60-64 IleusandBowelObstruction. Flashcards

1
Q

What are the types of bowel Obstruction (6)

A

Mechanical obstruction

Functional obstruction.

Simple obstruction

Strangulation obstruction

Open-loop obstruction

Closed-loop obstructions

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Mechanical obstruction definition

A

Mechanical obstruction.
means that luminal contents cannot pass through the gut tube because the lumen is blocked.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

definition of

Functional obstruction.

A

There are neurogenic or functional obstructions in which luminal contents are prevented from passing because of disturbances in gut motility that prevent coordinated peristalsis from one region of the gut to the next.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

simple obstruction definition

A

the intestinal lumen is partially or completely occluded without compromise of intestinal blood flow.

may be complete, meaning that the lumen is totally occluded

or

incomplete, lumen is narrowed but permitting distal passage of some fluid and air.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Strangulation obstruction.

  • def
  • ceonsequences

complete/ incomplete obstruction

A

In strangulation obstruction, blood flow to the obstructed segment is compromised and tissue necrosis and gangrene are imminent.

Strangulation usually implies that the obstruction is complete.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Open-loop obstruction. def

A

open-loop obstruction occurs when intestinal flow is blocked but proximal decompression is possible through vomiting.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Closed-loop obstructions

  • def
  • is decompression possible
A

closed-loop obstruction occurs when inflow to the loop of bowel and outflow from the loop are both blocked. This obstruction permits gas and secretions to accumulate in the loop without a means of decompression, proximally or distally

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

classification of Intestinal obstruction

A

Dynamic- Peristalsis against a mechanical obstruction

  • intraluminal
  • intramural
  • Extraluminal

Adynamic – absent or non propulsive peristalsis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Dynamic classification of Bowel Obstruction

A

Intraluminal

  • Foreign bodies, Gallstones,
  • Parasites, Enteroliths, Intussuseption
  • Swallowed objects

Intramural

  • Congenital: Meckels, Atresia, Stenosis,
  • Inflammatory: crohns, Diverticulitis, Radiation enteritis
  • Traumas: Intramural/Extramural
  • Tumors: mg/ benign

Extraluminal

  • Adhesions
  • Meckels bands
  • Hernia
  • Volvulus
  • External Mass Effect
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Adynamic /functional obstruction - absent or non propulsive peristalsis

( func obs has disturbances in gut motility )

A
  1. paralytic ileus (neuourigenic)
  2. Mesenteric Vascular Occlusion
  3. Pseudo-obstruction
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Pathophysiology of Intestinal Obstruction

A

When a loop of bowel becomes obstructed, intestinal gas and fluid accumulate.

Stasis of luminal content favors bacterial overgrowth!!alters intestinal fluid transport properties and motility, and causes variations in intestinal perfusion and lymph flow. →

altered flow leads to Changes in hydrostatic and osmotic pressures on the blood and lumen sides of the mucosa.

pressure changes lead to favor flow of extracellular fluid into the lumen. →

Perfusion is compromised as luminal pressures increase,bacteria invade, and inflammation leads to edema within the bowel wall.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

complications of closed-loop obstructions

A

closed loop obstructinos evolve rapidly compared to open loop

blood supply of the obstructed loop is compromisedgangrene and perforation → free perforation w/ Peritonitis ( clinically leads to a rigid abdomen) ​

Toxins from necrotic tissue and bacterial overgrowth are released into the systemic circulation → shock ensures

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

conplications of open-loop obstructions

A

dosent evolve as quickly since proximal jeujenum can be decompressed by vomitting

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Complications / charaacteristics clinical sx of Proximal obstruction

A

vomiting →loss of gastric, pancreatic, and biliary secretions, → electrolyte disturbances.

  • sx of Elyte disturbance
  • dehydration,
  • metabolic alkalosis
  • hypochloremia -( gastric)
  • hypokalemia -(bile)
  • hyponatremia -(hypovolemic hyponatremia)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Characteristics Complications of Obstructions of the distal ileum

  • speed of progression
  • most marked comp
A

this type of obs leads to slowly progressing distention of the small intestine.

distal jejunal obstruction tend to present with complications resulting from

  1. Loss of intestinal contents from vomiting, as well as
  2. distention of Lower abdom seg
  3. compromise of intestinal wall perfusion.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

General sx of intestinal obstruction

A

Abdominal pain. - first symptom - colicky in the early stages → severe, constant as the process progresses

  • Prox obstruction - with an acute onset of pain (less than 1 day)
  • Distal - indolent course (a few days)
  • strangulated in contact with the inner abdominal wall → well-localised severe pain

Nausea and vomiting.- follows the pain - emphasis must placed on the nature

  • bilious emesis - proximal obstruction
  • feculant* emesis - *Distal obstruction

Constipation - at ANY LEVEL = absolute constipation for both stool and gas.

17
Q

Physical findings of Intestinal Obstruction

A

Inspection

  • Distension!! - lower the obstruction in the small bowel, the greater the distension.
  • Visible peristalsis may occasionally in a thin patient

Palpation

  • mass - suggests a specific cause for the obstruction,
    • irreducible mass - strangulated hernia
  • tenderness and guarding - strangulation / perforation

Percussion

  • tympanitic note - presence of gas-filled loops of bowel
    • absent - if Slow evolution of complications ( Distal ileal obstruction)

Auscultation

  • Early → Increased Frequency of high-pitched, tinkling bowel sounds that resemble water lapping the side of a small boat
  • Late → absent bowel sounds → PERITONITIS from PERFORATED LOOP!!
18
Q

N.B. what does it mean When mechanical obstruction is indicated by other clinical findings but bowel sounds are absent?

