Gastrointestinal & Urinary Problems Of The Athlete

Most grastrointestinal and urinary problems encountered by the athlete are from blunt abdominal trauma (Fig. 1).  

Blunt Trauma Blunt abdominal trauma is the commonest problem in the athlete. The initial assessment is the same in all cases. The mechanism of injury is central to defining the possible injuries. Clinical assessment should exclude severe, life threatening injuries. Routine observations first. (An athlete should maintain their blood pressure in the presence of a large haemorrhage). Tachycardia is a more accurate assessment of the extent of blood loss. Pallor indicates marked blood loss. If thee is suspicion of significant intra-abdominal injury, start intravenous fluids early whilst continuing to assess. Analgesia after the initial surgical assessment is complete.  

Splenic Trauma From a direct blow to the left upper qauadrant (shoulder in rugby tackle; fall from a cycle) or in association with left thoracic wall injuries (Figs, 2, 3, 4). Pain may be localised to left upper quadrant or generalised. Left shoulder tip pain is often present. Pallor, tachycardia or shock indicate a large haemorrhage. Abdominal signs vary from mild left upper quadrant tenderness to marked generalised peritonitis with abdominal distension. Initial management includes fasting, intravenous fluid resuscitation and nasogastric tube insertion. An urgent laparotomy is performed in patients that are shocked or have evidence of ongoing blood loss, persistent tachycardia, falling haemoglobin or progressive abdominal distension. An haemodynamically stable patient is managed non-operatively initially and investigated with a CT scan or ultrasound to diagnose and assess the extent of the splendid injury. Children and adults that remain haemodynamically stable can be managed nonoperatively with close observation, analgesia and chest physiotherapy. Operative intervention is required if there is any clinical deterioration or there is evidence of ongoing blood loss. As a guide any child requiring more than 25% of their blood volume replaced requires operative intervention. When operative intervention is required, splenic conservation is attempted rather than splenectomy I order to avoid post-splenectomy complications including overwhelming postsplenectomy sepsis. Conservative measures include suture repair, rapping the spleen in a mesh bag and partial splenectomy. Splenic injuries can be graded according to the

operative findings (Fig. 5); Grade I, II and III injuries can usually be managed conservatively (Fig. 2) although Grade III may require partial splenectomy. Grade IV and V usually require splenectomy (Fig. 3). If splenectomy is performed immunization with pneumococcal, meningococcal and haemophyllus vaccines within 48 hours is performed. Liver trauma Liver trauma is uncommon in low velocity injuries (football), but more common with a high velocity injury (cyclist or motor sports). It is produced by either a blow to the right upper quadrant, associated with right thoracic injuries or a crush injury (rolled on by a horse). Hepatic injuries following a low velocity injury are usually minor, whereas crush injuries are often severe. The pain may be right upper quadrant, epigrastric or generalised. The initial assessment is to determine if the patient is shocked and has evidence of ongoing haemorrhage. The shocked patient with a distended abdomen that has not responded quickly to fluid resuscitation requires an urgent laparotomy. If the patient is stable or responds quickly to fluid resuscitation with no evidence of ongoing blood loss a CT scan or ultrasound is performed to assess and grade the injury. Type IV (extensive injury/devascularised segment/deep haematoma>3cm) injuries invariable require laparotomy and repair. Types I, II and III (capsular tear, superficial injury, deep haematoma <3cm) injuries can be managed non-operatively initially if the patient remains haemodynamically stable. Any deterioration requires a laparotomy. Grade I injuries rarely require operative intervention, whereas grade III injuries require a laparotomy in 40 to 60% of cases. Bleeding may be stopped with suturing, local haemostatic agents or packing. A severe liver rupture (Type IV and V) may require packing and repeat laparotomy and subsequent resection of non-viable liver. Subsequent complications include hepatic abscess and biliary peritonitis. Duodenal and pancreatic injuries Injuries to the duodenum and or pancreas follow a direct blow across the epigastrium with compression of the duodenum and pancreas across the spinal column. The patient may complain of moderate to severe epigastric pain with associated vomiting. As these injuries are retroperitoneal and usually not associated with any significant haemorrhage there are usually no signs of shock, no pallor and may only have minimal epigastric tenderness. A tachycardia if often present. As the early signs of duodenal injury may be minimal the diagnosis may be delayed. Delay in treatment of a duodenal rupture by 24 hours is associated with a marked increase in morbidity and mortality. When there is a history of a direct blow to the epigastrium with ongoing epigastric pain; duodenal and pancreatic trauma must be excluded early. Clues to the diagnosis may be leucocytosis, raised serum amylase or loss of the psoas shadow or retroperitoneal gas on a plain abdominal x-ray. A gastrograffin meal shall determine if there is any duodenal rupture. A dynamic enhanced CT scan with oral contrast shall usually define any duodenal rupture and also define any pancreatic trauma

