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DOI: 10.1055/s-2001-17632
Verletzungen des Intestinums: Diagnostik und Therapie
Intestinal injuries: diagnostics and therapyPublication History
Publication Date:
05 October 2001 (online)
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Zusammenfassung.
Die Gesamtinzidenz intestinaler Verletzungen beim stumpfen und penetrierenden Abdominaltrauma wird mit 25,2 % angegeben. Die Zeit ist der entscheidende Faktor für den therapeutischen Erfolg bei der Behandlung von Darmverletzungen im Rahmen des stumpfen oder offenen Abdominaltraumas. Eine Verzögerung der Therapie um mehr als 24 Stunden geht mit Mortalitätsraten von bis zu 50 % einher. Derzeit gibt es kein zuverlässiges diagnostisches Verfahren, das intestinale Verletzungen eindeutig nachweist. Gelingt es nicht, eine Dünn- oder Dickdarmverletzung durch die möglichen Untersuchungsverfahren inklusive Laparoskopie aufzudecken oder mit Sicherheit auszuschließen, ist bei persistierender klinischer Symptomatik die Probelaparotomie durchzuführen. In der Diagnostik intestinaler Verletzungen nach stumpfem oder offenem Bauchtrauma müssen alle bildgebenden Verfahren im Vergleich zur klinischen Verlaufseinschätzung kritisch gewertet werden. Anamnese und die körperliche Untersuchung haben nach wie vor den höchsten Stellenwert.
Intestinal injuries: diagnostics and therapy.
The overall incidence of intestinal injuries in blunt or penetrating abdominal trauma is about 25 %. The decisive point in the treatment of these injuries is the time. A delay of more than 24 hours in treatment leads to mortality rates up to 50 %. A safe diagnostic method for the evidence or exclusion of intestinal injury does not exist yet. Uncertain cases call for an explorative laparotomy. Invasive and noninvasive diagnostic procedures have to be taken into account together with clinical data. The history and the result of the clinical examination are still of highest value in the diagnosis of blunt and penetrating abdominal trauma.
Schlüsselwörter:
Stumpfes Bauchtrauma - penetrierendes Bauchtrauma - intestinale Verletzungen - Übersicht.
Key words:
Blunt abdominal trauma - Penetrating abdominal trauma - Intestinal injuries - Review
Literatur
- 1 Maniatis V, Chryssikopoulos H, Roussakis A. et al . Perforation of the alimentary tract: evaluation with computed tomography. Abdom Imaging. 2000; 25 373-379
- 2 Nagel M, Saeger H D, Massoun H, Buschulte J. [Injuries of the small bowel and colon resulting from abdominal trauma]. Unfallchirurg. 1991; 94 105-109
- 3 Kujath P, Radloff A C. (Hrsg) .Peritonitis. Bremen-London-Boston; UNI-MED Verlag 2001 36
- 4 Rüter A, Trentz O, Wagner M. (Hrsg) .Unfallchirurgie. München Wien Baltimore; Urban & Schwarzenberg 1995: 261-351
- 5 Brunner R G, Shatney C H. Diagnostics and therapeutic aspects of rectal trauma. Blunt versus penetrating. Am Surg. 1987; 53 (4) 215-219
- 6 Nagel M, Kopp H, Hagmüller E, Saeger H D. [Gunshot and stab wounds of the abdomen]. Zentralbl Chir. 1992; 117 453-459
- 7 Degiannis E, Boffard K. Duodenal injuries. Br J Surg. 2000; 87 1473-1479
