What is the management for bleeding after rectal trauma?

Management of Bleeding After Rectal Trauma

Patients with rectal trauma and hemorrhagic shock require immediate surgical bleeding control with colostomy and mucus fistula formation, presacral drainage, and rectal washout—do not delay for extensive diagnostic workup. 1, 2

Immediate Assessment and Hemodynamic Stabilization

• Establish IV access immediately and begin crystalloid resuscitation targeting systolic blood pressure of 80-100 mmHg until definitive bleeding control is achieved (permissive hypotension strategy). 1, 3
• Monitor serum lactate and base deficit every 30-60 minutes to estimate bleeding severity and shock—these are far more reliable than single hematocrit measurements. 1, 3
• Never rely on isolated hematocrit values as they are unreliable markers for acute bleeding severity in the trauma setting. 1, 3
• Minimize time between presentation and intervention—every minute counts in preventing mortality from hemorrhagic shock. 1, 3

Hemodynamically Unstable Patients (Hemorrhagic Shock)

This is the critical decision point: unstable patients need immediate operative intervention, not imaging. 1

• Proceed directly to urgent laparotomy for bleeding control without delay for extensive diagnostic workup. 1, 3
• Perform colostomy with mucus fistula formation, presacral drainage, and rectal washout—this constitutes the standard surgical approach for rectal trauma with active bleeding. 2
• Apply damage control surgery principles if the patient demonstrates deep hemorrhagic shock, ongoing bleeding with coagulopathy, hypothermia, or acidosis. 1, 3
• Use direct surgical packing and local hemostatic procedures as primary bleeding control methods. 1, 3
• Consider angiographic embolization of rectal arteries if bleeding persists despite initial surgical interventions—this has been successfully used for middle rectal artery hemorrhage causing hemorrhagic shock. 1, 4

Hemodynamically Stable Patients

• Perform diagnostic sigmoidoscopy immediately—bright red rectal bleeding after trauma mandates endoscopic evaluation to identify the bleeding source. 2
• Obtain CT scan of abdomen and pelvis with IV contrast when hemodynamic status allows, particularly to identify presacral hematomas or mesenteric injuries that may penetrate into the rectum. 1, 3, 5, 6
• Consider early colonoscopy for precise localization if sigmoidoscopy is non-diagnostic and the patient remains stable. 3

Pharmacologic Adjuncts

• Administer tranexamic acid at 10-15 mg/kg IV bolus followed by 1-5 mg/kg/hour infusion for ongoing hemorrhage to reduce bleeding. 1, 3
• Transfuse packed red blood cells if hemoglobin drops below 7 g/dL, targeting 7-9 g/dL to avoid exacerbating bleeding through over-resuscitation. 3
• Correct coagulopathy early with appropriate blood products if ongoing hemorrhage is present. 1, 3

Special Considerations and Pitfalls

• Blunt rectal trauma carries higher mortality than penetrating trauma due to greater number and severity of associated injuries—expect at least three associated injuries in blunt trauma patients. 2
• Patients on anticoagulation (warfarin) are at high risk for presacral hematoma formation that can penetrate into the rectum and cause massive bleeding—these patients should be managed at highly specialized facilities. 5
• Iatrogenic rectal injuries (from foreign bodies, fecal collection devices, or endoscopic procedures) can cause acute mucosal lacerations with active arterial bleeding requiring endoscopic or surgical hemostasis. 4, 7
• "Seat belt sign" in motor vehicle crashes should raise suspicion for mesenteric or mesosigmoid hematomas that can rupture into the rectum—CT scan is mandatory even in stable patients. 6
• Never dismiss rectal bleeding as minor—it indicates potential significant intrarectal injury requiring urgent evaluation. 2
• Avoid excessive fluid resuscitation to normal blood pressure before bleeding control, as this disrupts clot formation and worsens coagulopathy. 1, 3

Surgical Technique Specifics

• Standard operative approach includes: colostomy formation, mucus fistula creation, presacral drainage, and rectal washout. 2
• Missed rectal injuries are associated with mortality—the only death in one penetrating trauma series occurred when the rectal injury was initially missed. 2
• Conservative management may be considered only for isolated mucosal injuries in hemodynamically stable patients without ongoing bleeding. 2