshot and Stab wounds) and blunt abdominal trauma differs substantially.
  • Gunshot abdominal wounds: Chances of internal injury is very high in gunshot wounds thus little preoperative evaluation is required and laparotomy is mandatory.
  • Stab wounds to abdomen:
  • In contrast to GSWs, SWs are less likely to injure intra-abdominal organs.
  • Patients with isolated penetrating abdominal wound if hypotensive, or in shock or showing peritoneal signs go for exploratory laparotomy.
  • Management of stable patients is debatable and controversial. ‘Various methods are used to determine whether laparotomy is necessary or not.
  • Anterior stab wound- In ant. stab wounds local wound exploration can be performed to determine if there is any penetration of the peritoneal cavity. If the tract terminates without entering the peritoneum, the injury can be managed as a deep laceration and laparotomy is not needed. Otherwise, penetration of the peritoneum is assumed, and significant injury must be excluded by further diagnostic evaluations. Options include diagnostic peritoneal lavage, laparoscopy, CT, FAST, and admission with observation.
  • Flank and back wounds- There is more debate over the management of stab wounds to the flank and back. These injuries are special because of the risks associated with retroperitoneal organ injury-colon, kidneys and ureter. Triple contrast CT (i.e. oral, IV, and rectal contrast) is advised to detect colon and retroperitoneal injuries and the need for laparotomy. Other methods like DPL, laparoscopy are also advised.

[According to EAST Guidelines, 2007, http://www.east.orgCurrent recommendations for nonoperative management of penetrating trauma include the use of Triple contrast CT and serial examination.]

  • Blunt abdominal injury:
  • Hemodynamically stable patients sustaining blunt trauma are adequately evaluated by abdominal ultrasound or CT (CT in selected cases to refine the diagnosis) unless other severe injuries take priority and the patient needs to go to the operating room before the objective abdominal evaluation. In such instances, DPL or focussed abdominal sonography for trauma (FAST) is usually performed in the operating room to rule out intra-abdominal bleeding requiring immediate exploratory laparotomy. US has largely replaced DPL.
  • Management of hemodynamically unstable pt: a hemodynamically unstable pt is evaluated by FAST and if intra-abdominal fluid detected, undergoes laparotomy. [See the algorithm below]

 



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