title: Management of the lower gastrointestinal system in burn: A comprehensive review.
abstract: 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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Department of Plastic, Reconstructive and Burns Surgery, City Campus, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom. Electronic address: jimmyng@nhs.net.
authors.forename: J W G
authors.initials: JW
authors.lastname: Ng
authors.affiliation: Department of Plastic, Reconstructive and Burns Surgery, City Campus, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom.
authors.forename: S A
authors.initials: SA
authors.lastname: Cairns
authors.affiliation: Department of Plastic, Reconstructive and Burns Surgery, City Campus, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom.
authors.forename: C P
authors.initials: CP
authors.lastname: O'Boyle
mesh_terms: D000701:Analgesics, Opioid / Q000009:adverse effects*; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D018988:Bacterial Translocation; D002056:Burns / Q000150:complications / Q000628:therapy*; D003112:Colonic Pseudo-Obstruction / Q000209:etiology / Q000652:urine*; D003125:Colostomy; D000072700:Conservative Treatment; D003248:Constipation / Q000139:chemically induced / Q000628:therapy*; D019299:Decompression, Surgical; D005440:Fluid Therapy; D006801:Humans; D059325:Intra-Abdominal Hypertension / Q000209:etiology / Q000628:therapy*; D007441:Intubation, Gastrointestinal; D054368:Laxatives / Q000627:therapeutic use*; D054843:Negative-Pressure Wound Therapy; D010502:Perineum / Q000293:injuries; D018805:Sepsis / Q000209:etiology / Q000628:therapy*; D013396:Suction
chemical_list: D000701:Analgesics, Opioid; D000900:Anti-Bacterial Agents; D054368:Laxatives
keywords: Abdominal compartment syndrome; Bacterial translocation; Burns; Gastrointestinal effects; Perineal burn; Pseudo-obstruction