Bowel obstruction Flashcards
Common cause of small bowel obstruction in adults
Adhesion due to prev. surgery Hernia (inguinal, incisional, parastomal) Crohn's disease Intestinal malignancy Appendicitis
Common cause of small bowel obstruction in children
Appendicitis
Intussusception
Intestinal atresia
Volvulus.
Common symptoms of bowel obstruction
Abdominal pain (crampy, intermittent) Bloating Abdominal mass (possible) Inability to pass flatus or stool Vomiting
Findings on abdominal x-rays for SBO
Partial SBO: gas throughout the abdomen and into the rectum.
Complete SBO: no distal gas, and staggered air-fluid levels.
Complicated SBO: free air under the diaphragm suggestive of perforation; thumb-printing of the bowel suggestive of ischaemia.
Differentials of small bowel obstruction
Ileus Infectious gastroenteritis Large bowel obstruction Intestinal pseudo-obstruction Appendicitis Pancreatitis
Non operative treatment for bowel obstruction
Fluid resuscitation
Bowel decompression (nasogastric tube)
Analgesia
Prophylactic Antibiotic if considering surgery
Surgical management for complete SBO or complicated partial SBO
Exploratory Laparotomy
Endoscopic balloon dilation (Crohn’s disease)
Common causes of large bowel obstruction
Colorectal cancer (90%) Colonic volvulus - sigmoid or caecal (5%) Benign strictures (3%) - (i.e., diverticular, inflammatory, ischaemic, radiation-induced, or anastomotic) Rest are: Hernia Foreign body Benign neoplasm Gynaecological neoplasm Pelvic abscess or endometriosis
Pathophysiology of LBO
The colon proximal to the cause of mechanical obstruction dilates and, with increased colonic pressure, mesenteric blood flow is reduced producing mucosal oedema with transudation of fluid and electrolytes into the colonic lumen. This can produce dehydration and electrolyte imbalances. With progression, the arterial blood supply becomes jeopardised with mucosal ulceration, full thickness wall necrosis, and eventual perforation. This provides conditions for bacterial translocation, which can produce septic complications. The caecum is the usual site of rupture, as it has the largest diameter, resulting in faecal soilage of the peritoneal cavity and sepsis.
Symptoms of LBO
Colicky abdo pain- Increasing constant pain and pain on movement, coughing, or deep breathing may imply perforation or impending perforation.
Abdominal distention
Tympanic abdomen
Change in bowel habits
Palpable rectal/abdominal mass
Normal diameter of bowels
Small bowel 3cm
Colon 6cm
Caecum 9cm
3/6/9 rule
Surgical management of LBO
Sigmoid Volvulus
Flexible or rigid sigmoidoscopy with insertion of rectal tube (in situ 24hrs)
Where peritonitis or mucosal gangrene has been identified, emergency mid-line laparotomy is required.
Caecal volvulus
Laparotomy. Resection with or without ileostomy is required for non-viable colon
Colorectal malignancy
High risk- Ileostomy or diverting proximal colostomy
Low risk- primary anastomosis in the right colon rather than ileostomy
Diverticular disease
A persistent obstruction merits surgical intervention with either a non-eponymous Hartmann’s procedure or a resection and primary anastomosis, with or without a proximal diverting stoma
Post op advice for laparotomy patients
Rest-Usually takes 6 weeks to start getting back to regular routine and months to be fully fit.
Avoid excessive, pushing, pulling or lifting
Avoid heavy lifting or activities for 12 weeks
Eat balanced diet avoid fatty foods, cakes, excessive alcohol
Immediate Post op complications
Immediate
Primary hemorrhage (starts during procedure)
Reactive hemorrhage ( post op due to increase in BP)
Basal Atelectasis
Shock: Blood loss, MI, PE or Septicaemia
Low urine output
Early post op complications
Pain Acute confusion not due to dehydration or septicemia Nausea & vomiting: analgesia or anesthetic related, paralytic ileus Post Op fever Secondary hemorrhage-infection Pneumonia DVT UTI Acute urinary retention Post op wound infection Pressure sores
