Gastrointestinal Injuries During Delivery



Gastrointestinal Injuries During Delivery


Yesenia Rojas-Khalil

Stephen E. Manek



GENERAL PRINCIPLES



Physical Examination



  • Bowel injuries missed at the time of cesarean birth typically present clinically within 6 hours of injury but can manifest as late as 72 hours if the injury is caused by thermal energy.



  • Postoperatively, patients present with low-grade fever, tachycardia, and diffuse abdominal pain and distension. As time progresses, patients will develop signs consistent with systemic inflammatory response syndrome (see Table 4.10.1), worsening abdominal distention, ileus, guarding, and peritonitis. If left untreated, it will result in septic shock and end-organ dysfunction.


  • Intraoperatively, the presence of succus or bile is suggestive of a bowel injury.


Differential Diagnosis



  • Postoperative ileus


  • Narcotic-induced constipation


  • Small bowel obstruction


  • Intra-abdominal infection


  • Ogilvie syndrome (colonic pseudo-obstruction)


  • Intestinal volvulus


  • Abdominal compartment syndrome, in the setting of complicated delivery requiring a large volume transfusion of blood products or fluids.


Nonoperative Management



  • There is no role for conservative nonoperative management. Iatrogenic bowel injuries noted both intraoperatively and postoperatively must be surgically repaired.


  • If an injury is diagnosed postoperatively, initiate sepsis protocol to include intravenous broad-spectrum antibiotics, and electrolyte and acid-base normalization with fluid resuscitation.


  • Broad-spectrum antibiotics that empirically cover gut flora should cover gram-negative and anaerobic bacteria.


  • Resuscitation, however, should not delay return to the operating room as this can be done simultaneously with the assistance of the anesthesiology team.


IMAGING AND OTHER DIAGNOSTICS



  • Physical examination and a high level of clinical suspicion are often enough to warrant reexploration. The most common imaging modalities that aid in diagnosis are x-ray and CT scan.


Abdominal X-Ray Series



  • An abdominal x-ray series includes three views: Upright chest, upright abdominal, and a supine abdominal film.


  • Ensure that patient is upright, and entirety of the diaphragm is visualized to look for free air or pneumoperitoneum (Figure 4.10.1). Patients who are unable to tolerate being upright can have a left lateral decubitus view while lying flat supine.

    Note that free air is considered a normal postoperative finding up to 3 to 5 days postoperatively (5). Additionally, the lack of pneumoperitoneum does not exclude a bowel perforation and thus should be interpreted in the context of clinical presentation.














Computed Tomography (CT) Scan



  • If no contraindication, utilize intravenous contrast.


  • Consider oral contrast to look for contrast extravasation if suspicious for a proximal small bowel lesion.


  • Consider rectal contrast to look for contrast extravasation if suspicious for a colonic injury.

    Look for discontinuity of the bowel wall extraluminal air (see above), bowel wall thickening, abnormal bowel wall enhancement, abscess, and inflammatory masses adjacent to the bowel (Figure 4.10.2) (6).


PREOPERATIVE PLANNING



  • Before cesarean birth, perform a thorough history and physical examination with attention on previous abdominal surgeries and other causes of intraperitoneal inflammation. Look for abdominal scars suggestive of previous intraperitoneal surgery.


  • Anticipating a hostile abdomen allows heightened awareness of possible iatrogenic bowel injury. Examples include very thin or obese patients, previous abdominal surgery, severe endometriosis, or other complex pelvic pathology.








  • If returning to the operating room after a missed iatrogenic bowel injury, ensure that patient is adequately resuscitated, and electrolytes are corrected.


  • Review any relevant imaging with the treatment team and the interpreting radiologist to anticipate injury location.


SURGICAL MANAGEMENT

Sep 9, 2022 | Posted by in OBSTETRICS | Comments Off on Gastrointestinal Injuries During Delivery
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