Gi Problems From Sport

Gastrointestinal,  Genitourinary 

 

Injuries    

 

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Introduction

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Basic rules

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Laparotomy for trauma ○

Spleen

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Liver

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Stomach

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Small bowel

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Colon

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Rectum

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Kidney

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Bladder 

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Expanding retroperitoneal haematoma.

Male urethra

Perineum 

Scrotum and testis

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Vulva

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Abdominal wall

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Gastrointestinal symptoms associated with sport

Introduction Gastrointestinal or genitourinary sport trauma is managed identically to gastrointestinal or genitourinary trauma from any cause. As sport covers most human physical endeavour from running to extreme forms of augmented transport, from wrestling to football and the use of firearms, so the potential range and mechanism of sport injury is enormous. The injured sportsperson can be physically well conditioned, muscular and full of ‘fight or flight’ adrenaline. The physical conditioning can help protect from injury but at the same time can hinder diagnosis by masking the physical signs of injury. Most sportspeople do not conform to this physical ideal, the range of body habitus, physical condition and underlying medical condition is as broad as the sports people play. A game of rugby

football in an area of endemic malaria for example has special implications for splenic injury. Basic rules Despite these potentially confounding factors basic rules apply.

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In any injured patient the trauma ‘ABC’ applies (Airway, Breathing, Circulation)

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The patient should be fasted.

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There is no need to make a precise diagnosis ‘in the field’The only decision that needs to be made is ‘does this person need more attention than I (the sports medicine physician) can provide here’. If the answer is yes then they must be transferred rapidly to an emergency room.

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Intravenous fluids should be started on suspicion of significant injury rather than after confirmation of a problem.

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Narcotic analgesia should be delayed until surgical assessment is complete.

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Any one of the following list of complaints is a cause for concern; •

Abdominal pain that does not go away

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Pain that is getting worse

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Pain made worse by walking or moving

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Pain that radiates through or around to the back

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Difficulty breathing

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Vomiting or passing blood in the stool or urine

Any one of the following list of signs is a cause for concern; •

Increase in pulse rate (tachycardia)

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ncrease in breathing rate (tachypnoea)

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Abdominal bruising; bruising on the outside may herald bruising (or rupture) of an internal organ

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Penetrating injury

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Involuntary guarding (tensing) of the abdominal muscles

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Abdominal distension

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The patient looks pale

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The patient looks unwell

The body has only so many ways of reacting to trauma. Bleeding is same whether it is

coming from a transected mesentery, the liver or spleen. The urgency of transfer is the same and the subtleties of managing one or the other are the responsibility of the admitting surgeon. Do not spend too much time wondering whether the abdominal distension and pulse of 160 is because of liver damage or a splenic injury...call the ambulance. The trauma protocol of the receiving institution will be invoked irrespective of the mechanism of injury. The subtleties of choosing peritoneal lavage, CT scan or immediate laparotomy will vary with surgeon, institution and country. Laparotomy for trauma Cross-matched blood is available in the operating room. Reliable intravenous access is ensured by central line and large bore cannula. The patient is placed supine on the operating table. If there is blood in the rectum a modified lithotomy position is used with Dan Allan or Lloyd Davies stirrups. The abdomen and chest is prepared and the prep is carried down to the genitals, perineum and mid thigh. A foley catheter is inserted if one is not already in place (see urethral injury). Pneumatic leg compression stockings are used. Experienced assistance is essential and a self retaining retractor most desirable. Stand on the right side of the patient. A long midline incision is preferred. Any massive source of bleeding is dealt with directly. Several packs can be held in place to tamponade the bleeding while the wound is extended (xiphisternum to pubis). Retraction. Empty blood by bailing clots and using large packs which absorb blood more rapidly than a sucker. Take the sucker off and use the suction tube alone, protecting it in your cupped hand will make an effective ‘sump’ sucker able to deal with clots while the loops of bowel are kept at bay. Formal exploration of the entire abdomen is mandatory. If you have a systematic approach, use it. If you need one, start in the upper abdomen where the gastrointestinal tract enters and use this to guide you systematically. Stomach, spleen (reaching high up under the left costal margin and cupping it with the palm), liver (all peritonealised surfaces), duodenum (noting the space lateral to the second part for staining), right kidney while you have the area exposed, pancreas, remainder of duodenum having lifted the mass of small bowel to the right, then every inch of small bowel and its mesentery down to the caecum, around the colon and down into the pelvis, bladder and rectum. If minor bleeding is encountered, pack the area for later attention; massive bleeding should be dealt with. Be meticulous with completing the systematic examination of all abdominal organs. Attention can be distracted by the process of repairing an injury and then closing the abdomen leaving an injury further down the check list undetected.

