Colonic pseudo-obstruction in burns patients

Postburn Abdominal Pain of Gastrointestinal Origin: A Scoping Review

After burn injury, patients may have abdominal pain due to several causes and etiologies, some of which could be life-threatening, including pancreatitis, stress ulcers, Clostridium difficile infection, and so forth. This pain sometimes poses a major diagnostic challenge. This scoping review is the first reported review to address and discuss this entity of patients after burn injury in abdominal pain of gastrointestinal origin. A scoping review of PubMed, Google Scholar, and other electronic research sites was performed. All relevant articles of any study design were included in this review. Variables included in this study were sex distribution, age, related total burn surface area, incidence rate, characteristics of pain, diagnosis, management, outcomes, and mortality rate. The medical literature identified 114 articles. According to our inclusion criteria, 91 articles were reviewed in this article. Through these articles, we reviewed in detail the characteristics of postburn abdominal pain, the relevant diseases responsible for this complaint, the epidemiologic features of these diseases, and potential management approaches aiming to help burn specialists in making earlier diagnosis and, thus, timely treatment. Early recognition of postburn abdominal pain, as well as timely diagnosis and treatment, play a significant role in prognosis and mortality. Thus, it is extremely important for burn specialists and plastic surgeons to thoroughly investigate postburn abdominal pain. Also, one of the aims of this review was to shed light on the important role of the multidisciplinary team in burn patient management to improve the prognosis.

Management of the lower gastrointestinal system in burn: A comprehensive review

BACKGROUND

Burn produces complex gastrointestinal (GI) responses. Treatment, including large volume fluid resuscitation and opioid analgesia, may exacerbate GI dysfunction. Complications include constipation and opioid-induced bowel dysfunction (OBD), acute colonic pseudo-obstruction (ACPO), bacterial translocation and sepsis, and abdominal compartment syndrome (ACS). Contamination of perineal burns contributes to delayed healing, skin graft failure and sepsis and may impact upon morbidity and mortality. The authors carried out a literature review on management of the lower GI system in burn. This study aimed to explain: current prevention and treatment modalities; drawbacks and complications associated with available treatments, and to provide direction for development of best practice guidelines. ACS is associated with high mortality and should be treated with careful fluid resuscitation and diuresis, to minimise and remove oedema.

METHODS

A comprehensive search of English language literature was performed on PubMed, Medline and Embase. Both MeSH and keywords searches were used.

RESULTS

Evidence available on the management of lower gastrointestinal system in burn is summarised. Levels of evidence available are generally low (level III-IV).

CONCLUSION

Structured, graded interventions are required for prevention and treatment of constipation and OBD. Correction of electrolyte imbalance, adequate enteral intake and mobilisation are pre-requisites. Laxatives should be used according to World Gastroenterology Organisation recommendations. Resistant constipation may respond to changes in medication, but ACPO should be suspected and treated when present. Other complications, such as bacterial translocation and ACS are common in major burns. There is evidence that selective digestive tract decontamination reduces mortality and infectious episodes in major burns. ACS is associated with high mortality and should be treated with careful fluid resuscitation and diuresis. Surgery is reserved for non-responsive and severe cases. Perineal burns present challenges in wound and bowel management. Faecal management systems and negative pressure wound therapy (NPWT) may improve wound control and hygiene, but diversion colostomy will still be beneficial in some cases. There is a clear need for rigorous studies to guide practice more effectively in these challenging conditions.

Effect of burn stress on gastric motility

AIM: To investigate the effect of burn stress on gastric motility as well as the changes of related neuropeptides.

METHODS: Radioimmunological assay was performed to detect the dynamic changes of related neuropeptides, including CCK-8, vasoactive intestinal peptide (VIP), somatostatin (SS), and gastrin (GAS) in patients with burn injury and healthy volunteers using ambulatory manometry. Strain-gauge transducers were pre-equipped at the antrum of rats to establish the models of burn injury (30% full skin scalding), and gastric motility and the changes of plasma VIP and CCK-8 contents were recorded before and after modeling. Exogenous peptides (VIP, CCK-8) were intravenously administrated to determine the gastric motor responses.

RESULTS: There were no complete migrating motor complex (MMC) cycles in burn patients. Interdigestive and postprandial gastric motility patterns were mainly resting state without constant phase or with low ampulitude contraction, persistent and irregularly high-frequency contraction and propagated burst activity. In patients with burn injury, the plasma levels of CCK-8, SS, and GAS were significantly higher than those in the controls (5.63 ± 1.31 ng/L vs 1.84 ± 0.87 ng/L, P < 0.05; 235.36 ± 49.72 ng/L vs 50.70 ± 12.62 ng/L, P < 0.01; 124.16 ± 28.6 ng/L vs 49.71 ± 15.57 ng/L, P < 0.01), while the level of VIP was significant lower than that in the controls (19.87 ± 7.26 ng/L vs 35.44 ± 14.81 ng/L, P < 0.05). In fasting rats, gastric motor activity was regular with resting and contractile states before stress. VIP inhibited gastric motility whereas CCK-8 enhanced it. The regularity of gastric motility was destroyed and the motor activity was increased after stress. However, VIP inhibited the enhanced gastric motility. The plasma level of VIP rose in 1 and 2 hours (165.21 ± 58.29 ng/L vs 40.42 ± 16.36 ng/L, P < 0.01; 89.78 ± 32.36 ng/L vs 48.92 ± 13.65 ng/L, P < 0.05), whereas the contents of CCK-8 was immediately increased (8.95 ± 2.84 vs 4.11±1.74, P < 0.05) and then returned to the normal level after stress.

CONCLUSION: Burn stress can lead to disorders of gastric motility and plasma level changes of gastrointestinal motility associated neuropeptides, which may modulate gastric motility.

The use of temporary laparoscopic loop ileostomy in lumbosacral burns

The technique of laparoscopic formation of loop ileostomies has been previously described for use in a variety of conditions. We present this as an option for faecal diversion in severe burns involving the back and buttock region and describe its use in two cases. Faecal diversion allows for easier wound care and nursing. Intra-abdominal assessment of these very sick patients can also be performed simultaneously. The technique is relatively simple, readily available and associated with minimal morbidity. Furthermore, this technique minimises interference with the abdominal wall as a donor site for skin grafts.

Conservative management of acute pseudo-obstruction in a major burn

We present a case of recurrent acute colonic pseudo-obstruction (ACPO) in a burn patient that responded to a postural change which has not been previously reported.

Silver sulfadiazine induced Clostridium difficile toxic megacolon in a burn patient: case report

A 53 yr old diabetic male presented with a 34% total body surface area (TBSA) deep partial- and full-thickness burns. On post burn days 4 and 9, all of his burns were excised and grafted. Although he had only been treated with topical antibiotics, he developed Clostridium difficile colitis after his second surgery that progressed to Toxic Megacolon and perforation. The incidence and treatment of Toxic Megacolon secondary to C. difficile is reviewed. Early diagnosis and treatment with colonoscopic decompression may obviate the need for surgery.