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Traumatic rectal injuries

Is the combination of computed tomography and rigid proctoscopy sufficient?

Trust, Marc D., MD; Veith, Jacob, MD; Brown, Carlos V.R., MD; Sharpe, John P., MD; Musonza, Tashinga, MD; Holcomb, John, MD; Bui, Eric, MD; Bruns, Brandon, MD; Andrew Hopper, H., MD; Truitt, Michael, MD; Burlew, Clay, MD; Schellenberg, Morgan, MD; Sava, Jack, MD; Vanhorn, John, PA-C; Eastridge, Brian, MD; Cross, Alicia M., MD; Vasak, Richard, MD; Vercuysse, Gary, MD; Curtis, Eleanor E., MD; Haan, James, MD; Coimbra, Raul, MD; Bohan, Phillip, MD; Gale, Stephen, MD; Bendix, Peter G., MD The AAST Contemporary Management of Rectal Injuries Study Group

Journal of Trauma and Acute Care Surgery: December 2018 - Volume 85 - Issue 6 - p 1033–1037
doi: 10.1097/TA.0000000000002070
WTA 2018 PODIUM PAPER
Editor's Choice

BACKGROUND There are no clear guidelines for the best test or combination of tests to identify traumatic rectal injuries. We hypothesize that computed tomography (CT) and rigid proctoscopy (RP) will identify all injuries.

METHODS American Association for the Surgery of Trauma multi-institutional retrospective study (2004–2015) of patients who sustained a traumatic rectal injury. Patients with known rectal injuries who underwent both CT and RP as part of their diagnostic workup were included. Only patients with full thickness injuries (American Association for the Surgery of Trauma grade II-V) were included. Computed tomography findings of rectal injury, perirectal stranding, or rectal wall thickening and RP findings of blood, mucosal abnormalities, or laceration were considered positive.

RESULTS One hundred six patients were identified. Mean age was 32 years, 85(79%) were male, and 67(63%) involved penetrating mechanisms. A total of 36 (34%) and 100 (94%) patients had positive CT and RP findings, respectively. Only 3 (3%) patients had both a negative CT and negative RP. On further review, each of these three patients had intraperitoneal injuries and had indirect evidence of rectal injury on CT scan including pneumoperitoneum or sacral fracture.

CONCLUSION As stand-alone tests, neither CT nor RP can adequately identify traumatic rectal injuries. However, the combination of both test demonstrates a sensitivity of 97%. Intraperitoneal injuries may be missed by both CT and RP, so patients with a high index of suspicion and/or indirect evidence of rectal injury on CT scan may necessitate laparotomy for definitive diagnosis.

LEVEL OF EVIDENCE Diagnostic, level IV.

From the Dell Medical School (M.D.T., J.V., C.V.R.B.), University of Texas at Austin, Austin, TX; University of Tennessee Health Science Center (J.P.S., T.M.), Memphis, TN; University of Texas Health Science Center at Houston (J.H.), Houston, TX; University of San Francisco-East Bay (E.B.), Oakland, CA; R. Adams Cowley Shock Trauma Center (B.B.), Baltimore, MD; Vanderbilt University (H.A.H.), Nashville, TN; Methodist Health System (M.T.), Dallas, TX; University of Colorado-Denver Health (C.B.), Denver, CO; University of Southern California (M.S.), Los Angeles, CA; MedStar Washington Hospital Center (J.S.), Washington, DC; Legacy Emmanuel Medical Center (J.V.), Portland, OR; University of Texas Health Science Center San Antonio (B.E.), San Antonio, TX; University of Oklahoma (A.M.C.), Oklahoma City, OK; Harbor-UCLA Medical Center (R.V.), Los Angeles, CA; University of Arizona (G.V.), Tucson, AZ; University of California Davis (E.E.C.), Sacramento, CA; Via Christi Health (J.H.), Wichita, KS; University of California San Diego (R.C.), San Diego, CA; Oregon Health and Science University (P.B.), Portland, OR; East Texas Medical Center (S.G.), Tyler, TX; and Brigham and Women's Hospital (P.G.B.), Boston, MA.

Submitted: January 14, 2018, Accepted: May 12, 2018, Published online: September 11, 2018.

Address for reprints: Marc D. Trust, MD, Department of Surgery and Perioperative Care, Dell Medical School at The University of Texas at Austin, Dell Seton Medical Center at The University of Texas at Austin, 1500 Red River St, Brackenridge Annex 301, Austin, TX 78701; email: mdtrust@ascension.org.

Presented at the 48th Annual Meeting of the Western Trauma Association, February 25th to March 2nd, 2018, Whistler, British Columbia, Canada.

© 2018 Lippincott Williams & Wilkins, Inc.