Spleen Splenic trauma results from a blow or crush to the left side of the abdomen or lower chest. The patient complains of abdominal or left shoulder tip pain (from diaphragmatic irritation). Pallor, tachycardia and hypotension are signs of blood loss and impending shock. The abdomen will be tender or guarded and may be distended. Sportspeople from countries where malaria is endemic are especially prone to splenic injury; bear this in mind as the global sporting community shrinks. The patient is fasted, intravenous fluids are commenced through a wide bore cannula and the patient is transferred urgently to a trauma centre. Shock unresponsive to resuscitation or other evidence of ongoing blood loss (progressive abdominal distension, falling haemoglobin, persistent tachycardia) requires emergency laparotomy through a midline incision. The stable patient can have a CT scan to confirm the diagnosis. The possibility of delayed secondary haemorrhage demands conservative management in hospital with intravenous access, frequent observations and crossmatched blood available. Surgery will be required for clinical deterioration. Contact sport is prohibited for six months to a year. Splenic conservation is facilitated by a generous midline incision, capable assistance and complete, formal mobilization. Operative trauma is avoided. Capsular avulsions may respond to topical haemostatic agents and cautery (the argon beam coagulator is useful). Subcapsular haematomas may require a polyglycolic acid mesh sac which can also be useful for deep rents although deep suture and even partial splenectomy may be required. The spleen is an important immunological organ and should be preserved if possible. The splenectomized individual is vulnerable to infection from encapsulated organisms and should be immunized against pneumococcal, meningococcal and haemophilus organisms. Liver A direct blow to the right upper quadrant, epigastrium or right chest can produce liver trauma although it is uncommon. Crush can produce a more extensive injury. As with splenic trauma the patient complains of abdominal or shoulder tip pain (from diaphragmatic irritation). Pallor, tachycardia and hypotension are signs of blood loss and impending shock. The abdomen will be tender or guarded and may be distended.

The patient is fasted, intravenous fluids are commenced through a wide bore cannula and the patient is transferred urgently to a trauma centre. Shock unresponsive to resuscitation or other evidence of ongoing blood loss (progressive abdominal distension, falling haemoglobin, persistent tachycardia) requires emergency laparotomy through a midline incision. The stable patient can have a CT scan to confirm the diagnosis. Capsular tears, superficial lacerations and deep haematomas (smaller than three cm) can usually be managed conservatively (as long as the patient remains stable) however extensive lacerations, devascularized segments and large haematomas (greater than three cm) will usually require surgery. The liver can be expeditiously mobilized by dividing the falciform, and if necessary the diaphragmatic ligaments. Severe injuries may need to be packed; do not put the packs into the rent as this will keep the vessels open, place the packs above and below the liver so as to force the rent closed and apply pressure. This may be an opportunity to transfer the patient to a specialized liver unit. Abscess and bile leak are longer term complications. Duodenal and pancreatic injuries Requiring a direct epigastric blow (e.g. the kick of a horse) to compress the pancreas and or duodenum against the spine, this deep, often retroperitoneal injury can remain hidden. Duodenal injuries are usually hard to recognize as the leak can be contained by the retroperitoneum and there need not be any signs until sepsis supervenes. Blunt duodenal injury (the invariable case in sporting accidents) is even harder to recognize. Remain suspicious, delays in diagnosis increase morbidity and any patient with persistent epigastric pain, usually but not always radiating through the back or shoulders must have pancreatic duodenal injury excluded. Duodenal haematoma will present with symptoms of gastric outlet obstruction. The serum amylase may be elevated with duodenal perforation. The plain abdominal xray may have an absent psoas shadow, retroperitoneal air or a scoliosis. Oral contrast enhanced CT scan may demonstrate a leak and peripancreaticoduodenal oedema. Intraluminal haematoma my be treated conservatively if perforation has been excluded. Total parenteral nutrition may be required. The duodenum is approached through a long midline incision. Haematoma or bile stained fluid at any of the lateral margins of the duodenum suggests perforation. The right side of the duodenum is exposed by Kocherising the second part and carrying this dissection toward the midline in the retropancreatic duodenal plane. Further exposure requires