- 8 McKenzie A D, Bell G A. Nonpenetrating injuries of the colon and rectum. Surg Clin North Am. 1972; 52 (3) 735-747
- 9 Cogbill T H, Moore E E, Feliciano D V. et al . Conservative management of duodenal trauma: a multicenter perspective. J Trauma. 1990; 30 (12) 1469-1475
- 10 Shilyansky J, Pearl R H, Kreller M, Sena L M, Babyn P S. Diagnosis and management of duodenal injuries in children. J Pediatr Surg. 1997; 32 (6) 880-886
- 11 Stevens S L, Maull K I. Small bowel injuries. Surg Clin North Am. 1990; 70 (3) 541-560
- 12 Schumpelick V, Ambacher T, Riesener K P. [Current therapy of injuries of the colon and retroperitoneum]. Chirurg. 1999; 70 1269-1277
- 13 Adkins R B, Zirkle P K, Waterhouse G. Penetrating colon trauma. J Trauma. 1984; 24 (6) 491-499
- 14 Ekkernkamp A, Brand J, Wernet E, Muhr G, Rehn J. [Factors affecting the therapeutic outcome of abdominal trauma. An analysis of 558 Patients]. Unfallchirurg,. 1992; 95 380-386
- 15 Anderson M L, Pasha T M, Leighton J A. Endoscopic perforation of the colon: Lessons from a 10-year-study. Am J Gastroenterol. 2000; 95 (12) 3418-3422
- 16 Melullis M J, Schiedeck T HK, Müller G, Markert U, Bruch H P. Iatrogene Verletzungen des Gastrointestinaltraktes. Indikation zur frühzeitigen laparoskopischen Intervention. Minimal Invasive Chirurgie,. 1998; 7 (1) 17-20
- 17 El-Banna M, Abdel-Atty M, El-Meteini M, Aly S. Management of laparoscopic-related bowel injuries. Surg Endosc. 2000; 14 779-782
- 18 Smith R S, Fry W R, Morabito D J, Koehler R H, Organ C H. Therapeutic laparoroscopy in trauma. Am J Surg. 1995; 170 632-637
- 19 Gerspach J M, Bellman G C, Stoller M L, Fugelso P. Conservative management of colon injury following percutaneous renal surgery. Urology. 1997; 49 (6) 831-837
- 20 Kropp S, Bleich S, Rudolph B, von Rothkirch M, Ritter E, Birkholz M. Death caused by stomach rupture due to overinflation during oxygen administration via stomach tube. Arch Kriminol. 1996; 198 (5 - 6) 176-183
- 21 Talmor M, Hoffman L A, Lieberman M. Intestinal perforation after suction lipoplasty: A case report and review of literature. Ann Plast Surg. 1997; 38 (2) 169-172
- 22 Hornig G W, Shillito J. Intestinal perforation by peritoneal shunt tubing: report of two cases. Surg Neurol. 1990; 33 288-290
- 23 Schulhof L A, Worth R M, Kalsbeck J E. Bowel perforation due to peritoneal shunt. Surg Neurol. 1975; 3 265-269
- 24 Kim H C, Han J K, Kim T K. et al . Duodenal perforation as a delayed complication of placement of an esophageal stent. J Vasc Interv Radiol. 2000; 11 (7) 902-904
- 25 Thumbe V K, Houghton A D, Smith M SH. Duodenal perforation by a wallstent. Endoscopy. 2000; 32 (6) 495-497
- 26 Bianchini A U, Mehta S N, Mulder D S, Barkun A N, Mayrand S. Duodenal perforation by a Greenfield Filter: Endoscopic diagnosis. Am J Gastroenterol. 1997; 92 (4) 686-687
- 27 Beall A C, Bricker D L, Alessi F J, Whisennand H H, DeBakey M E. Surgical considerations in the management of civilian colon injuries. Ann Surg. 1971; 173 (6) 971-978
