Abd Hernia/intestinal obstruction

Question 1

Question 2

Abd hernia

general

Answer 2

Protrusion of the abdominal contents through an acquired or congenital area of weakness or defect in the wall
Common medical condition
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Classification:
Abdominal wall hernia
Umbilical hernia
Epigastric hernia
Spigelian hernia
Incisional hernia – 10-15%

Groin hernia
Inguinal hernia – 75%
Femoral hernia

Question 3

abd hernia

Reducible

Answer 3

Contents of the hernia can be manipulated back into their original position through the defect from which they emerge

Question 4

abd hernia

Incarcerated hernia(irreducible)

Answer 4

Hernia is compressed by the defect causing it to be irreducible (unable to be pushed back into its original position)

Question 5

Abd hernia

Obstructed hernia

Answer 5

Refers mainly to hernias containing bowel, where the contents of the hernia are compressed to the extent that the bowel lumen is no longer patent and causes bowel obstruction

Question 6

abd hernia

Strangulated hernia

Answer 6

Compression around the hernia prevents blood flow into the hernial contents causing ischemia of the tissues and associated pain

Question 7

Umbilical hernia

general

Answer 7

Protrusions through the umbilical ring
Rarely strangulate

Types:
Congenital
Infants
Most resolve spontaneously within a few years
Large defects may require elective surgery after age 5
Acquired
Adults secondary to obesity, ascites, pregnancy, or chronic peritoneal dialysis
Cosmetic concern and can be surgically repaired

Question 8

Epigastric hernia

general

Answer 8

Protrusion in the midline of the abdomen through the rectus abdominis muscle
Occurs between the xiphoid process and umbilicus
Typically asymptomatic

Question 9

Spigelian hernia

general

Answer 9

Also known as a lateral ventral hernia
Protrusion through the spigelian fascia which is comprised of the transverse abdominis and internal oblique aponeuroses
Occurs in the lower abdomen

Least common of all hernias
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High risk for complications – bowel obstruction, incarceration, and strangulation

Question 10

Incisional hernia

general

Answer 10

Protrusion that occurs at the site of a previous abdominal surgery
Tend to be large and painful

Question 11

Anatomy of the Inguinal Canal

Answer 11

Inguinal ligament runs between theanterior superior iliac spine(ASIS) and thepubic tubercle(PT)

Inguinal canal is a tube-like structure runs within the ligament (spermatic cordand round ligament)

Deep inguinal ring: entry point from the abdominal cavity into the canal; found just above the midpoint of the inguinal ligament

Superficial inguinal ring: exit point from the canal; found just above and lateral to the pubic tubercle

Question 12

Inguinal hernia

general

Answer 12

Occur above the inguinal ligament and medial to the pubic tubercle
Presents as a bulge in the groin

Types:
Indirect
Traverses the internal inguinal ring into the inguinal canal
Direct
Extend directly forward and do not pass through the inguinal canal
Hesselbach’s Triangle

Question 13

Question 14

Answer 14

Question 15

Femoral hernia

general

Answer 15

Protrusion into the femoral canal that runs below the inguinal ligament and lateral to the pubic tubercle

Most common in elderly women

High risk for strangulation and obstruction

Question 16

Question 17

Abd hernia

Dx

Answer 17

Clinical
Examination of the patient in a lying and standing position
Cough or perform a Valsalva maneuver while palpating the abdominal wall to identify a hernia

Ultrasound
Performed if the physical exam is equivocal

Question 18

Abd hernia

Tx

Answer 18

Treatment:
Surgical repair
Open or laparoscopically
Elective or urgent basis

Question 19

Question 20

Intestinal obstruction

general

Answer 20

Condition in which digested material is prevented from passing normally through the bowel

Classified as:
Mechanical obstruction
Due to physical blockage
Functional obstruction
Due to disruption of normal motility

Can involve:
Small bowel - 80%
Large bowel - 20%

Can be:
Partial: some intestinal contents pass through
Complete: no passage of luminal contents beyond the obstruction point

Question 21

SBO

Mechanical Etiologies

Answer 21

Adhesions (post-surgical)
Tumors
Hernias
Crohn’s disease (inflammatory strictures or adhesions)
Gallstones (gallstone ileus)
Volvulus
Intussusception
Foreign bodyingestion