which can be graded and managed accordingly (haematoma/serosal tear to duodenal wall rupture or pancreatic duct disruption; laparotomy) debridement/repair for latter one or two).  

Small bowel and colon Injuries to the small bowel and colon are rare following low velocity injuries, and are more commonly associated with a very forceful blow to the abdomen or a deceleration injury. The injuries include serosal tears, rupture and mesenteric tears. The pain may be central, localised or generalised. There may be associated vomiting and abdominal distention. Signs include tachycardia, low grade fever and signs of localised or generalised peritonitis. Initial management involves fluid resuscitation, analgesia and plain abdominal x-rays. Signs on x-ray include free air and distended or thick walled loops of bowel. Frequently the x-rays are unremarkable. A CT scan may detect a bowel injury or blood in the peritoneal cavity that is otherwise unexplained. The definitive management is laparotomy and either repair or resection of the effected bowel segment. In the presence of significant abdominal signs or clinical deterioration, even if there are no abnormalities on CT scan a laparotomy is indicated. Rectum and anus There are two specific types of anorectal injuries seen in athletes; impaling injury and injection of water under high pressure. Impaling is uncommon but involves falling directly on to an object that impales the anus and rectum. The injury may involve the anus alone, the rectum alone or both anus and rectum. Diagnosis is from the history. Examination of the perineum may reveal a skin tear, anal sphincter tear or may be normal. Further examination of the anus and rectum is best performed under a general anaesthetic to asses the injury fully. Broad spectrum antibiotics are given. Operative management essentially involves primary repair with or without a diverting colostomy. Injection from water under pressure is an unusual injury that occurs in sports such as water skiing where a fall astride allows water to be forced into the rectum under considerable pressure. This causes a “blow out” injury at the rectosigmoid junction. Patients present with a history of the fall followed by lower abdominal pain. There is tachycardia, fever and signs of peritonitis in the lower abdomen. Diagnosis is with a gastrograffin enema, where the leak shall be demonstrated, usually at the recto-sigmoid junction. Management includes fluid resuscitation, analgesia and broad spectrum antibiotics. Operation depends on the extent of the injury and degree of faecal contamination. The rectum requires debridement and may be repaired and a diverting colostomy formed. If the

injury is severe, the rectum is debrided, oversewn and an end colostomy created. Colonic continuity is restored 3 to 6 months later. Kidney The history of the injury is a blow to the loin or front of the abdomen. There is usually loin pain, although with high velocity injuries to the front of the abdomen the pain is more widespread. There may be macroscopic haematuria. The findings of examination depend on the extent of the injury. The observations are stable with mild to moderate loin tenderness and microscopic haematuria in association with a minor renal contusion. Patients with a shattered kidney are tachycardiac, pale and shocked with marked loin tenderness and macroscopic haematuria. The absence of haematuria does not exclude a renal injury, particularly an injury to the vascular pedicle (Fig. 6).  

Initial management involves resuscitation where necessary and analgesia. Imaging of the kidney is required either with an intravenous pyelogram (Fig. 7) or an enhanced CT scan (better; as allows assessment of the spleen and liver as well. Most injuries are minor and include a contusion or small cortical tear with a subcapsular haematoma). These injuries can be managed non-operatively. More extensive injuries involving the pevlicalaceal system or kidneys with multiple lacerations usually require operative intervention. If the patient is haemodynamically stable then referral to a urologist for definitive management is required. Those injuries requiring surgery may be repaired or managed with a partial nephrectomy. An unstable patient with a renal injury requires urgent surgery and often a nephrectomy.  

Bladder Rupture of the urinary bladder occur following a blow to the lower abdomen when the bladder is full or in association with a severe pelvic fracture. This is associated with lower abdomen pain, often an inability to void and macroscopic haematuria. There is lower abdominal tenderness and thee may be a fullness that is dull to percussion. When the diagnosis is suspected a urinary catheter should be inserted and broad spectrum antibiotics administered, macroscopic haematuria is invariably seen. Diagnosis is with a retrograde cystogram with either pre-peritoneal or intraperitoneal extravasation of contrast. Management is operative repair and prolonged catheter drainage.  

