Bowel obstruction Flashcards
Causes of bowel obstruction? common (3) less common (bonus - 6)
adhesions, followed by tumors and hernias
Bonus - strictures, intussusception, volvulus, Crohns Disease, foreign bodies, and gallstones
Classic symptom history for bowel obstruction
Abdo pain Nausea and vomiting Feel distended No bm Not passing flatus
Classic physical exam findings for SBO
simple (2)
more severe (3)
looks distended, firm maybe
diffusely tender to palpation
Could be peritonitic, gaurding, rebound if perfed
Imaging for SBO
Xray - Abdo and CXR to assess for perf, air fluid levels
CT abdo - if need to further characterize or assess for complications like abscess formation
Which patients are in need of emergent surgical intervention or surgical consultation?
All patients with SBO need surgical consult
More emergent if strangulated, signs of necrosis, perforation
Most common cause of large bowel obstruction?
malignancy
Four terms important to communicate obstruction.. Degree of obstruction (2) Most severe (1)
Partial or complete
- gas or liquid stool can pass vs no substance
Strangulated
- perfusion compromised and necrosis ensues, leads to to perforation, peritonitis
Potential immediate interventions for patient with bowel obstruction who presents with copious vomiting…
vitals - HR 130, BP 95/65, RR 24, Sats 90-93%, T 36
ABC’s - airway considerations
Airway
- consider intubation for airway protection if copious emesis and not mentating well
- consider NG tube to control vomiting (and antiemetics obv)
Potential immediate interventions for patient with bowel obstruction who presents with copious vomiting…
vitals - HR 130, BP 95/65, RR 24, Sats 90-93%, T 36
ABC’s - breathing considerations
Breathing - supplemental oxygen as necessary
Potential immediate interventions for patient with bowel obstruction who presents with copious vomiting…
vitals - HR 130, BP 95/65, RR 24, Sats 90-93%, T 36
ABC’s - circulation considerations
Circulation - large bore IV x2 if worried, tachycardia or hypotension administer a fluid bolus and drip
What symptoms on history might be more prevalent in proximal SBO?
nausea and vomiting
Character of abdo pain in obstruction?
Simple obstruction - crampy and intermittent
Strangulation or ischemia - development to severe pain
Explain how a patient with an bowel obstruction might have a 12-24 hour history of diarrhea?
Diarrhea early in the course of bowel obstruction is possible as the distal portion of the bowel empties which then progresses to an inability to pass flatus and obstipation
Patient with a diagnosed bowel obstruction with no history of abdo surgery, what should you think about?
- underlying cause might be tumor or hernia
Important PMHx questions when you suspect bowel obstruction? (2)
- any abdo surgeries b/c adhesions
- GI diseases like Crohns or Colitis
Two reasons to examine genitals in men with abdo pain?
testicular torsion
HERNIA!
What are you looking for on DRE for abdo pain presentation?
What finding and what does it suggest?
visible blood - may suggest strangulation
hemoccult positive stool - may suggest malignancy
What factor about bowel obstructions impacts whether your patient may be distended or not on history or exam?
Location - abdominal distension is more prevalent in distal obstructions
What are 3 signs that would make you more concerned for strangulated bowel?
hint - vitals (2), exam (1)
Fever
Tachycardia
Peritonitic
What should you do if the abdo xray is unremarkable but you’re still worried about their abdo pain?
- serial exams or home if they’re reliable
- consider US if you’re worried about radiation
- consider getting CT abdo
Three good reasons to get a CT abdo in context of confirmed or likely bowel obstruction (3)
- identify other cause of the acute abdominal pain such as abscess, hernia, tumor, or inflammation.
- etiologies of SBO (extrinsic causes such as adhesions and hernia vs intrinsic causes such as neoplasms or Crohn disease).
- recognize complications of the obstruction that might change urgency or method of management.
Initial management of a confirmed SBO with a ++vomity patient
hint - obvious stuff (3), vomit related (1), big question (1)
bonus - managementy (1), good docs would do this (1)
Symptoms - pain, nausea
Resuscitation - fluids, electrolyte replacement
Surgical or not, and urgency of this (ie consult)
Bonus
GI decompression - NG tube
Cause of the obstruction (?malignancy)
Why should you frequently reassess your SBO abdo pain patient?
Things change, make sure that the patient is not developing signs of strangulation - severity of pain, vitals changing, peritoneal signs
Worst complication of bowel obstruction?
Strangulation is the most lethal complication of small bowel obstruction, dead bowel must be resected
