Bowel Obstruction

Question 1

Define bowel obstruction

Answer 1

Impendance in the upward movement of the bowel contents

Question 2

Outline the 4 ways in which we classify bowel obstruction

Answer 2

1. Large or small bowel
2. Mechanical or functional
3. Simple or complicated
4. Partial or complete

Question 3

What are the common causes : in the wall, outside the wall and in the lumen for mechanical obstruction

Answer 3

1. In the wall : tumors and strictures
2. In the lumen : constipation and gallstones
3. Outside the wall : hernias and adhesions

Question 4

What are the four symptoms of bowel obstruction and elaborate on the mechanism

Answer 4

1. Chronic abdominal pain : colicky in nature
2. Abdominal distension
3. Constipation/obstipation
4. Vomiting

Question 5

1. What are two conditions that lead to complicated bowel obstruction?
2. What is the presentation and systemic manifestations
3. What are the complications

Answer 5

1. Closed loop obstruction and strangulated obstruction
2. They present with severe constant pain and local tenderness/peritonism
   Systemic manifestations are : fever, tachycardia and increased inflammatory markers
3. Pressure necrosis and perforation

Question 5

1. What are two conditions that lead to complicated bowel obstruction?
2. What is the presentation and systemic manifestations
3. What are the complications

Answer 5

1. Closed loop obstruction and strangulated obstruction
2. They present with severe constant pain and local tenderness/peritonism
   - Abdomen does not move with respiration
   - rebound tenderness
   - percussion tenderness
   - might feel a mass : rigidity
   - feculent matter on NG tube
   - might be blood on PR

Systemic manifestations are : fever, tachycardia and increased inflammatory markers

3. Pressure necrosis and perforation

Question 6

1. What would you see on Supine and Erect abdominal xrays

2. What are the specific features for small and large bowel obstructions on xrays

Answer 6

1. Erect : multiple air fluid levels and air under the right hemidiaphragm would indicate a perforation
   Supine : distended loops of bowel
2. Small bowel: vulvuli conniventes
   Large bowels : hostrations

Question 7

List the imaging studies you would do and what they would help with

Answer 7

1. Cxray erect
2. Abdominal xray supine and erect
3. Ct scan : strangulation or not
4. Contrast studies : a. Barium enema for large bowel
   b. Barium follow through for small bowel
5. CT colonography : sensitive to intraluminal pathology
6. Colonoscopy : role in colon cancer
7. Capsule endoscopy : for small bowel

Question 8

1. What Is the management of a simple small bowel obstruction
2. What is the management of a complicated bowel obstruction?
3. What is the management of a simple large bowel and a complicate large bowel obstruction

Answer 8

1. IV fluids and nasogastric suction (drip and suction)will relieve the obstruction
2. Optimize and resect then anastomosis . Surgery could either be laparoscopy or laparotomy
3. Optimize and do endoscopic derotation where you pass a flatus tube and for complicated : resect then bring a stoma

Question 9

Which conditions are paralytic ileus mostly seen ? (3)

Answer 9

1. Post operatively following abdominal surgery for 2-3 days
2. With any acute abdominal pathology, I.e appendicitis, acute pancreatitis, perforated peptic ulcer
3. With underlying medical conditions - extra abdominal pathology

Question 10

What are featured of paralytic ileus both on presentation and Xray

Answer 10

1. Distended but not painful abdomen and the rest like any other mechanical obstruction except that there’s diminished bowel sounds
2. similar to mechanical obstruction but air in distended bowel is seen all the way down to the rectum

Question 11

What is the management of paralytic ileus

Answer 11

• Conservative apart from any underlying condition requiring surgery
• IV fluids , NG tube with pt kept NPO and treatment of the underlying medical condition and correction of electrolytes since Potassium is implicated at the cause too