Bowel obstruction Flashcards
Etiology of small bowel obstruction
Adhesions Hernia (ventral, inguinal, femoral, internal) Neoplasms Stricture (chrons, ischemia) Radiation enteritis Intussusception Volvulus Gallstone ileus Bezoar SMA syndrome
Cardinal features of SBO
- Vomiting
- Colic
- Constipation
- Abdominal distension
Important to recognise strangulating hernia
- Constant abdominal pain
- Tenderness, guarding
- TachyC
- Fever, leukocytosis
Radiographic findings in SBO
- Dilated small bowel
- Step ladder
- Air-fluid level
- May have gas in distal bowel if:
Incomplete
Adynamic ileus - Look for obstructing foreign bodies.
Investigations in SBO
1. AXR Air fluid Distended SB loops Absent gas in rectum 2. FBC \++WCC may indicate severe with necrosis -ve RBC may indicate blood loss into bowel if necrosis 3. UEC \+Urea in volume depletion Hypochloremic/kalemic, alkalosis in deH
Consider
CT
USS
Laparoscopy/laparotomy
MEDICAL Management in SBO
Medical management
1. ABC, 02 if need, IV access, catheter
2. IV fluid replacement!-1L over 1 hour, or bolus if shock. Investigations
3. NGT decompression
4. NBM
5. Analgesia. Caution-do not want to mask peritonitic signs
6. Stat metoclopramide 10mg IV
7. Urine output monitoring
8. Peritonitis-urgent surgical review
9. Heparin incase needs surgery- TED stocking
10. If need lap- cross match 4 units blood
11. Consult
12. Admit, consent for surgery if required
13. Chart regular medications, inform GP
14. Regular observations->shock, peritonitis
15 Preop
Adequate fluid resuscitation
Electrolyte replacement
Prophylaxis with cefazolin
DVT prophylaxis
NGT decompression
NBM
RSI
Surgical management in SBO- pre-op, adhesive, hernia, closed loop
1. Preoperative Adequate fluid resuscitation Electrolyte replacement Prophylaxis with cefazolin DVT prophylaxis NGT decompression NBM RSI 2. Adhesive Surgery if risk of intestinal ischemia, failure to improve with medical 3. Hernia Surgery promptly 4. Closed loop Resection and primary anastamosis if bowel not viable Torsion, complex adhesion, obstructed external hernia
When might an exploratory operation be considered
- Complete obstruction
- IA sepsis
- Excessively prolonged course
Considerations in recurrent SBO
Medical Mx \+pain, temp, +WCC, \+NGT output Xbowel function distension, \+bowel dilitation on plain AXR
Causes of SBO post op
- Ileus
- Internal hernia
- Peritoneal defects
- IA abscesses
If crohns is cause, is it usually medically managed or surgically managed
- Most commonly medically managed
2. If not successful, surgery may be indicated
Etiology of large bowel obstruction
Most common
- Carcinoma
- Sigmoid volvulus
- Diverticular disease
Other
- Stricture
- Radiation
- Intussusception
- Adhesions
- Fecal impaction
Features of LBO
- Colic
- Distension
- Constipation or obstipation
- Peritonitis if perforation
Investigations in LBO
1. AXR Marked colonic distension Kidney bean shape in volvulus 2. CT/USS may ID malignancy 3. FBC \+WCC, anemia 4. UEC \+Cr, urea 5. Amylase/lipase \+with IA event 6. Coagulation Prolonged if sepsis from perforation 7. ECXR Rule out perforation
Medical Management in LBO
Medical management
1. ABC, 02 if need, IV access, catheter
2. IV fluid replacement!-1L over 1 hour, or bolus if shock. Investigations
3. NGT decompression
4. NBM
5. Analgesia. Caution-do not want to mask peritonitic signs
6. Stat metoclopramide 10mg IV
7. Urine output monitoring
8. Peritonitis-urgent surgical review
9. Heparin incase needs surgery- TED stocking
10. If need lap- cross match 4 units blood
11. Consult
12. Admit, consent for surgery if required
13. Chart regular medications, inform GP
14. Regular observations->shock, peritonitis
15 Preop
Adequate fluid resuscitation
Electrolyte replacement
Prophylaxis with cefazolin
DVT prophylaxis
NGT decompression
NBM
RSI
Surgical management in LBO
1. Peritonitis Surgery 2. Volvulus Endoscopic decompression Stenting Resection, anastamosis, Hartmann's 3. Stricture Stenting
