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Summer FDTN Exam 5 > Bowel obstruction > Flashcards

Bowel obstruction Flashcards

1
Q

What parts make up the small intestine

A

Duodenum
Jejunum (40%)
Ileum (60%)

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2
Q

What supplies the small intestine

A

Vascular: SMA
Innervation: ANS

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3
Q

What is the sequence of the large bowel

A 
Cecum 
Ascending colon (hepatic flexure) 
Transverse colon (splenic flexure) 
Descending colon 
Sigmoid 
Rectum
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4
Q

What supplies the large bowel

A

Vascular: SMA and IMA
Innervation: ANS

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5
Q

What is the physiologic role of the small intestine

A

Digestion with absorption of water, electrolytes, and nutrients

  • intestinal motility mixes, propels, and stores enteric contents
  • reabsorbs 80% of fluids
  • affected by hormones, drugs, toxins, and disease
  • transit time is 4 hours
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6
Q

What is the physiologic role of the large bowel

A

Absorbs water and electrolytes from liquid stools, mostly right colon

  • stores feces in the left colon
  • transit time is 18-48 hours
  • affected by emotions, diet, disease, infection, and bleeding
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7
Q

What studies help you visualize bowel obstruction

A

KUB (3 way abd xr)- A/P supine, upright, PA chest
CT abdomen (use water soluble contrast)
Small bowel follow through w/o UGI
US not as helpful as CT

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8
Q

KUB allows you to visualize

A

Gas patterns; SBO vs LBO vs Ileus

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9
Q

What causes a SBO

A

Normal flow of intestinal contents is interrupted (adhesions, volvulus, intussusception, tumors, FB, gallstones)
MCC worldwide is hernias, but MCC in US is adhesions!

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10
Q

What are adhesions

A

Fibrous bands of scar tissue that bind tissue or organs
Occur 2/2 inflammatory process or injury )diverticulitis, appendicitis, PID, endometriosis)
Cause obstruction by extrinsic compression

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11
Q

What is intestinal volvulus

A

Bowel twists on itself causing a closed loop obstruction

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12
Q

What is intussusception

A

Telescoping of the bowel on itself

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13
Q

What happens to the intestine after obstruction

A

Proximal to obstruction: bowel dilates
Swallowed air and gas from bacteria worsen dilation
Bowel walls become edematous 2/2 loss of absorptive fxn
Fluid can extravasate into abdomen (fluid loss)

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14
Q

What does strangulation of bowel cause

A

pressure inside the bowel= compromised perfusion, ischemia, necrosis, sepsis

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15
Q

Fluid loss is 2/2

A

vomiting
decreased absorption
third space loss
-all lead to dehydration!

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16
Q

What history points you to different Dx

A

Abdominal distention: distal obstruction
Vomiting: proximal obstruction
Feculent smelling emesis: bacterial overgrowth

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17
Q

What is the difference between constipation and obstipation

A

Constipation: passing flatus but not stool
Obstipation: Can’t pass flatus or stool

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18
Q

Exam findings that indicate SBO are

A

Patient in distress 2/2 abd pain and dehydration
Tachycardia
DMM
inspect for surgical scars and hernias
Abdominal distention (tympanic w/ increased air, dull w/ ascites)
Diffuse abd ttp (rebound and pt still? think strangulation)

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19
Q

What are bowel sounds like in SBO

A

Early dz: high pitched rushes

Late: abdomen silent

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20
Q

Plain films can show you

A 
Dilated bowel proximal to obstruction with collapse distally 
Air fluid levels 
Closed loop obstructions (high risk strangulation) 
Free air (perforation)
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21
Q

How do you manage SBO initially

A

IVF
Correct metabolic abnormalities
Assess need for surgery

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22
Q

How do you manage a partial SBO

A

IVF, decompression of stomach with NG tube (take air OUT)
follow labs (CBC, electrolytes, UA) and UO
Monitor for signs of strangulation
-Most resolve w/ conservative management

