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Clin Med III Exam 2 > Bowel Obstruction > Flashcards

Bowel Obstruction Flashcards

1
Q

partial obstruction

A

fluid/air continue to pass

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2
Q

Complete obstruction

A

cessation of passage of stool or flatus

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3
Q

Causes of osbtruction

A

extrinsic/extra-luminal (external to bowel)
Intrinsic (w/i wall of bowel)
intraluminal (defect that prevents passage of GI contents)

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4
Q

Pathophys behind bowel obstruction

A

Excessive dilatation can compromise vascular supply leading to poor perfusion which can result in complications of: ischemia –> necrosis –> perforation
(volume depletion due to fluid sequestration in edeamatous bowel)

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5
Q

Most common obstruction

A

SBO (surgical emergency)

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6
Q

Vascular supply to small bowel

A

Superior mesenteric artery (SMA)

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7
Q

Etiology/Risk Factors

A

ADHESION (post abdominal/pelvic surgery)**

Hernia
Neoplasm
Intestinal inflammation/intra-abdominal abscess
strictures (inflammatory, radiation, ischemic, anastomotic)
FB ingestion
Intussuscption
Volvulus

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8
Q

Hx for SBO

A 
surgery - risk increases w/ time - after 10 years
Family hx of cancer/radiation
any hernias?
N/V/D/C, hematochezia
pain worse or better?
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9
Q

Sx of SBO

A

Abdominal pain

  • start periumbilical, intermittent “cramping”
  • more focal and constant pain can indicate peritonitis (bad sign)
Bloating/distention
anorexia
N/V/C
\+/- fever/chills/hematochezia
Obstipation - inability to pass flatus or stool (bad sign)
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10
Q

PE for SBO

A

+/- fever, tachy, hypotension, shock (red flag)

General: mild/mod distress, lying motionless (red flag: peritonitis)

Skin: +/- decreased turgor, dry mucous membranes

Abdomen:

  • distention, scars, hernias
  • high pitched “tinkling” BS (early) or hypoactive/absent (late)
  • percussion: tympany
  • palpation: diffuse or local pain, mass?
  • PERIOTNEAL SIGNS: guarding, rigidity, rebound tenderness (red flag)
  • DRE: gross/occult blood, fecal impaction or rectal mass?
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11
Q

Dx for SBO

A

CBC
CMP
Amylase/Lipase
UA
Lactate/LDH (tissue destruction)
Plain abdominal films (supine and upright)
CT scan- identify location, severity, etiology, complications

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12
Q

CBC/CMP in SBO

A

+/- H/H, leukocytosis, anemia

+/- Bun/Cr (dehydration) +/- lyte abnormalities

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13
Q

X-ray in SBO

A

dilated bowel w/ air fluid levels
proximal bowel dilation w/ distal bowel collapse

CXR: free air = perforation (red flag)

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14
Q

Types of x-ray for SBO

A

supine

upright

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15
Q

CT in SBO

A

dilated proximal bowel and collapsed distal
Bowel wall thickening > 3mm
Submucosal edema

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16
Q

More diagnostics if CT/x-ray contraindicated or need more assessment

A

Abdominal US
CT/MR enterography
UGI/SBFT

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17
Q

Tx of SBO

A 
Admit
Consult surgery/GI
Trial of non-operative:
- NPO
- IVF
- electrolyte monitoring/replacement
- bowel decompression w/ NG tube******
- anti-emetics, analgesic, abx
- +/- gastrografin - dx and therapeutic
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18
Q

How long do you monitor for non-operative SBO management

A

2-5 days (decrease distention, passage of flatus/stool, decrease NG output)

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19
Q

SBO indications for surgery

A
  • complicated (ischemia, necrosis, perforation)
  • intestinal strangulation
  • worsening sx or unresolved sx w/ NG tube and bowel rest
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20
Q

Signs of complicated bowel obstruction

A 
worsening abdominal pain
fever
tachycardia
leukocytosis
metabolic acidosis
peritonitis
21
Q

Signs of peritonitis

A 
look sick
lie still
hypoactive/absent BS
peritoneal signs
significantly TTP
22
Q

Causes of strangulation

A

hernia
volvulus
intussusception (rare in adults; associated w/ tumor)

23
Q

What is ileus?

