WSES guidelines on blunt and penetrating bowel injury: diagnosis, investigations, and treatment

Conclusion

• Management of the awake and oriented blunt abdominal trauma patient starts with the primary survey, E-FAST, physical examination and the secondary survey, blood chemistry, vital signs followed by contrast-enhanced abdominal CTGrade: High
• The presence of a seatbelt sign should prompt a CT scan and a high index of suspicion for bowel injuryGrade: High
• Patients with high-risk mechanisms (i.e. handlebar, seatbelt sign) and non-specific CT findings should be admitted for observation including serial clinical examinationGrade: Moderate
• In patients not clinically evaluable, the diagnosis of hollow viscus injuries relies on injury pattern, vital signs, inflammatory markers trends and follow-up CTGrade: Moderate
• In selected cases a repeat CT might be considered. Patients with equivocal signs on initial CT scan should be re-imaged after 6 h. Patients that demonstrate evolving clinical signs suspicious for bowel injury, re-imaging should be consideredGrade: High
• Although highly sensitive, serum procalcitonin and CRP are not necessarily specific and as supportive biomarkers will help to exclude bowel injuries; but if too heavily relied upon, may lead to nontherapeutic laparotomy, or missed bowel injuryGrade: Moderate
• The presence of highly specific CT findings such as extraluminal air, extraluminal oral contrast, or bowel-wall defects warrants prompt surgical explorationGrade: Moderate
• The presence of highly sensitive CT findings such as free fluid in the absence of solid organ injury, abnormal enhancement of bowel wall, and mesenteric stranding can be used as an adjunct to the clinical picture but should not solely determine managementGrade: Moderate
• Scoring systems that include radiologic, biochemical, and clinical signs can guide management in difficult scenariosGrade: Moderate
• A repeat CT scan can be considered in patients with high-risk mechanisms without peritoneal signs and subtle signs on initial CT of bowel injury who do not show clinical improvement or are not clinically evaluableGrade: Moderate
• NOM can be performed at specialised centres in patients with penetrating abdominal trauma provided that the patient is haemodynamically compensated and cooperative. NOM might be more suitable for stab wounds vs GSWGrade: Moderate
• When CT does not identify hard signs of bowel injury, LWE or screening laparoscopy to investigate for peritoneal violation will guide toward a laparotomy or NOM. Patients without peritoneal violation can be safely dischargedGrade: Moderate
• NOM requires at least 48 h of serial clinical examinations, performed by consistent specialists or consultants, vital sign monitoring, and serial inflammatory markers testingGrade: Moderate
• Following penetrating trauma, highly specific CT findings for bowel injury following penetrating trauma include extraluminal air, extraluminal contrast, bowel-wall defects and metallic fragments within the intestinal wall or lumenGrade: Moderate
• Following penetrating trauma, highly sensitive CT findings for bowel injury following penetrating trauma include free fluid in the absence of solid organ injury, abnormal enhancement of bowel wall and mesenteric stranding. These can be used as an adjunct in the clinical picture but should not solely determine managementGrade: Moderate
• IV contrast-enhancing CT scan has equal sensitivity to triple contrast in detecting bowel injury and is favourable in time-sensitive trauma situationsGrade: Low
• Serial clinical examinations are complementary to CT in guiding surgical management in trauma centres that practice the NOM approach in penetrating abdominal traumaGrade: Moderate
• Diagnostic peritoneal lavage has a limited role. It can be used as an adjunct to a negative laparoscopy to definitively exclude bowel injury, particularly in conjunction with the use of biomarkersGrade: Moderate
• Diagnostic laparoscopy can be used in haemodynamically compensated patients with highly sensitive findings of bowel injury on CTGrade: Moderate
• In penetrating trauma, local wound exploration is used to confirm peritoneal breaching. When positive, serial clinical examinations should follow, where there is clinical suspicion for bowel injury a diagnostic/therapeutic laparoscopy or laparotomy is warranted. Conversion to laparotomy is always possible and highly recommended if any doubts or difficulties ariseGrade: Moderate
• Based on the surgeon experience and logistics of the trauma centre, bowel injuries identified during diagnostic laparoscopy can be treated laparoscopicallyGrade: Moderate
• Primary repair of small bowel injuries is preferred when possibleGrade: High
• Primary anastomosis of colon injuries is safe in a subgroup of patients selected based on physiology, concomitant injuries, and resilience to a possible anastomotic leakGrade: Moderate
• Diverting stomas remain a safe option and are recommended in high-risk patients with high-risk colon anastomosesGrade: Moderate
• The risk of anastomotic leak following DCS increases with: Time from initial surgery Ongoing transfusion requirements, ongoing inotropic support, tissue oedema and intraabdominal sepsis Time to abdominal fascia closureGrade: Moderate
• There is a lack of evidence to demonstrate the superiority of anastomotic techniques following a bowel resection in trauma patientsGrade: High
• The decision to perform either a handsewn or stapled bowel anastomosis in the setting of emergency trauma laparotomy should be individualised to the patient’s condition and the surgeon’s technical abilitiesGrade: Moderate
• In the context of blunt abdominal trauma with or without solid organ injury, bowel injuries are often missed. A high indexed of suspicion is requiredGrade: High
• Delay in the diagnosis of bowel injury is linked to increased morbidity and mortalityGrade: Moderate
• Long-term follow-up of patients with blunt abdominal trauma is required to identify the sequelae of mesenteric injuriesGrade: Low