- 28 Flint L M, McCoy M, Richardson J D, Polk H C. Duodenal injury. Analysis of common misconceptions in diagnosis and treatment. Ann Surg. 1980; 191 (6) 697-702
- 29 Eigler F W, Coone H J. [Injuries of small and large bowel]. Langenbecks Arch Chir Suppl II (Kongreßbericht 1990). 1990: 625-629
- 30 Ballard R B, Badellino M, Eynon C A, Spott M A, Statz C F, Buckman R F. Blunt duodenal rupture: a 6-year statewide experience. J Trauma. 1997; 43 (2) 229-233
- 31 Enderson B L, Maull K I. Missed injuries. The trauma surgeon's nemesis. Surg Clin North Am. 1991; 71 (2) 399-418
- 32 Cobb L M, Vinocur C D, Wagner C W, Weintraub W H. Intestinal perforation due to blunt trauma in children in an era of increased nonoperative treatment. J Trauma. 1986; 26 (5) 461-463
- 33 Kearny P A, Vahey T, Burney R E, Glazer G. Computed tomography and diagnostic peritoneal lavage in blunt abdominal trauma. Arch Surg. 1989; 124 344-347
- 34 Bulas D I, Taylor G A, Eichelberger M R. The value of CT in detecting bowel perforation in children after blunt abdominal trauma. Am J Roentgenol. 1989; 153 561-564
- 35 Ciftci A O, Tanyel F C, Salman A B, Büyükpamukcu N, Hicsönmez A. Gastrointestinal tract perforation due to blunt abdominal trauma. Pediatr Surg Int. 1998; 13 259-264
- 36 Hammann J, Spohn K. Peritonitis nach stumpfen Verletzungen des Bauches. Chirurg. 1971; 42 (10) 437-444
- 37 Malhorta A K, Fabian T C, Katsis S B, Gavant M L, Croce M A. Blunt bowel and mesenteric injuries: The role of screening computed tomography. J Trauma. 2000; 48 (6) 991-1000
- 38 Shankar K R, Lloyd D A, Kitteringham L, Carty H ML. Oral contrast with computed tomography in the evaluation of blunt abdominal trauma in children. Br J Surg. 1999; 86 (8) 1073-1077
- 39 Bittner R, Roscher R. [Gastric, duodenal and pancreatic trauma: Diagnostics and operative procedures]. Langenbecks Arch Chir Suppl II (Kongreßbericht 1990). 1990: 617-623
- 40 Dapunt O, Karlbauer A, Möseneder H, Boeckl O. Verletzung des Magen-Darm-Traktes nach stumpfem Bauchtrauma. Chirurg. 1985; 56 (11) 695-698
- 41 Fabian T C, Croce M A, Stewart R M, Pritchard F E, Minard G, Kudsk K A. A prospective analysis of diagnostic laparoscopy in trauma. Ann Surg. 1993; 217 (5) 557-565
- 42 Asensio J A, Berne J, Demetriades D, Murray J, Gomez H, Falabella A. et al . Penetrating esophageal injuries: Time interval of safety for preoperative evaluation - how long is safe?. J Trauma. 1997; 43 (2) 319-324
- 43 Asensio J A, Chahwan S, Forno W, MacKersie R, Wall M, Lake J. et al . Penetrating esophageal injuries: Multicenter study of the American Association for the Surgery of Trauma. J Trauma. 2001; 50 289-296
- 44 Feliciano D V, Burch J M, Spjut-Patrinely V, Mattox K L, Jordan G L. Abdominal gunshot wounds. An urban trauma center's experience with 300 consecutive patients. Ann Surg. 1988; 208 (3) 362-370
- 45 Demetriades D, Charalambides D, Lakhoo M, Pantanowitz D. Gunshot wounds of the abdomen: role of selective conservative management. Br J Surg. 1991; 78 220-222
- 46 Woolcott R. The safety of laparoscopy performed by direct trocar insertion and carbon dioxide insufflation under vision. Aust N Z J Obstet Gynaecol. 1997; 37 (2) 216-219
