Gastrointestinal Injuries During Delivery
Stephen E. Manek
Gastrointestinal injury is a rare but life-threatening iatrogenic complication of childbirth via cesarean birth.
Small bowel is most commonly injured, but injuries to the colon and intraperitoneal rectum can also occur (1).
Typically, the gravid uterus displaces bowel out of the operative field, thus iatrogenic injury rates during cesarean birth are cited at <1% (2,3).
Previous abdominal surgery is the largest risk factor for gastrointestinal injury. Intra-abdominal inflammation owing to diseases such as endometriosis, pelvic inflammatory disease (PID), and inflammatory bowel disease (IBD) can also increase the risk of iatrogenic bowel injury (4).
Scar tissue that adheres bowel to the anterior abdominal wall and other abdominal structures increases the risk of bowel injury during peritoneal entry.
Bowel injury can occur during lysis of adhesions if required before delivery.
Bowel can be inadvertently sutured during uterine or peritoneal closure.
All bowel injuries should be addressed and repaired immediately at the time of recognition to prevent intra-abdominal sepsis and future morbidity and mortality.
If the injury is diagnosed after the index operation, the patient must return to the operating room for exploratory laparotomy and bowel repair.
Surgical repair of gastrointestinal injury is a vital skill for obstetricians practicing in locations where general surgeons are not readily available. Surgical technique is easily taught under the tutelage of an experienced surgeon.
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.
Small bowel obstruction
Ogilvie syndrome (colonic pseudo-obstruction)
Abdominal compartment syndrome, in the setting of complicated delivery requiring a large volume transfusion of blood products or fluids.
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.
Table 4.10.1 Systemic Inflammatory Response Syndrome Criteria
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.
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.
Figure 4.10.2. Cross-section computed tomography scan image demonstrating pneumoperitoneum and free intra-abdominal fluid.
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.
If bowel injury is noted intraoperatively, the injury should be repaired during the index operation immediately to minimize spillage of stool.
If bowel injury is diagnosed postoperatively, the patient should be started on broad-spectrum antibiotics and fluid resuscitation for return to the operating room and definitive repair.
The goals of surgery are to identify the location of the bowel injury, obtain control of spillage and sepsis, preserve the bowel while minimizing the risk of future complications (e.g., stricture), and thoroughly wash out the abdomen.
Thoroughly examine the entire intestine in a systematic fashion. We recommend beginning the small bowel because this is the most likely site of injury. Begin by examining the small bowel from the ligament of Treitz to the ileocecal valve for missed injuries.
Next, examine the colon starting with the cecum and move distally to the rectum. Finally, examine the stomach. This is an unlikely site of injury, given its distance from the pelvis; however, some patients may develop a postoperative ileus in the setting of intra-abdominal sepsis, and proper placement of a nasogastric tube for postoperative management may be helpful.
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