Most common causes of SBO…think ABC
A = Adhesions
B = Bulge (hernias)
C = Cancer

Question 22

SBO

Functional etiologies

Answer 22

Surgery
Peritonitis
Trauma (pelvic and spinal fractures)
Intestinal ischemia
Medications(opiates,calcium channel blockers, diuretics)
Electrolyte imbalance (low potassium)

Question 23

LBO

Mechanical etiologies

Answer 23

Colorectal cancer: most common cause
Metastatic cancers (ovarian, pancreatic,lymphoma)

Volvulus(sigmoid and cecal): most commonbenign cause

Strictures from:
Priorcolonresection
Inflammatory disease (diverticulitis, ischemiccolitis, inflammatory bowel disease)
Post-surgical adhesions
Hernias

Question 24

LBO

functional etiologies

Answer 24

Severe systemic illness
Surgery (most commonly from cesarean section or hip surgery)
Trauma
Spinal anesthesia
Medications (opiates,anticholinergics,calcium channel blockers)

Question 25

# Bowel obstructions patho

Answer 25

Ingested fluids and food, digestive secretions, and gas accumulate above the obstruction causing the proximal bowel to distend The bowel segment distal to the obstruction collapses Secretory and absorptive functions become depressed and the bowel becomes edematous and congested Distention is self-perpetuating and can lead to vascular compromise (venous then arterial) → ischemia → gangrene → perforation

Question 26

# BO

Question 27

# SBO symptoms

Answer 27

Symptoms Occur shortly after onset Abdominal pain Crampy or colicky in nature Most often diffuse and intermittent Severe and constant → ischemia or perforation has developed Vomiting – may report temporarily relief Abdominal distention/bloating Obstipation

Question 28

# SBO PE findings

Answer 28

Signs Bowel sounds: Hyperactive, high-pitched (**early**) Decreased or absent (**late**) Percussion: tympany or hyper-resonance; dullness if fluid filled

Question 29

# LBO Symptoms

Answer 29

Mild and develop gradually Abdominal pain Usually below the umbilicus Crampy in nature Abdominal distension/bloating Vomiting More common with right colon obstruction Obstipation

Question 30

# LBO PE findings

Answer 30

Distended abdomen Percussion: tympany

Question 31

# Small bowel obstructions Xray

Answer 31

**Supine and upright abdominal x-rays with upright chest x-ray** Usually adequate to diagnose obstruction Small bowel Proximal bowel dilatation > 3 cm Decompressed distal bowel Air-fluid levels with stacked small bowel loops in the upright views Similar x-ray findings occur with an ileus (paralysis of the intestine without obstruction)

Question 32

# SBO CT scan

Answer 32

**CT scan** of the abdomen and pelvis Recommended if there are signs of inflammation or ischemia Used more often for suspected small-bowel obstruction, especially in the elderly

Question 33

# SBO

Answer 33

Left: Supine abdominal x-ray showing obstruction of the small bowel. Dilated loops of small bowel should be noted. Right: Upright abdominal x-ray showing obstruction of the small bowel. Multiple air-fluid levels should be noted.

Question 34

# SBO

Answer 34

The small bowel is dilated and filled with air and fluid. Oral contrast is seen in some of the loops but has not traveled down to the distal small bowel. The collapsed cecum and sigmoid colon should be noted (arrows). A specific point of obstruction (transition point) cannot always be seen on CT, but the dilated proximal bowel and collapsed distal bowel are highly suggestive of the diagnosis.

Question 35

# LBO Xray

Answer 35

**Supine and upright abdominal x-rays with upright chest x-ray** Large bowel Proximal colonic distention of the colon Cecum > 9 cm Remaining colon > 6 cm Collapse of the colon distal to the obstruction

Question 36

# LBO Barium enema

Answer 36

Barium enema Liquid barium is inserted into the colon through the rectum Enhances the colon to locate and determine the cause of obstruction Can sometimes lead to resolution of the obstruction

Question 37

Question 38

Small or Large Bowel Obstruction?

Answer 38

small notice the increased fluid (large intestine takes out fluids) and not a lot of gas in abd, gas is ususally proximal to obstruction