- 47 Riedl S, Buhr H J, Herfarth C h. [Effect of diagnostic imaging techniques on choice of therapy and prognosis of traumatic pancreas and duodenal injuries]. Langenbecks Arch Chir. 1994; 379 (1) 38-43
- 48 Weigelt J A. Duodenal injuries. Surg Clin North Am. 1990; 70 (3) 529-539
- 49 Robbs J V, Moore S W. Pillay SP. Blunt abdominal trauma with jejunal injury: a review. J Trauma. 1980; 20 (4) 308-311
- 50 Moore E E, CogbillTH, Malangoni M A, Jurkovich G J, Champion I, Gennarelli T A. Organ injury scaling II: Pancreas, duodenum, small bowel, colon and rectum. J Trauma,. 1990; 30 (11) 1427-1429
- 51 Waldner H, Erhard J, Hallfeldt K, Schweiberer L. [Emergency laparoscopy for abdominal stab wounds]. Chirurg. 1995; 66 1105-1109
- 52 Schmidt U, Maull K, Gould H, Frame S. [The role of computed tomography in blunt hollow visceral injury]. Unfallchirurg. 1994; 97 54-56
- 53 Bünte H, Filler D. Das traumatisch bedingte Abdomen. Münch Med Wochenschr. 1974; 116 (27) 1301-1308
- 54 Sherck J P, Oakes D O. Intestinal injuries missed by computed tomography. J Trauma. 1990; 30 (1) 1-7
- 55 Kirschner P, Brünner H. Die Verletzung des Dünndarms im Rahmen stumpfer abdomineller Kombinationstraumen. Therapiewoche. 1974; 39 4268-4273
- 56 Yoshii H, Sato M, Yamamoto S, Motegi M, Okusawa S, Kitano M. et al . Usefulness and limitations of ultrasonography in the initial evaluation of blunt abdominal trauma. J Trauma. 1998; 45 (1) 45-50
- 57 Ivatury R R, Nassoura Z E, Simon R J, Rodriguez A. Complex duodenal injuries. Surg Clin North Am. 1996; 76 (4) 797-812
- 58 Snyder W H, Weigelt J A, Watkins W L, Bietz D S. The surgical management of duodenal trauma. Arch Surg. 1980; 115 422-429
- 59 Waydhas C, Nast-Kolb D, Blahs U, Pfeifer K J, Schweiberer L. Abdominelle Sonographie versus Peritoneallavage in der Schockraumdiagnostik beim Polytrauma. Chirurg. 1991; 62 (11) 789-793
- 60 Hoffmann R, Nerlich M, Muggia-Sullam M, Pohlemann T, Wippermann B, Regel G. et al . Blunt abdominal trauma in cases of multiple trauma evaluated by ultrasonography: a prospective analysis of 291 patients. J Trauma. 1992; 32 (4) 452-458
- 61 McKenny M, Lentz K, Nunez D, Sosa J L, Sleeman D, Axelrad A. et al . Can ultrasound replace diagnostic peritoneal lavage in the assessment of blunt abdominal trauma?. J Trauma. 1994; 37 (3) 439-441
- 62 Bode P J, Niezen R A, van Vugt A B, Schipper J. Abdominal ultrasound as a reliable indicator for conclusive laparotomy in blunt abdominal trauma. J Trauma. 1993; 34 (1) 27-31
- 63 McKenny M, Martin L, Lentz K, Lopez C, Sleeman D, Aristide G. et al . 1000 consecutive ultrasounds for blunt abdominal trauma. J Trauma. 1996; 40 (4) 607-612
- 64 Donohue J H, Federle M P, Griffiths B G, Trunkey D D. Computed tomography in the diagnosis of blunt intestinal and mesenteric injuries. J Trauma. 1987; 27 (1) 11-17
- 65 Kunin J R, Korobkin M, Ellis J H, Francis I R, Kane N M, Siegel S E. Duodenal injuries caused by blunt abdominal trauma. Value of CT in differentiating perforation from hematoma. Am J Roentgenol. 1993; 160 1221-1223
