Abd Hernia/intestinal obstruction Flashcards
Abd hernia
general
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
abd hernia
Reducible
Contents of the hernia can be manipulated back into their original position through the defect from which they emerge
abd hernia
Incarcerated hernia(irreducible)
Hernia is compressed by the defect causing it to be irreducible (unable to be pushed back into its original position)
Abd hernia
Obstructed hernia
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
abd hernia
Strangulated hernia
Compression around the hernia prevents blood flow into the hernial contents causing ischemia of the tissues and associated pain
Umbilical hernia
general
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
Epigastric hernia
general
Protrusion in the midline of the abdomen through the rectus abdominis muscle
Occurs between the xiphoid process and umbilicus
Typically asymptomatic
Spigelian hernia
general
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
Incisional hernia
general
Protrusion that occurs at the site of a previous abdominal surgery
Tend to be large and painful
Anatomy of the Inguinal Canal
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
Inguinal hernia
general
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
Femoral hernia
general
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
Abd hernia
Dx
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
Abd hernia
Tx
Treatment:
Surgical repair
Open or laparoscopically
Elective or urgent basis
Intestinal obstruction
general
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
SBO
Mechanical Etiologies
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
SBO
Functional etiologies
Surgery
Peritonitis
Trauma (pelvic and spinal fractures)
Intestinal ischemia
Medications(opiates,calcium channel blockers, diuretics)
Electrolyte imbalance (low potassium)
LBO
Mechanical etiologies
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
LBO
functional etiologies
Severe systemic illness
Surgery (most commonly from cesarean section or hip surgery)
Trauma
Spinal anesthesia
Medications (opiates,anticholinergics,calcium channel blockers)
Bowel obstructions
patho
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
BO
SBO
symptoms
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
SBO
PE findings
Signs
Bowel sounds:
Hyperactive, high-pitched (early)
Decreased or absent (late)
Percussion: tympany or hyper-resonance; dullness if fluid filled
LBO
Symptoms
Mild and develop gradually
Abdominal pain
Usually below the umbilicus
Crampy in nature
Abdominal distension/bloating
Vomiting
More common with right colon obstruction
Obstipation
LBO
PE findings
Distended abdomen
Percussion: tympany
Small bowel obstructions
Xray
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)
SBO
CT scan
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
SBO
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.
SBO
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.
LBO
Xray
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
LBO
Barium enema
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
Small or Large Bowel Obstruction?
small
notice the increased fluid (large intestine takes out fluids)
and not a lot of gas in abd, gas is ususally proximal to obstruction
