Diagnosis and management of traumatic rectal injury: A Western Trauma Association critical decisions algorithm

Abstract

Rectal trauma is uncommon, hindering clinical experience with these injuries and rendering high-quality scientific examination of diagnostic and management options challenging. In general, hemodynamically normal patients at risk for rectal injury based on injury mechanism, trajectory, and associated injuries proceed to the CT scanner for IV contrast scans of the abdomen and pelvis. If concern for rectal injury persists based on a CT scan, proctoscopy is the next step in rectal evaluation.Hemodynamically abnormal patients proceed directly to the operating room for hemorrhage control, followed by assessment of the intraperitoneal rectum via laparotomy and of the extraperitoneal rectum via proctoscopy. Regardless of the patient's hemodynamic status, management is then pursued once the injury has been delineated as intraperitoneal or extraperitoneal. Intraperitoneal rectal injuries are managed as colon injuries and extraperitoneal rectal injuries are generally treated with proximal diversion as a loop sigmoid colostomy alone. Several areas of remaining controversy exist andwill require further study, including the optimal time for colostomy reversal; the persistent role, if any, for presacral drainage; and the possibility of nonoperative management for small, nondestructive penetrating extraperitoneal rectal injuries.