- 66 Mirvis S E, Gens D R, Shanmuganathan K. Rupture of the bowel after blunt abdominal trauma: Diagnosis with CT. Am J Roentgenol. 1992; 159 1217-1221
- 67 Nemcek A A. CT of acute gastrointestinal disorders. Radiol Clin North Am. 1989; 27 (4) 773-786
- 68 Liu M, Lee C H, P'eng F K. Prospective comparison of diagnostic peritoneal lavage, computed tomographic scanning and ultrasonography for the diagnosis of blunt abdominal trauma. J Trauma. 1993; 35 (2) 267-270
- 69 Barras J P, Gilg M, Regli B, Schweizer W. Sekundäre Peritonitis nach negativem Computertomogramm beim stumpfen Abdominaltrauma. Helv Chir Acta. 1993; 60 513-516
- 70 Meredith J W, Ditesheim J A, Stonehouse S, Wolfman N. Computed tomography and diagnostic peritoneal lavage. Complementary roles in blunt trauma. Ann Surg. 1992; 58 44-48
- 71 Becker C D, Mentha G, Schmidlin F, Terrier F. Blunt abdominal trauma in adults: role of CT in the diagnosis and management of visceral injuries. Eur Radiol. 1998; 8 772-780
- 72 Sherck J, Shatney C, Sensaki K, Selivanov V. The accuracy of computed tomography in the diagnosis of blunt small-bowel perforation. Am J Surg. 1994; 168 670-675
- 73 Hawkins M L, Scofield W M, Carraway R P, Laws H L. Diagnostic peritoneal lavage in blunt trauma. South Med J. 1988; 81 (3) 293-296
- 74 Steenblock U, Claudi B, Dittmann M, Wolff G. Peritoneallavage beim stumpfen Bauchtrauma. Diagnostik und Verlaufsbeobachtung beim Mehrfachverletzten. Helv Chir Acta. 1977; 44 87-88
- 75 Fischer R P, Beverlin B C, Engrav L H, Benjamin C, Perry J F. Diagnostic peritoneal lavage. Fourteen years and 2586 patients later. Am J Surg. 1978; 136 701-704
- 76 Root H D, Hauser C W, McKinley C R, LaFave J W, Mendiola R P. Diagnostic peritoneal lavage. Surgery. 1965; 57 (5) 633-637
- 77 Soyka J M, Martin M, Sloan E P, Himmelman R G, Batesky D, Barrett J A. Diagnostic peritoneal lavage: Is an isolated WBC count > 500/ mm3 predictive of intra-abdominal injury requiring celiotomy in blunt trauma patients?. J Trauma. 1990; 30 (7) 874-879
- 78 Guarino J, Hassett J M, Luchette F A. Small bowel injuries. Mechanisms, patterns and outcome. J Trauma. 1995; 39 (6) 1076-1080
- 79 Feussner H, Papaziogas W, Siewert J R. [Modern diagnostic workup of blunt abdominal trauma]. Chirurg. 1999; 70 1246-1254
- 80 Schreiber M A, Gentinello L M, Rhee P, Jurkovich G J, Maier R V. Limiting computed tomography to patients with peritoneal lavage-positive results reduces cost and unnecessary celiotomies in blunt trauma. Arch Surg. 1996; 131 954-959
- 81 Rückert K, Starker M, Schreyer T, Kümmerle F. Ultraschall und Peritoneallavage in der Dianostik des stumpfen Bauchtraumas. Hefte zur Unfallheilkunde. 1984; 163 80
- 82 Alyono D, Perry J F. Significance of repeating diagnostic peritoneal lavage. Surgery. 1982; 91 (6) 656-659
- 83 McAnena O J, Marx J A, Moore E E. Peritoneal lavage enzyme determinations following blunt and abdominal trauma. J Trauma. 1991; 31 (8) 1161-1164
- 84 Rossi P, Mullins D, Thal E. Role of laparoscopy in the evaluation of abdominal trauma. Am J Surg. 1993; 166 707-711