A

advanced condition or there is peritonitis which has resulted from perforation of an involved loop!

19
Q

What is the Imaging modality of choice for Intestinal obstruction

what is the appearance of inestinal obstruction on this imaging modality ]

A

Plain abdominal X-rays taken in the erect and/or supine positions are the standard and most reliable means of diagnosis.

Characteristic appearance of small-bowel ob‐struction is a number of distended, gas- and fluid-filled loops of bowel with, in the erect posture,

20
Q

Wat are the 5 Queations that MUST be answered through clinical dg, labs and Imaging in order to determine whether the Management of Intestinal Obstriction will be CONSERVATIVE or SURGICAL

A
  1. Is the pain proportional to the physical findings?
  2. How rapidly are the symptoms and signs evolving (minutes, hours,or more slowly)?
  3. Does the patient suffer from dehydration and serum electrolyte and pH imbalances?
  4. Is the obstruction complete or incomplete?
  5. Is there a possibility of strangulation?
21
Q
A
22
Q

Indications of

Non-operative management / CONSERVATIVE of Intestinal Obstruction

A
  1. firm evidence that there is not a threat to the viability of the bowel and thus no risk of strangulation or perforation)
  2. incomplete obstruction of the small bowel with features which suggest non-progression;
  3. adhesive obstruction is the only instance a Complete obstructio is permitted .
23
Q

what does Conservative management of Intestinal obstruction actually involves

A
  • proximal decompression by a nasogastric tube with aspiration either continuously or on a regular intermittent basis,
  • Homeostasis-> water and electrolyte replacement,
  • monitoring -> repeated (4-6-hourly) evaluation of the clinical state-abdominal pain, development of tenderness, changes in bowel sounds and in cardiovascular status,
  • repeated reassessment -> plain X-rays or contrast studies and haematological and biochemical
24
Q

Indications for Operative management.of Intestinal Obstruction

A

irreducible Mass

  • established or suspected strangulation;
  • causes requiring surgical removal (e.g. tumor)

complete bowel obstruction+ tenderness

  • -indicative of closed-loop obstruction with possible perforation,

failure of resolution after a period of non-operative management,

25
Q

WHat procedures preceede operatvie management of Intestinal Obstruction

A
  1. gastric suction,
  2. water and electrolyte replacement.
26
Q

what is the only indication of urgent operation (w/o pre op procedures) of Intestinal obstruction

how is it managed in the operative field

A

only indication for urgent operation is when strangulation or other causes of non-viability of the bowel are likely.

  1. At operation, the obstruction is relieved
  2. underlying cause removed. if possible!
  3. Dead or damaged intestine must be excised.

Occasionally an irremovable obstruction (e.g. a fixed neoplasm) is bypassed.

27
Q

Paralytic ileus definition

A

Type of adynamic obstruction with no peristaltic waves d/2 neuromuscular failure of auerbach/ meissner’s plexus

  • doesn’t involve a physical blockage.
  • Muscle or nerve problems disrupt the normal coordinated muscle contractions of the intestines
28
Q

Types of paralytic ileus = PIRM paralysis

whichi is self limiting

which leads to adhesions

which fractures can cause ileus

which elecytolyte imbalances causes ileus

A
  1. Post operative ileus & pharmacologic- Sefl limiting, prolonged after 24 hrs iif protein is low
  2. Infective ileus - aka Intra-abdom Sepsis - causes local or general ileus and can lead to adhesions
  3. Reflex ileus -(neurogenic) - Fractures of the Spine or rip cuasing RP heamorrhage
  4. Metabolic ileus - uremia or hypokalemia
29
Q

PP pf paralytic ileus

A

disorganized electrical activity leads to paralysis of intestinal segments. This lack of coordinated propulsive action leads to the accumulation of gas and fluids within the bowel

30
Q

post op ( Abdominal or pelvic surgery) paralytic ileus

A

Normal resumption of bowel activity after abdominal surgery follows a predictable pattern:

  • small bowel typically regains function within hours;
  • stomach regains activity in 1-2 days; a
  • colon regains activity in 3-5 days.
31
Q

Pharmacological Paralytic Ileus

A

medications that affect muscles and nerves,

  • TCA’s , such as amitriptyline and imipramine (Tofranil), and
  • OPIODS such as those containing hydrocodone (Vicodin) and oxycodone (Oxycontin)
32
Q

Risk factors for Paralytic ileus

A
  • Abdominal or pelvic surgery, which often causes adhesions — a common intestinal obstruction
  • Crohn’s disease, which can cause the intestine’s walls to thicken, narrowing the passageway
  • Cancer in your abdomen, especially if you’ve had surgery to remove an abdominal tumor or radiation therapy
33
Q

Clinical picture of Paralytic ileus

A

Sx

distention, fullness, and bloating. - Abdominal cramping is usually not present.

effortless vomiting, and poor appetite. Patients may or may not continue to pass flatus and stool.

phys exam

tympanic on percussion

absent or hypoactive bowel sounds

imaging

x-ray - air fluid lvls

CT w/ Gastrofinn - gold for postop ileus

34
Q

RX of ileus

A
  • Most cases of postoperative ileus resolve with watchful waiting and supportive treatment
    • Naso -gastric-tube decompression
    • food restriction until bowel sounds return
    • intravenous hydration
    • NSAIDS may improve ileus by reducing local inflammation
    • discontinue meds causing Ileus (opiods)
  • surgery (laparoscopic) if conservative fails
35
Q

complicatoins of paralytic ileus

A

same as other intestinal obsructions

NECROSIS from loss of perfusion

PERITONITIS after perforation

36
Q
A