EP210 - A Case of Rectal Laceration Secondary to a Jet Ski Water Stream Blast Injury

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Purpose/Background: Traumatic anorectal injuries from jet ski blast effect accidents are rare occurrences. As such, little is found in the literature regarding management; rectal lacerations are more commonly seen with penetrating military and obstetric trauma. Current management of extra-peritoneal rectal injuries are a subject of debate: proximal diversion, primary repair, presacral drainage, distal irrigation and debridement, or a combination of the above. Given the low incidence of rectal jet ski blast injuries, the purpose of this report is to share the management for this unique injury.

Methods/Interventions: The patient was a 30-year-old female who was a passenger on a jet ski when she fell backwards into the water, and the water stream blast struck her in the perineum. She experienced instant vaginal, perineal, and anorectal pain. Rectal bleeding prompted presentation to a local hospital. The patient was hemodynamically stable and no other injuries identified, however, a CT abdomen and pelvis (Image 1) revealed soft tissue edema of the extra-peritoneal anorectum and circumferential air in the mesorectum without evidence of intraperitoneal injuries. Patient was airlifted to a level 1 trauma center for management of a blast related rectal injury.

Results/Outcomes: Colorectal surgery was consulted and promptly evaluated. Abdominal examination was significant for bilateral lower quadrant tenderness. Initial anal exam was normal with normal sphincter tone and left buttock bruising. Patient was taken to the operating room and examined under anesthesia where a flexible sigmoidoscopy revealed an anterior wall, full thickness injury in the distal rectum. No injuries to the vaginal base were detected. Given the injury was extra-peritoneal, the laceration was repaired primarily without diversion. Post-operatively, patient remained hemodynamically stable with mild bilateral lower quadrant abdominal tenderness. Repeat CT with rectal contrast (Image 2) was done on postoperative day two that showed continued air in the mesorectum and extravasation of rectal contrast. Given the persistent rectal defect and concern for the blast effect injecting feces, fuel, and lake water debris into the mesorectum, the patient was taken back to the operating room for a diverting loop ileostomy and endoscopic clips were applied to the proximal extent of the injury. Because of the concerns of contamination of the mesorectum, the mechanism of injury and the fact that it might be difficult to evaluate the mesorectum, the patient was discharged on antibiotics.

Conclusion/Discussion: Few case reports exist regarding management of isolated extra-peritoneal, hydrostatic, rectal jet ski blast injuries. Several case reports cite associated anal and intraperitoneal injuries. Our patient remained clinically well. Non-diverted rectal lacerations have higher rates of contamination and sepsis. The continued abdominal pain, mesorectal air and mechanism of injury prompted the decision to return to the operating room for diversion. Furthermore, a loop ileostomy provides adequate diversion and is technically easier to reverse. To our knowledge, this is the first case report for use of diverting loop ileostomy, primary repair and endoscopic clips for a distal rectal injury obtained from a jet ski water stream hydrostatic blast injury. At the three month follow up, a flexible sigmoidoscopy showed intact rectal mucosa and a gastrografin enema showed no leak. Plans are undergoing for ileostomy reversal in the near future.