- 85 Ammann J, Engelhardt G, Blessing H. Die Stellung der Laparoskopie beim stumpfen Bauchtrauma. Helv Chir Acta,. 1977; 44 89-91
- 86 Grassi R, Pinto A, Rossi G, Rotondo A. Conventional plain-film radiology, ultrasonography and CT in jejuno-ileal perforation. Acta Radiol. 1998; 39 52-56
- 87 Leppäniemi A K, Voutilainen P, Haapiainen R K. Indications for early mandatory laparotomy in abdominal stab wounds. Br J Surg. 1999; 86 76-80
- 88 Fry R D. Anorectal trauma and foreign bodies. Surg Clin North Am. 1994; 74 (6) 1491-1505
- 89 Grasberger R C, Hirsch E F. Rectal trauma. A retrospective analysis and guidelines for therapy. Am J Surg. 1983; 145 795-799
- 90 Nast-Kolb D, Waydhas C, Kastl S, Duswald K H, Schweiberer L. Stellenwert der Abdominalverletzung für den Verlauf des Polytraumatisierten. Chirurg. 1993; 64 (7) 552-559
- 91 Nast-Kolb D, Trupka A, Ruchholtz S, Schweiberer L. Abdominaltrauma. Unfallchirurg. 1998; 101 (2) 82-91
- 92 Ertel W, Trentz O. Das stumpfe und penetrierende Abdominaltrauma. Unfallchirurg. 1996; 99 288-303
- 93 Ivatury R R, Simon R J, Weksler B, Bayard V, Stahl W M. Laparoscopy in the evaluation of the intrathoracic abdomen after penetrating injury. J Trauma. 1992; 33 (1) 101-109
- 94 Ivatury R R, Simon R R, Stahl W M. A critical evaluation of laparoscopy in penetrating abdominal trauma. J Trauma. 1993; 34 (6) 822-828
- 95 Ortega A E, Tang E, Froes T, Asensio J A, Katkhouda N, Demtriades D. Laparoscopic evaluation of penetrating thoracoabdominal traumatic injuries. Surg Endosc. 1996; 10 19-22
- 96 Demetriades D, Rabinowitz B. Indications for operation in abdominal stab wounds. A prospektive study of 651 patients. Ann Surg. 1987; 205 (2) 129-132
- 97 Goldberger J H, Bernstein D M, Rodman G H, Suarez C A. Selection of patients with abdominal stab wounds for laparotomy. J Trauma. 1982; 22 (6) 476-480
- 98 Hallfeldt K KJ, Trupka A W, Erhard J, Waldner H, Schweiberer L. Emergency laparoscopy for abdominal stab wounds. Surg Endosc. 1998; 12 907-910
- 99 Ertekin C, Yamaner S, Güloglu R, Günay K, Belgerden S. [The role of diagnostic laparoscopy in the treatment of penetrating injuries of the lower thoracic wall and anterior abdominal wall]. Zentralbl Chir. 1997; 122 (7) 535-537
- 100 Leppäniemi A, Salo J, Haapiainen R. Complications of negative laparotomy for truncal stab wounds. J Trauma. 1995; 38 (1) 54-58
- 101 McIntyre R, Auld C D, Cuschieri R J, Taggart I, McKay A J. Penetrating abdominal stab wounds: a plea for a more conservative policy. Injury. 1989; 20 355-358
- 102 Nagel M, Ockert D, Saeger H D. [Management of abdominal stab wounds]. Unfallchirurg. 1994; 97 419-423
- 103 Namias N, Kopelman T, Sosa J L. Laparoscopic colostomy for a gunshot wound to the rectum. J Laparoendosc Surg. 1995; 5 (4) 251-253
- 104 Sosa J L, Baker M, Puente I, Sims D, Sleeman D, Ginzburg E. et al . Negative laparotomy in abdominal gunshot wounds: Potential impact of laparoscopy. J Trauma. 1995; 38 (2) 194-197
Prof. Dr. H.-P. Bruch
Klinik für Chirurgie
Medizinische Universität
Ratzeburger Allee 160
23538 Lübeck