Male urethra The membranous urethra is injured in a fall astride and presents with perineal pain, inability to void and blood at the urethral meatus Fig. 8). There is often a perineal or scrotal haematoma, marked perineal tenderness and blood at the urethral meatus. Do not insert a urethral catheter. Management is to perform a retrograde urthethragram (figure ? Michael Rochord) to assess the injury. If there is no urethral disruption a catheter is

carefully inserted. If there is urethral disruption but there shall be a delay in urological management a suprapubic catheter is inserted with broad spectrum antibiotics. Scrotum and Testis A direct blow to the scrotum is a painful and not infrequent sports injury. The majority of blows do not produce a serious injury. Occasionally there may be a scrotal haematoma or rupture of the testis. This shall present with persistent pain and swelling following blow to the scrotum. An ultrasound of the scrotum shall distinguish between a scrotal haematoma which can be managed non-operatively and a testicular rupture that requires surgical exploration. A ruptured testis is explored in order to ensure the testis is viable and to repair the injury (Fig. 9). Torsion of the testis may be intermittent, incomplete or complete (Fig. 10). Intermittent, incomplete torsion presents with episodic, unilateral testicular pain during exercise (relieved by scrotal manipulation), exclude horizontally lying testis which requires bilateral orchidopexy. Complete testicular torsion presents with sudden severe testicular pain that does not settle (often history minor trauma). Swollen tender testis. Urgent surgical exploration required. Do not waste time imaging the testis (high false negatives).  

Unconscious Patient The clinical assessment of the abdomen in the unconscious injured patient is difficult as many of the clinical signs are absent due to the unconscious state. Clearly if the patient is shocked with abdominal distention or other evidence of an abdominal injury an urgent laparotomy is required. When the unconscious patient is haemodynamically stable without an overt evidence of an abdominal injury, an abdominal injury must be excluded by either a diagnostic peritoneal lavage or an abdominal CT scan. A CT scan is often preferred as the patient requires a CT of the head to assess the head injury. A CT scan also determine the degree of injury, particularly to the liver or spleen, allowing a decision of non-operative management to be made. Whereas a positive diagnostic peritoneal lavage requires that a laparotomy be performed, even though the injury may be minor. If the patient is deteriorating from a head injury, then time should not be wasted performing a CT of the abdomen and a diagnostic peritoneal lavage is performed.  

Heatstroke, Heat Exhaustion A severe episode of heat stroke may be associated with renal failure secondary to acute tubular necrosis. This may be prevented by rapid, early aggressive fluid resuscitation of the heatstroke patient. However, once established requires careful management in a high dependency unit and may require a brief period of haemodialysis prior to recovery of the renal function.  

Hepatic dysfunction or even acute hepatic failure may be in association with heatstroke. This usually starts 24 hours after the episode of collapse and presents with abnormal liver function tests and jaundice. It may progress to fulminant hepatic failure. Treatment is support of the circulation, coagulation and respiration in an intensive care unit.  

Haematuria Macroscopic haematuria may occur after strenuous exercise and is often recurrent in an individual. It is usually of no significance but if it is of concern to the athlete can be investigated with urine microscopy, culture and an intravenous pyelogram (invariably normal). Fig. 1   Sport gastrointestinal and urinary problems      

    

Organ

Problems

 

 

Spleen

Haematoma

 

 

Rupture

 

 

 

 

Liver

Haematoma

 

 

Rupture

 

 

Hepatic failure (heatstroke)

 

 

Pancreas

Contusion

 

Transection

 

Pancreatitis

 

 

 

 

Duodenum

Contusion/haematoma

 

Rupture

 

 

 

 

Rectum/Anus

Impaling

 

High pressure insufflation

 

 

  System         Gastrointestinal

                         

 

 

 

 

Small and large

Mesenteric tear

 

Bowel

Rupture

 

 

 

 

 

 

Kidney

Haematuria

 

Renal failure (heatstroke)

 

Haematoma

 

Rupture

 

 

Bladder

Rupture

 

 

 

 

Male urethra

Rupture

 

 

 

 

Testis

Rupture

Genito­Urinary

Torsion