mobilization of the viscera supplied by the superior mesenteric artery which overlies the third part of the duodenum; small bowel, caecum and right and transverse parts of the colon. The caecum and right colon are mobilized on their primitive mesentery along with the base of the small bowel mesentery (which represents the left edge of this embryological plane); this plane is carried up to and over the third part of the duodenum. Simple perforations are debrided and sutured. Segmental resection and anastomosis may be necessary. Patching with a jejunal loop or Roux-en-Y may be used if primary repair is not possible. Duodenal diversion with closure of the pylorus, gastroenterostomy, and decompression for the duodenal loop may be required for rupture. Severe cobined duodenal and pancreatic trauma could require a Whipple procedure. Duodenal decompression, percutaneous, via the stomach or using a nasoduodenal tube is necessary. Feeding jejunostomy should be considered. The area must be drained adequately. Complications include sepsis and pancreatic or duodenal fistula. Stomach The stomach is usually resistant to injury from blunt trauma. The important exception is the full stomach that can burst with a direct blow or crush. Do not be sidetracked into repairing the stomach until the laparotomy has been completed and the full extent of the injuries determined. If the stomach is leaking gastric contents place a clamp or quick suture to control the contamination before moving on. The injury is debrided if necessary. If the laceration crosses into the origin of the greater or lesser omentum, clear this meticulously (in the manner of a highly selective vagotomy) to allow seromuscular apposition with the repair. stomach is repaired with large interrupted absorbable sutures. A two layer continuous repair is acceptable. Take a larger bite of the seromuscular than the mucosal layer. The repair should be inverted. Decompress the stomach with a nasogastric tube. Small bowel Small bowel injury includes serosal tear, full thickness rupture and mesenteric injury (haematoma or laceration). Physical signs are indistinguishable from those above. Development of signs can be delayed by days, especially in the case of an isolated small bowel rupture. Developing ileus, progressive distension and tenderness with a low grade fever are important signs. Abdominal X-ray may show free air or thickened bowel loops. CT scan will reveal free

intra-abdominal fluid or thickening of bowel wall or planes. Serosal tear is usually an incidental finding at laparotomy, Recognition of a full thickness rupture can be delayed by several days as the associated peritonitis can develop slowly. Abdominal wall bruising is an important indicator of possible underlying injury and requires peritoneal lavage or CT. Mesenteric haematoma can extend to the root of the mesentery and cause venous congestion. An expanding mesenteric haematoma must be entered to control the bleeding. A small mesenteric tear can cause a surprisingly large haemoperitoneum. Resection or repair is carried out with an interrupted or continuous absorbable seromuscular suture. Staples can be used. Run every centimetre (inch) of the small bowel and mesentery. When repairing an injury consider the lumen of the small bowel and place a suture line transversely across the bowel where possible. The principles of the successful anastomosis apply to the repair as well as to the formal resection and anastomosis; good blood supply, no tension, no distal obstruction. Colon Give broad spectrum antibiotics to cover the range of colonic organisms. The colon adjacent to the injury is mobilized on its embryological mesentery. Colon may be repaired primarily if there is no risk of subsequent breakdown of the repair. The injury must be less than 12 hours old, there can be no intraperitoneal contamination, the wall of the colon must be viable with a good blood supply. A diaphragmatic defect is a contraindication to primary repair. If primary repair is not considered safe the suture line can be exteriorized for early return to the abdomen once sound healing has been confirmed (5-10 days). The defect itself can be brought out as a stoma. Both of these procedures can require extensive mobilization to allow the colon to reach the skin and lie over a colostomy rod without tension. An exteriorized repair must lie free of the skin edge so that a breakdown will result in a colostomy rather than a subcutaneous leak. An injury too low to be exteriorized should be treated as a rectal injury. Rectum Rare in sport accidents a rectal injury is suspected with a pelvic crush or penetrating wound in the region of the pelvis (buttocks, hips, perineum). Blood may be found on the

examining finger after rectal examination during the secondary survey in the emergency room. The principles of management of rectal injury are well established and require thorough cleansing of the rectum to decrease its potential as a source of contamination during subsequent management;

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Modified lithotomy position using Dan Allan or Lloyd Davies stirrups.

