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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
Q

What is paralytic ileus

A

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

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26
Q

Biggest differences between SBP and paralytic ileus

A

SBO: crampy abdominal pain, gas on small intestine only
PI: minimal abdominal pain, gas in small and large bowel

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27
Q

How do you diagnose paralytic ileus

A

Plain films: diffuse bowel dilation involving small and large bowel

28
Q

How do you treat paralytic ileus

A

NPO
NG tube
IVF
most resolve in 4 days

29
Q

What are the MCC of LBO

A 
Adenocarcinoma* 
Scarring 
Volvulus 
-also, IBD, FB, fecal impaction
-RARE to see adhesions causing LBO!
30
Q

Where do LBO occur most often

A

Sigmoid colon

31
Q

How do LBO present

A

Crampy abdominal pain
abdominal distention
nausea, vomiting
obstipation

32
Q

On PE for LBO you may find

A

Abdominal distention w/ tympany
high pitched rushes and gurgles (BS)
Localized, tender palpable mass (if strangulated closed loop)

33
Q

What will diagnostics of LBO show

A

Plain films: distended proximal colon, air fluid levels, NO air in rectum

34
Q

What is a distinguishing factor in diagnosing LBO

A

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
Q

Where does volvulus occur most

A

Sigmoid colon!
Can also be seen in cecum
Will note massive abdominal distention w/ abdominal pain, vomiting, and obstipation

36
Q

What shows you the exact location of volvulus

A

barium enema!

Will see “birds beak”

37
Q

How do you manage volvulus

A

Partial LBO: trial conservative therapy (NG tube, IVF, prep colon for surgery)
Complete: laparotomy
May be reduced w/ sigmoidoscopy!**

38
Q

Complications of sigmoidoscopy are

A

perforation
peritonitis
sepsis
-If perforation occurs, immediate laparotomy w/ resection of bowel and diverting colostomy

39
Q

What are the primary Sx of rectal disease

A

pain
bleeding
discharge

40
Q

What is the dentate line

A

Anorectal junction;
Above: columnar epithelium, no sensation just pressure
Below: squamous epithelium, VERY sensitive

41
Q

What are hemorrhoids

A

normal vascular structures in the anal canal arising from a plexus of dilated superior and inferior veins

42
Q

What causes hemorrhoids

A

Prolonged sitting, straining

Pregnancy, advanced age, increased pelvic pressure, portal HTN, diarrhea, constipation

43
Q

How do you classify hemorrhoids

A

Internal: above dentate line
External: below dentate line

44
Q

Primary Sx of hemorrhoids are

A

Bleeding (bright red)
Pruritis
Prolapse
Pain 2/2 thrombosis

45
Q

What are first degree hemorrhoids and how do you treat them

A

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
Q

What are second degree hemorrhoids

A

Protrusion w/ defecation, reduce spontaneously

Treat like 1st degree! ASx fiber and fluids, Sx coagulate ot ligate

47
Q

What are third degree hemorrhoids and how do you treat them

A

Protrude with defecation, need to be reduced manually

Rubber band ligation or surgical hemorrhoidectomy bc non-surgical Tx are not really effective

48
Q

What are fourth degree hemorrhoids and how do you treat them

A

Protrude permanently, incarcerated

Surgical hemorrhoidectomy

49
Q

How do you manage external hemorrhoids

A

Symptomatic management, unless thrombosed

50
Q

What are thrombosed hemorrhoids

A

blood clot in a hemorrhoid, cause severe perianal pain

Usually self limited and resolve in 7-10 days

51
Q

How do you treat thrombosed hemorrhoids

A

Sitz bath
mild analgesics
Hydrocortisone suppository or foam
If seen in first 24-48 hrs, evacuate under local anesthesia

52
Q

How do you visualize anal polyps and anal cancer

A

Use an anoscope! Like a speculum for your anus

53
Q

Where do you refer patients if you are concerned about anorectal problems

A

a colorectal specialist

GI will just refer them there anyways

54
Q

What is an abscess

A

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
Q

How do abscesses present

A

perianal pain and swelling
Spontaneous drainage of pus
Fever, redness, swelling

56
Q

How do you treat an abscess

A

Drain (I&D best in OR to avoid damaging the anal sphincter)
Antibiotics
this is a serious infection!!

57
Q

What is a fistula-in-ano

A

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
Q

What must you r/o if you see an anal fistula

A

Crohn’s disease!

59
Q

How do you treat anal fistulas

A

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
Q

What are anal fissures

A

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
Q

How do anal fissures present

A

pain worse during BM and associated with bright red streaking blood in stool
Pain disproportionate to size of fissure

62
Q

With anal fissures, what may you note on PE

A

External skin tags

sphincter spasm 2/2 pain

63
Q

How do you manage anal fissures

A

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
Q

What is rectal prolapse

A

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
Q

How do you manage rectal prolapse

A

Prevent constipation

Refer to colorectal surgeon

66
Q

What is a rectocele

A

Fascia weakens allowing rectum to bulge into vagina

Summer FDTN Exam 5 (12 decks)

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