Occult Colocutaneous Fistula Following Pelvic Fracture

Scott Thomas; Mark Walsh; Donald Zimmer; Bruce Speicher; Matthew Sarb; Bryan Boyer; Anne Newbold; Clifford Arnold; Michael Donnino

摘要

An enterocutaneous fistula is a rare complication following a pelvic fracture, and a colocutaneous fistula is even rarer. Whereas most cases of bowel entrapment due to a pelvic fracture involve the mobile small bowel, we are reporting a case in which the sigmoid colon became entrapped in the pelvic fragments. Bowel entrapment led to the delayed development of an adynamic ileus, followed by an open communicating fistula between the colon and the skin. Twenty-one cases of bowel entrapment within a pelvic fracture following blunt trauma have been reported in the literature since 1907.1,2 Only five of the twenty-one cases involved the large bowel, excluding the rectum. 2,3,5,6 However, none of the subjects in these cases presented with spontaneous rupture of a colocutaneous fistula, as did the patient in the present study. Work was done in the Department of Emergency Medicine at Memorial Hospital, South Bend, IN. Case A fifty-three year old man presented to the emergency department after being struck by a five hundred pound clamp used to align natural gas pipeline. The clamp struck the patient in the left flank/hip region and pinned him to the seat of a tractor. The findings during his primary emergency department evaluation included normal vital signs and bruising of the abdominal wall over his left iliac crest. X-rays revealed a three centimeter closed fracture of his iliac wing, which was non-displaced (Figure 1). A minor contusion of his spleen was identified on the abdominal CT scan. He was discharged home on bed rest and given oral narcotics for pain control.Forty-eight hours post-injury, the patient visited a different emergency department in a neighboring state complaining of abdominal discomfort and constipation. At this second visit, his vital signs were normal. Physical exam revealed that the patient was in a moderate amount of pain. He complained of a tender left flank with a large, red, and warm hematoma covering the flank and iliac crest. His abdomen was soft, without guarding or rebound tenderness, and auscultation revealed normal bowel sounds. A repeat CT scan of the abdomen was unchanged from his initial presentation. The CBC showed a WBC of 10,700 with a normal hemoglobin level. He was discharged home with a stool softener, additional narcotics for pain control, and crutches for ambulation.Nine days after his initial injury, while sitting on the toilet to defecate, the patient expelled projectile stool through a fistula on the left side of his abdominal wall. Food particles and stool were splattered on the bathroom wall. He was transported by paramedics to yet another hospital. On exam, his vital signs included an oral temperature of 100.3 F, a pulse of 125, and a blood pressure of 114/52. He had a large defect in the skin over his left flank and a tender abdomen (Figure 2). Surgery consultation confirmed an obvious colocutaneous fistula which required immediate exploratory laparotomy and colostomy.Exploration through laparotomy revealed a small, non-bleeding splenic laceration and a large abscess cavity between the sigmoid colon, the iliac crest, and the skin. There was a three centimeter defect in the sigmoid colon that communicated with the fistula. It was clear from surgical exploration that the mechanism behind the etiology of this fistula involved the fractured segment of the pelvis. Initial speculation was raised as to whether the etiology of this fistula may simply have been due to the crushing effect of the trauma, however surgical examination put this issue to rest. The fractured iliac crest protruded into the abscess cavity confirming it as the source of colonic perforation leading to the fistula formation. The necrotic tissue was debrided, the abdomen was irrigated, and sigmoid colectomy with colostomy and Hartmann rectal stump closure were performed.During his hospital course the patient required intravenous antibiotics, parenteral hyperalimentation, and local wound management. On post-operative day

机译：肠皮瘘是骨盆骨折后的一种罕见并发症，而肠皮瘘甚至更罕见。尽管大多数由于骨盆骨折导致的肠管卡住病例涉及活动性小肠，但我们报告了一种乙状结肠陷于骨盆碎片的病例。肠管夹带导致无活动性肠梗阻的延迟发展，随后结肠和皮肤之间的开放性瘘管开放。自1907年以来，已有21例钝性创伤后盆腔骨折引起肠管卡住的报道。1,2二十一例中只有五例涉及大肠，不包括直肠。 2,3,5,6然而，在这些情况下，没有一个对象像本研究中的患者那样表现出自发性皮肤瘘的破裂。在印第安纳州南本德纪念医院的急诊医学科进行了这项工作。案例一名五十三岁的男子在被用于对准天然气管道的五百磅重的夹具撞击后向急诊科求助。该夹钳在左翼/臀部区域撞击患者，并将其固定在拖拉机的座位上。在他的主要急诊科评估期间，研究结果包括正常的生命体征和左his顶腹壁的淤青。 X射线检查显示his骨翼有3厘米闭合闭合骨折，且未移位（图1）。在腹部CT扫描中发现脾脏轻度挫伤。他因卧床休息出院回家并接受了口服麻醉剂来控制疼痛。受伤后四十八小时，该患者因腹部不适和便秘而去了邻国另一个急诊科。在第二次访问中，他的生命体征正常。体格检查显示该患者疼痛程度中等。他抱怨左胁骨柔软，有红色，温暖的大血肿，覆盖着and骨和。他的腹部柔软，没有保持或反弹压痛，听诊显示肠鸣音正常。腹部的CT复查与他最初的表现相同。 CBC显示血红蛋白水平正常的白细胞为10,700。出院后，他用了大便软化剂，额外的麻醉剂来控制疼痛和拐杖走路出院。初次受伤后九天，坐在马桶上排便的病人通过腹部左侧的瘘管将弹丸性大便排出。壁。食物颗粒和粪便溅在浴室的墙上。他被护理人员转移到另一家医院。经检查，他的生命体征包括口腔温度为100.3 F，脉搏为125和血压为114/52。他的左胁腹和腹部有大皮肤缺损（图2）。手术咨询证实了明显的结肠皮肤瘘，需要立即进行探索性剖腹术和结肠造口术。通过剖腹探查发现，乙状结肠，the和皮肤之间有一个小的，无出血的脾撕裂伤和巨大的脓腔。乙状结肠与瘘管有一个三厘米的缺损。从手术研究中可以明显看出，这种瘘的病因背后的机制涉及骨盆的骨折部分。人们开始怀疑瘘管的病因可能仅仅是由于创伤的压迫作用，但是手术检查使这一问题得以解决。 fracture骨骨折突入脓肿腔，证实其为结肠穿孔的来源，导致瘘管形成。清除坏死组织，冲洗腹部，并进行结肠乙状结肠切除术并进行结肠造口术和Hartmann直肠残端闭合术。在住院期间，患者需要静脉使用抗生素，肠胃外营养过高和局部伤口处理。术后一天

Occult Colocutaneous Fistula Following Pelvic Fracture

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