A

Hypomotility of GI tract in absence of mechanical bowel obstruction; often secondary to postoperative abdominal surgery (> w/ open and lower GI surgery)

inflammatory response

24
Q

Types of postop ileus

A

physiologic (benign, self-limited coarse)

Pathologic (no return of bowel function 4-6 days post op)

25
Q

Causes of ileus

A 
postop (most common)
hypomotility agents (opiods, antispasmodics, anticholinergics)
26
Q

Sx of ileus

A 
abdominal pain
distention/bloating
"gassiness"
N/V
Inability to tolerate PO
27
Q

PE for ileus

A

distention & tympany
variable reduction in BS
mild tenderness

28
Q

Dx of ileus

A

Supine/upright x-ray: dilated bowel BUT air present in both small bowel and colon; no air fluid levels

If needed, then CT

29
Q

Management of ileus

A 
Supportive
IVF
Lyte replacement
Pain mgt (avoid narcotics, use NSAIDS)
bowel rest (NPO/CL diet +/- nutrition support)
NG tube if persistent N/V
Serial abdominal exams
ambulate
30
Q

Vascular supply to large bowel

A

SMA

IMA

31
Q

Role of large bowel

A

absorb water and electrolytes (right colon); store feces (left colon)

32
Q

Etiology of LBO

A

ADENOCARCINOMA** (colon and rectal CA)

stricture: diverticulitis/ischemia
Volulvus (sigmoid & cecal)
IBD
Fecal impaction
FB
33
Q

Hx questions for LBO

A 
hematochezia, bleeding, change in stool
fam hx of CA
LLQ pain w/ diarrhea (diverticulitis)
Blood stool w/ diarrhea
Time
Chronic opiod use or chronic constipation
34
Q

Presentation of LBO

A
  • +/- fever/chills
  • Crampy abdominal pain
  • Bloating, distention
  • Constipation/Obstipation
  • +/- N/V
  • Normal to quiet bowel sounds
  • Abdominal tenderness
  • +/- peritoneal signs
  • Hematochezia
  • DRE- occult blood, impaction, rectal mass?
35
Q

Dx of LBO

A
  • CBC, CMP, UA, LDH/Lactate
  • Plain Abdominal Films – Supine and Upright
  • CXR to look for free air under diaphragm
  • Gastrograffin Enema (if x-ray unclear)
  • CT scan
36
Q

X-ray result for LBO

A

distended colon proximal to obstruction

37
Q

Tx of partial LBO

A 
Trial of conservative:
• Surgical Consult 
• NPO
• IV Fluids
• Antibiotics
• Decompression with NG tube if vomiting 
• Avoid narcotics and anticholinergics
38
Q

Tx of complete LBO

A 
Depends on cause:
• Cancer – surgical resection
• Complete stricture – surgical resection
• Volvulus
- Cecal: surgical resection (if > 12 cm)
- Sigmoid: sigmoidoscopy with reduction
• Intussusception – barium enema
• Fecal impaction – enema
39
Q

What is volvulus

A

Abnormal twisting of a portion of the GI tract, usually the intestine, which can impair blood flow

40
Q

Types of volvulus

A

Sigmoid (most common)

Cecal

41
Q

Sigmoid volvulus risk factors

A 
elderly (~70YO)
Chronic constipation
redundant sigmoid colon
colonic dysmotility
hypomotility agents
42
Q

Presentation of sigmoid volvulus

A 
cramping
ab pain
N/V 
pain before vomiting
constipation
distended tympanitic abdomen
TTP
43
Q

Dx of sigmoid volvulus

A

upright x-ray
CT
contrast enema - dx and therapeutic

44
Q

Tx of sigmoid volvulus

A

Flex sig: decompress and de-rotate

Surgery: resect redundant sigmoid colon and prevent recurrence

45
Q

Cecal volvulus risk factor

A

33-53 years

46
Q

Presentation of cecal volvulus

A

episodic pain to acute abdominal catastrophe
distended
typmanic

47
Q

Dx of cecal volvulus

A

upright x-ray - dilated cecum typically displaced medially superiorly

CT scan- usually diagnostic

48
Q

Tx of cecal volvulus

A

Surgical

Clin Med III Exam 2 (8 decks)

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