Small and Large Bowel Flashcards

1
Q

What is the most common CT finding associated with blunt intestinal injury?

A

presence of free fluid
Free fluid in the absence of solid organ injury is present in over 80% of patients with blunt intestinal injury

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2
Q

What are “bucket handle” injuries

A

involve avulsion of the bowel mesentery caused by shear force in high-impact blunt trauma. They are commonly missed on initial CT

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3
Q

When is selective nonoperative management a reasonable option for patients with gunshot or stab wounds to the abdomen?

A

-if the patient is stable, the wounds are tangential, and there are no peritoneal signs.
-with a reliable examination may be discharged after 24 hours

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4
Q

What alternative diagnostic method can be considered in stable patients with equivocal clinical and radiographic findings?

A

Diagnostic laparoscopy can be considered in selected stable patients to confidently rule out injury.

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5
Q

When can blunt mesenteric hematomas be safely observed in asymptomatic patients?

A

-if CT findings are negative for bowel compromise, obstruction, or active arterial extravasation
-may present days later with delayed perforation secondary to devascularization.
-require more than 24 hours of observation to rule out the risk of delayed perforation.

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6
Q

How should a systematic inspection of the small bowel be conducted during surgery?

A

identifying the ligament of Treitz proximally and “running the bowel” hand over hand, with an assistant following to identify the ileocecal valve.

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7
Q

How should hematomas involving the bowel wall be managed?

A

always be opened and evaluated for underlying injury, especially in the case of stab wounds.

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8
Q

Why should the mesenteric border be carefully inspected during surgery?

A

often subtle and can be overlooked.

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9
Q

What should be assessed in the associated mesentery during surgery?

A

full-thickness defects, active bleeding, hematomas, and regions of significant devascularization.

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10
Q

When does ligating mesenteric vessels increase the risk of subsequent ischemia?

A

Multiple ligations, proximal ligations, and ligations near the distal terminal ileum increase the risk of ischemia.

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11
Q

What should be done in cases of proximal or root mesenteric arterial bleeding?

A

Precise evaluation for SMA injury is needed, with possible primary repair or revascularization

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12
Q

What should be considered if moderate to large-sized mesenteric hematomas are not explored?

A

Consider a second-look operation to assess intestinal viability

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13
Q

How should full-thickness perforations or lacerations (grade II) involving ≤ 50% of the wall circumference without devascularization be repaired?

A

using full-thickness absorbable sutures, followed by a seromuscular imbricating layer

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14
Q

How should perforations or lacerations involving more than 50% of the wall circumference (grade III) be managed?

A

resection and anastomosis

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15
Q

How should grade III injuries involving the proximal jejunum or patients at risk for short bowel syndrome be managed?

A

repair these injuries primarily if significant luminal narrowing can be avoided

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16
Q

How are grade IV and V injuries managed?

A

Resection and anastomosis

17
Q

When should a hand-sewn anastomosis be considered during bowel surgery?

A

if there is significant bowel edema, a size mismatch, or friable tissue.

18
Q

How should the colon be inspected during surgery?

A

Inspection of the colon usually begins at the ileocecal valve and continues to the peritoneal reflection surrounding the intraperitoneal rectum

19
Q

What tool should be used for suspected extraperitoneal rectal injury?

A

A rigid proctoscope should be utilized

20
Q

How should posterior colonic injuries be evaluated?

A

white line of Toldt should be excised

21
Q

What should be identified and protected during colonic mobilization?

A

The ureters

22
Q

How should large bowel wall hematomas and paracolic hematomas be managed?

A

opened and explored

23
Q

What does air tracking within the omentum, mesenteric planes, or bowel wall suggest, and how should it be managed

A

possibility of occult perforations, which should be traced and identified

24
Q

Why should high-energy injuries from high-velocity projectiles or blast injuries be approached differently

A

may leave a zone of nonviable tissue and capillary damage that might not be apparent initially, potentially leading to delayed perforation

25
Q

What is a reasonable management strategy for grade I and II injuries associated with high-energy injuries?

A

Resection with primary anastomosis

26
Q

How are destructive colon wounds (grades III–V) managed?

A

Destructive colon wounds require either resection with anastomosis or colostomy

27
Q

When should the decision to perform an ostomy be considered?

A

presence of significant comorbidities, high blood transfusion requirements, hemodynamic instability, or compromised blood supply

28
Q

How should the abdominal wall be closed in the presence of fecal spillage or colonic contamination

A

The fascia should be closed primarily, while the skin should be left open or loosely approximated with staples

29
Q

How can the wound be managed postoperatively if the skin is left open or loosely approximated?

A

The wound can be managed with negative-pressure vacuum-sponge therapy or dressing changes to allow for secondary wound closure