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Exposure by mobilization in the presacral plane

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Rigid sigmoidoscopy with irrigation and a large bore sucker.

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Antegrade irrigation via the distal limb of a defunctioning colostomy or through the defect itself before closing if the defect is accessible.

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Drainage of the perirectal fascial planes. The drain is placed in the

presacral

plane and brought out between anus and coccyx

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Diversion of the faecal stream by defunctioning colostomy.

Kidney Suspected with flank bruising, bony injury (lower rib or lumbar vertebrae) and haematuria. Note that the absence of haematuria does not exclude renal injury; a devascularized kidney will not cause haematuria, nor will an injury that does not involve the collecting system. A thrombosed and occluded renal artery must be repaired within three hours to save the kidney from acute tubular necrosis. Expanding retroperitoneal haematoma

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Have proximal vascular control before exploring a haematoma; this may require extensive mobilization of embryological planes.

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Explore central haematomas corresponding in position to the aorta, inferior vena cava, duodenum and pancreas

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Explore lateral haematomas suggesting injury to the kidneys, ureters or meso colon

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Explore haematomas due to penetrating injury.

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Explore a haematoma in the region of the bladder to rule out bladder injury.

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Do not explore the haematoma due to massive retroperitoneal bleeding of a severe pelvic fracture.

Bladder More easily injured when full, bladder injury is suspected with haematuria, urinary retention, suprapubic pain or peritonitis. The rupture may be confined to the

retroperitoneum or be free into the peritoneal cavity. Diagnosed by contrast study a simple tear may be managed with foley catheter drainage alone. In most cases the bladder should be opened at laparotomy, the trigone, urethral and ureteric orifices are confirmed to be clear of injury and the injury and operative cystotomy are repaired with two layers of absorbable 2/0 or 3/0 suture. The bladder is drained with a catheter (transurethral or suprapubic) and the extravesical space is drained with penrose drains. Stent an injury to a ureteric orifice with a ureteric stent. Male urethra Caused by a fall astride or severe pelvic fracture. Do not attempt to pass a urinary catheter if blood is seen at the urethral meatus or there is oedema and bruising of the penis or perineum, suspect urethral injury and do a urethrogram. Discourage the patient from voiding to minimize extravasation. Passage of a catheter could convert a partial tear to a complete disruption. Suprapubic catheterization and specialist urological referral are required. If the patient requires urgent laparotomy the suprapubic catheter can be placed with the abdomen open, otherwise a percutaneous technique can be used. Anterior urethra extends from meatus to urogenital diaphragm. Early exploration is desirable but this should be carries out by a urologist. Posterior urethra extends from urogenital diaphragm to bladder neck. The prostate will be displaced on digital rectal exam, replaced by a soft boggy mass of haematoma. This injury is invariably associated with a major pelvic fracture.

Perineum Perineal, urethral and vaginal injury in the female is best treated with catheterization (suprapubic if necessary) and surgical repair of lacerations to control haemorrhage. Scrotum and testis Regrettably often a deliberate injury associated with contact sport. Ultrasound will confirm the diagnosis. The scrotum should be explored to evacuate haematoma and repair the tunica. Extruding parenchyma is excised to allow the tunica to be approximated with a running 4/0 absorbable suture. Vulva Caused by falls astride and the classical water skiing accident this injury is becoming less common as the role of protective clothing is appreciated.

Abdominal Wall •

groin strain

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hernia

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hip pointer

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‘stitch’

Gastrointestinal symptoms associated with sport Despite their aura of fitness and health, the athlete is susceptible (and in fact predisposed) to common and well characterized disease processes. The athletes physical conditioning may obscure signs and delay diagnosis and appropriate referral. A list of common gastrointestinal symptoms and possible causes is provided. Those conditions with particular relevance to the sport physician are noted. •

Visceral pain

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irritable bowel syndrome

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peptic ulceration

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cholelithiasis

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diverticulitis

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Heartburn

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reflux

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peptic ulceration

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Nausea

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bowel obstruction

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Vomiting

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gastroenteritis

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Diarrhoea

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infectious diarrhoea

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runners diarrhoea

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irritable bowel syndrome

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inflammatory bowel disease

Do take stool cultures before commencing therapy