ASSOCIATED (OCCULT) RECTAL INJURIES

DCBI casualties with perineal wounds or many fragments to the perineum, buttocks or groin should undergo a proctoscopy prior to leaving the operating room. Most of these casualties do not have the opportunity to undergo full CT scan prior to going to the OR and CT does not reliably exclude rectal injury. Therefore, fragmentation wounds to the perineum and perianal regions should generally prompt examination of the rectum (proctoscopy or flexible sigmoidoscopy) even if digital rectal examination in the emergency room is negative for blood. This may be difficult in the supine position and may be readily completed in the supported lateral position. Completion of the anorectal exam should be done prior to completing laparotomy to aid decision making with respect to colonic diversion. If clot, active bleeding, or injury is identified on anorectal examination, the distal sigmoid colon/proximal rectum should be divided and later matured at a subsequent operation into an end colostomy once the patient is stabilized further along the evacuation chain. Distal rectal wash out is not necessary unless there is bulky retained stool in the presence of a suspected penetrating injury.