Guideline sources The following summarized guidelines for the evaluation and management of bowel trauma are prepared by our editorial team based on guidelines from the World Society of Emergency Surgery (WSES 2022), the World Society of Emergency Surgery (WSES/AAST 2019), and the Eastern Association for the Surgery of Trauma (EAST 2012). 1 2 3 Guidelines 1. Diagnostic investigations Initial evaluation: obtain a primary survey, extended FAST, perform a physical examination, obtain a secondary survey, blood chemistry, check for vital signs followed by contrast-enhanced abdominal CT in awake and oriented patients with blunt abdominal trauma. A Show 4 more https://web.pathway.md/diseases/recAf3NCIUysPwkxL 1/4 6/29/23, 3:20 AM Bowel trauma Pathway Computed tomography: obtain CT in the presence of a seatbelt sign (a high index of suspicion for bowel injury). A Show 6 more 2. Diagnostic procedures Diagnostic peritoneal lavage: consider performing diagnostic peritoneal lavage as an adjunct to a negative laparoscopy to definitively exclude bowel injury, particularly in conjunction with the use of biomarkers. C Diagnostic laparoscopy: perform local wound exploration or screening laparoscopy to investigate for peritoneal violation, when CT does not identify hard signs of bowel injury, to guide toward a laparotomy or nonoperative management. Discharge patients without peritoneal violation. B Show 2 more 3. Medical management Non-operative management: consider offering nonoperative management at specialized centers in patients with penetrating abdominal trauma if the patient is hemodynamically compensated and cooperative. Recognize that nonoperative management might be more suitable for stab wounds when compared to gunshot wounds. C 4. Inpatient care Serial clinical assessment: Obtain at least 48 hours of serial clinical examinations, performed by consistent specialists or consultants, vital sign monitoring, and serial inflammatory markers testing during nonoperative management. B Admit patients with high-risk mechanisms (handlebar, seatbelt sign) and non-specific CT findings for observation including serial clinical examination. B 5. Perioperative care Perioperative prophylactic antibiotics: administer a single preoperative dose of prophylactic antibiotics with broad-spectrum aerobic and anaerobic coverage in all patients with penetrating abdominal trauma. A Show 3 more 6. Surgical interventions https://web.pathway.md/diseases/recAf3NCIUysPwkxL 2/4 6/29/23, 3:20 AM Bowel trauma Pathway Local wound exploration: perform local wound exploration or screening laparoscopy to investigate for peritoneal violation, when CT does not identify hard signs of bowel injury, to guide toward a laparotomy or nonoperative management. Discharge patients without peritoneal violation. B Indications for laparotomy: perform prompt surgical exploration in the presence of highly specific CT findings such as extraluminal air, extraluminal oral contrast, or bowel-wall defects. A Indications for bowel repair: recognize that the delay in the diagnosis of bowel injury is linked to increased morbidity and mortality. B Show 6 more 7. Specific circumstances Patients with duodenal injury (evaluation): obtain extended FAST for detecting free fluid and solid organ injury. A Show 7 more Patients with duodenal injury (non-operative management): use hemodynamic stability as the key factor in determining management strategy in patients with duodenal injury. B Show 4 more Patients with duodenal injury (operative management): perform immediate operative intervention in hemodynamically unstable (WSES class IV) patients and in patients with peritonitis, bowel evisceration, or impalement. B Show 4 more 8. Follow-up and surveillance Follow-up: obtain long-term follow-up in patients with blunt abdominal trauma to identify the sequelae of mesenteric injuries. B Clinical findings Symptoms Past events Abdominal pain Blunt abdominal trauma Penetrating abdominal trauma Vital signs Abdominal exam Hypotension Signs of shock Abdominal distension Tachycardia Peritoneal findings Imaging findings https://web.pathway.md/diseases/recAf3NCIUysPwkxL 3/4 6/29/23, 3:20 AM Bowel trauma Pathway Pneumoperitoneum References 1. Luke Smyth, Cino Bendinelli, Nicholas Lee et al. WSES guidelines on blunt and penetrating bowel injury: diagnosis, investigations, and treatment. 10.1186/s13017 022 00418-y. Open 2. Federico Coccolini, Leslie Kobayashi, Yoram Kluger et al. Duodeno-pancreatic and extrahepatic biliary tree trauma: WSES AAST guidelines. World J Emerg Surg. 2019 Dec 11;14 56. Open 3. Goldberg SR, Anand RJ, Como JJ et al. Prophylactic antibiotic use in penetrating abdominal trauma: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012 Nov;73 5 Suppl 4 S321 5. Open https://web.pathway.md/diseases/recAf3NCIUysPwkxL 4/4