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23
Q

How do you manage complete SBO or SBO w/ hernia

A

OR! need laparotomy to mobilize adhesions/repair hernia; resect ischemic bowel

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24
Q

Complications of SBO are

A 
wound infection 
anastomosis leak 
abscess 
peritonitis 
fistula formation 
short bowel syndrome w/ extensive resection
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25
What is paralytic ileus
decreased bowel motility 2/2 systemic or inflammatory process bowel becomes distended w/o mechanical obstruction Caused by: narcotics, bedrest, trauma, hypothyroid, electrolyte abnormalities, anesthesia, sepsis
26
Biggest differences between SBP and paralytic ileus
SBO: crampy abdominal pain, gas on small intestine only PI: minimal abdominal pain, gas in small and large bowel
27
How do you diagnose paralytic ileus
Plain films: diffuse bowel dilation involving small and large bowel
28
How do you treat paralytic ileus
NPO NG tube IVF most resolve in 4 days
29
What are the MCC of LBO
``` Adenocarcinoma* Scarring Volvulus -also, IBD, FB, fecal impaction -RARE to see adhesions causing LBO! ```
30
Where do LBO occur most often
Sigmoid colon
31
How do LBO present
Crampy abdominal pain abdominal distention nausea, vomiting obstipation
32
On PE for LBO you may find
Abdominal distention w/ tympany high pitched rushes and gurgles (BS) Localized, tender palpable mass (if strangulated closed loop)
33
What will diagnostics of LBO show
Plain films: distended proximal colon, air fluid levels, NO air in rectum
34
What is a distinguishing factor in diagnosing LBO
competence of ileocecal valve! If competent, can create a closed loop obstruction causing massive dilation of cecum (>12 cm) w/ increased risk of perforation
35
Where does volvulus occur most
Sigmoid colon! Can also be seen in cecum Will note massive abdominal distention w/ abdominal pain, vomiting, and obstipation
36
What shows you the exact location of volvulus
barium enema! | Will see "birds beak"
37
How do you manage volvulus
Partial LBO: trial conservative therapy (NG tube, IVF, prep colon for surgery) Complete: laparotomy May be reduced w/ sigmoidoscopy!**
38
Complications of sigmoidoscopy are
perforation peritonitis sepsis -If perforation occurs, immediate laparotomy w/ resection of bowel and diverting colostomy
39
What are the primary Sx of rectal disease
pain bleeding discharge
40
What is the dentate line
Anorectal junction; Above: columnar epithelium, no sensation just pressure Below: squamous epithelium, VERY sensitive
41
What are hemorrhoids
normal vascular structures in the anal canal arising from a plexus of dilated superior and inferior veins
42
What causes hemorrhoids
Prolonged sitting, straining | Pregnancy, advanced age, increased pelvic pressure, portal HTN, diarrhea, constipation
43
How do you classify hemorrhoids
Internal: above dentate line External: below dentate line
44
Primary Sx of hemorrhoids are
Bleeding (bright red) Pruritis Prolapse Pain 2/2 thrombosis
45
What are first degree hemorrhoids and how do you treat them
Bulge in anal canal, do not protrude ASx so just treat w/ bulking agents (fiber) and increase water intake to avoid constipation If Sx, infrared coagulation* or rubber band ligation work
46
What are second degree hemorrhoids
Protrusion w/ defecation, reduce spontaneously | Treat like 1st degree! ASx fiber and fluids, Sx coagulate ot ligate
47
What are third degree hemorrhoids and how do you treat them
Protrude with defecation, need to be reduced manually | Rubber band ligation or surgical hemorrhoidectomy bc non-surgical Tx are not really effective
48
What are fourth degree hemorrhoids and how do you treat them
Protrude permanently, incarcerated | Surgical hemorrhoidectomy
49
How do you manage external hemorrhoids
Symptomatic management, unless thrombosed
50
What are thrombosed hemorrhoids
blood clot in a hemorrhoid, cause severe perianal pain | Usually self limited and resolve in 7-10 days
51
How do you treat thrombosed hemorrhoids
Sitz bath mild analgesics Hydrocortisone suppository or foam If seen in first 24-48 hrs, evacuate under local anesthesia
52
How do you visualize anal polyps and anal cancer
Use an anoscope! Like a speculum for your anus
53
Where do you refer patients if you are concerned about anorectal problems
a colorectal specialist | GI will just refer them there anyways
54
What is an abscess
infected pocket 2/2 obstruction of perianal glands (between external and internal sphincter) Intersphenteric and Supralevator are not palpable on PE Perianal and Ischiorectal are palpable on PE
55
How do abscesses present
perianal pain and swelling Spontaneous drainage of pus Fever, redness, swelling
56
How do you treat an abscess
Drain (I&D best in OR to avoid damaging the anal sphincter) Antibiotics *this is a serious infection!!*
57
What is a fistula-in-ano
Chronic perianal infection occurring after drainage of a perirectal abscess Abnormal connection between anus at dentate line and perianal skin Causes pus drainage +/- stool drainage they do NOT heal spontaneously
58
What must you r/o if you see an anal fistula
Crohn's disease!
59
How do you treat anal fistulas
Fistulotomy: unroofing of fistula and allowing it to heal by secondary intention Avoid damaging the large portion of the sphincter muscle and prevent incontinence
60
What are anal fissures
Linear tears in the lining of the anal canal below the dentate line MC posteriorly MCC of severe anorectal pain Caused by trauma: constipation or severe diarrhea
61
How do anal fissures present
pain worse during BM and associated with bright red streaking blood in stool Pain disproportionate to size of fissure
62
With anal fissures, what may you note on PE
External skin tags | sphincter spasm 2/2 pain
63
How do you manage anal fissures
Avoid constipation or diarrhea Bulk laxatives (fiber helps constipation and diarrhea) Mild analgesics Sitz bath Nitroglycerin or Diltiazem cream (small amt to minimize ADE) Chronic: surgery, lateral internal sphincterotomy
64
What is rectal prolapse
Mass protruding through anus occurring initially w/ BM then retracting (can make dx based on hx too) Associated with chronic constipation, chronic straining, pregnancy, Hx of surgery
65
How do you manage rectal prolapse
Prevent constipation | Refer to colorectal surgeon
66
What is a rectocele
Fascia weakens allowing rectum to bulge into vagina

Summer FDTN Exam 5 (12 decks)

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