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Abdominal Trauma 187

• increasing pulse rate; Most anorectal injuries are due to penetrating trauma, and the penetrat-
ing objects often are potentially contaminated and capable of introduc-
• increasing abdominal distention and tenderness;
ing infections, particularly tetanus.
• loss of bowel function; Presentation
• presence of intestinal contents at DPL; and There may be a history of falling onto a sharp object or falling astride
an object. Motor vehicle crashes may also produce anorectal injury. The
• free intraperitoneal air on erect plain abdominal x-ray or CT scan.
common symptoms include:
When diagnosis is made, operative treatment is necessary. The
operative options include repair of laceration and closure of perforation • rectal bleeding;
and resection with primary anastomosis for extensive laceration, • vaginal bleeding;
multiple perforations, and intestinal gangrene from transverse • vaginal discharge; and
mesenteric tear.
Injuries to the left colon may be repaired primarily with or without • abdominal pain and tenderness.
the creation of a proximal colostomy, or the injured colon may be Fever, if present, is an indication of intraperitoneal involvement or
exteriorised as a colostomy and mucous fistula. late presentation. Careful abdominal examination should be done to
Penetrating Abdominal Trauma exclude intraperitoneal involvement. Examination of the perineum and
Penetrating abdominal trauma is less common than blunt trauma and anorectum after trauma is usually limited due to pain and tenderness.
As such, adequate evaluation should be done under general anaesthetic
accounts for approximately 14% of abdominal trauma in children. It is and good lighting.
frequently due to a fall onto sharp objects, a cow gore, gunshot wound,
and, rarely, a stab injury. Treatment depends on the penetration of the Evaluation
peritoneum. After adequate resuscitation and stabilisation, the wound is Under general anaesthetic, careful and meticulous examination of the
explored under general anaesthesia to identify peritoneal breach. perineum, anorectum, and vagina should be done. The aim of this
If the peritoneum is breached, a formal laparotomy is required, evaluation is to ascertain the nature and extent of injury. The examina-
through a separate incision, to identify and treat organ injuries. If a tion begins with inspection of the vagina, with particular attention to the
peritoneal breach is not detected (or a breach is only suspected), DPL is posterior vaginal wall, which is frequently injured in girls. Any lacera-
done and a laparotomy is performed if it is positive. tion in the perineum is noted, and the depth is ascertained. The ano-
Where available, a triple-contrast CT scan (oral, IV, plus bladder rectum is then examined; this may require proctosigmoidoscopy. Once
contrast) should be done. If the CT scan is negative, the patient is the evaluation is complete, the injury should be graded (Figure 29.4).
observed for 24–48 hours; if it is positive, a laparotomy should be done. Treatment
In stab injuries to the flank or back, a CT scan is done. If a CT The treatment of anorectal injuries is summarised in Figure 29.5. The
scan is not available, a laparotomy is done to exclude injuries to wound should be carefully explored. All dead or devitalised tissue
retroperitoneal organs. DPL is usually not useful. should be completely excised. The wound should be repaired if acces-
If there is obvious organ evisceration, the organ is covered with sible. Adequate drainage of the wound (perirectal) may be necessary.
clean moist gauze and polythene to decrease desiccation, loss of fluid, Laparotomy is required if intraperitoneal rectal injury is present. A protec-
and hypothermia. tive (proximal) colostomy may be necessary in some situations. Tetanus
Whenever laparotomy is performed, it must be thorough to avoid prophylaxis and broad-spectrum antibiotics should be given. Sphincteric
missing any injuries. Injuries to solid organs or the gastrointestinal tract function should be evaluated after wound healing is complete.
are treated as in blunt trauma.
Tetanus prophylaxis should be given if the child is unimmunised or Evidence-Based Research
if the immunisation status is unknown. Table 29.1 presents a retrospective review of management protocol
using ultrasonography in laparotomy.
Anorectal Injuries
Anorectal injuries are not common in children, but they may be associ-
ated with significant morbidity if not identified and treated properly. 12–13

GRADE III GRADE IV GRADE V

GRADE I GRADE II • Full thickness • Full thickness • Full thickness
injury above injury above injury above
internal internal internal
• <Full • Full sphincter sphincter sphincter
thickness thickness • No peritoneal • + peritoneal • + peritoneal
injury to anal injury below involvement involvement involvement
canal or rectal internal
mucosa sphincter ± • No injury to • + injury to other
internal other intraperitoneal
sphincter intraperitoneal organs
involvement organs

Figure 29.4: Grading of anorectal injuries.