Overview
Definition:
Small bowel injury refers to damage to any part of the duodenum, jejunum, or ileum, ranging from mucosal tears to complete transection
Repair aims to restore intestinal continuity and prevent leakage, infection, and associated morbidity.
Epidemiology:
Small bowel injuries are most commonly associated with blunt or penetrating abdominal trauma
They can also occur iatrogenically during endoscopic procedures or surgery
Incidence varies based on trauma mechanisms and regional demographics.
Clinical Significance:
Untreated or inadequately repaired small bowel injuries can lead to severe complications including peritonitis, sepsis, anastomotic leak, fistula formation, and malnutrition, significantly increasing mortality and morbidity
Timely and appropriate surgical intervention is crucial.
Diagnostic Approach
History Taking:
Detailed history of injury mechanism (trauma, surgical procedure, endoscopic intervention)
Mechanism of injury in trauma (e.g., seatbelt injury, stab wound, gunshot)
Associated symptoms like abdominal pain, nausea, vomiting, distension
Prior abdominal surgeries.
Physical Examination:
Abdominal assessment for distension, tenderness, guarding, rebound tenderness, and rigidity
Presence of pulsatile masses or peritonitis
Vital signs to assess for shock or sepsis
Auscultation for bowel sounds.
Investigations:
Abdominal radiography (plain X-rays) for free air or signs of obstruction
Computed Tomography (CT) scan of the abdomen and pelvis with oral and IV contrast is the investigation of choice, identifying the site, extent of injury, and associated intra-abdominal pathology
Peritoneal lavage can also detect injuries.
Differential Diagnosis:
Other causes of abdominal pain and peritonitis: solid organ injury, hollow viscus perforation (stomach, colon), mesenteric ischemia, appendicitis, diverticulitis, pancreatitis.
Surgical Management
Indications:
All identified small bowel injuries, particularly full-thickness perforations, significant contusions, devascularized segments, and suspected leaks, require surgical exploration and repair
Indications include signs of peritonitis, evidence of perforation on imaging, and hemodynamic instability.
Preoperative Preparation:
Resuscitation with intravenous fluids and blood products if necessary
Broad-spectrum antibiotics to cover Gram-negative and anaerobic organisms (e.g., Cefotetan or Piperacillin-Tazobactam)
Nasogastric tube insertion for decompression
Consent for possible bowel resection and anastomosis.
Procedure Steps:
Laparotomy or laparoscopy depending on the situation
Careful exploration of the entire small bowel
Identifying the site and extent of injury
Options for repair include primary closure for small, clean transections or perforations, or resection of the injured segment with primary anastomosis
The type of anastomosis (end-to-end, end-to-side) depends on the bowel ends and surgeon preference
Ligation of mesenteric tears is essential
Consider diversion (ileostomy) for severely contaminated injuries or patient instability.
Techniques For Repair:
Primary end-to-end or end-to-side anastomosis using sutures or staplers
For large defects or contaminated injuries, consider staged procedures with temporary ostomy and delayed reconstruction
Consideration for omental patch for small leaks or mucosal defects
Management of mesenteric tears by careful ligation of vessels and repair of the mesentery.
Postoperative Care
Initial Management:
Hemodynamic monitoring, fluid resuscitation, and analgesia
Continue broad-spectrum antibiotics
Maintain nasogastric tube decompression until bowel function returns
Monitor for signs of infection, anastomotic leak, or ileus.
Nursing Care:
Strict fluid balance, vital sign monitoring, wound care, and pain management
Early mobilization as tolerated
Nutritional support via parenteral nutrition if prolonged ileus is anticipated
Strict input/output monitoring.
Monitoring For Complications:
Close observation for abdominal distension, fever, tachycardia, increased pain, wound drainage, or signs of peritonitis, which may indicate an anastomotic leak
Serial abdominal examinations and laboratory tests (CBC, CRP)
Imaging may be required if leak is suspected.
Complications
Early Complications:
Anastomotic leak: the most feared complication, leading to peritonitis and sepsis
Intra-abdominal abscess
Ileus: prolonged cessation of bowel motility
Wound infection
Hemorrhage.
Late Complications:
Intestinal obstruction due to adhesions or stricture formation at the anastomosis
Enterocutaneous fistula
Malabsorption and nutritional deficiencies
Incisional hernia.
Prevention Strategies:
Meticulous surgical technique with adequate blood supply to anastomotic edges
Gentle handling of tissues
Proper tension-free anastomosis
Prophylactic antibiotics
Prompt recognition and management of intra-abdominal sepsis
Careful management of mesenteric tears.
Prognosis
Factors Affecting Prognosis:
The severity and extent of the injury
The presence of associated injuries
The patient's overall health status and comorbidities
The speed of diagnosis and surgical intervention
The presence and management of complications such as anastomotic leak or sepsis.
Outcomes:
With prompt diagnosis and appropriate surgical repair, the prognosis for small bowel injuries can be good
However, significant morbidity and mortality can result from delayed presentation or complications
Patients with extensive injuries or multiple comorbidities have a poorer prognosis.
Follow Up:
Follow-up should include monitoring for signs of obstruction, fistula, or malabsorption
Nutritional assessment and supplementation may be required
Patients may need long-term monitoring depending on the complexity of the injury and repair.
Key Points
Exam Focus:
Key principles of small bowel injury repair: assessment, choice of repair (primary closure vs
resection/anastomosis), importance of blood supply, mesenteric tear management, and prevention/management of anastomotic leak
Differentiate between blunt vs
penetrating injuries and their management implications.
Clinical Pearls:
Always explore the entire small bowel after trauma
Be meticulous with mesenteric tear repair to avoid devascularization
Consider staged procedures for heavily contaminated or severely injured bowel
Early diagnosis of anastomotic leak is critical.
Common Mistakes:
Inadequate assessment of the extent of injury
Failure to identify and manage mesenteric tears properly
Inadequate decompression of the bowel preoperatively
Delay in recognizing anastomotic leak
Overly aggressive resection leading to short bowel syndrome.