Gen Surg: small + large bowel obstruction and ileus

Question 2

How does large bowel obstruction present?

Answer 2

Abdominal pain
Bloating
Absolute constipation
Nausea and vomiting

Question 3

What are the causes of large bowel obstruction?

Answer 3

Colonic tumour
Volvulus (sigmoid or caecal)
Diverticular disease

Less common:
Hernias
Adhesions

Question 4

What investigations would you do for a large bowel obstruction?

Answer 4

Abdominal xray
CT abdo to establish a cause

Question 5

What are tympanic sounds in the abdomen?

Answer 5

Occurs over the air filled structures- should sound this way in the midline of the abdomen. It sounds long, high pitched and loud

Question 6

How would you manage post-op ileus?

Answer 6

Conservatively:
* insert NG tube for stomach decompression for symptom control.
* Place pt on NBM regime to allow bowel to rest.
* Reduce opiate analgesia as reducing bowel motion.
* Do daily bloods as could have electrolyte abnormalities and AKI can develop. Encourage mobilisation.

Question 7

What is post operative ileus?

Answer 7

A deceleration or arrest in intestinal motility following surgery. Classified as a functional bowel obstruction and is v common after abdominal or pelvic oath surgery.

Question 8

How does post operative ileus present?

Answer 8

• Failure to pass faeces or wind
• Sensation of bloating and distension.
• Nausea and vomiting.
• Inability to tolerate oral diet

O/E
Abdominal distension and absent bowel sounds.

Question 9

What is thumbprinting indicative of?

Answer 9

large bowel thickening usually caused by oedema

Question 10

What are the causes of small bowel obstruction?

Answer 10

Adhesions,
incarcerated hernias,
crohns disease,
appendicitis,
malignancy,
gallstone ileus,
foreign body ingestion

Question 11

Name a cause of intraluminal intestinal obstruction?

Answer 11

Gallstone ileus, foreign body, faecal impaction.

Question 12

Name a cause of mural intestinal obstruction

Answer 12

Malignancy, strictures, intussusception, mocker’s diverticulum, lymphoma.

Question 13

Name a cause of extraluminal intestinal obstruction

Answer 13

Hernia, adhesions, peritoneal mets, volvulus

Question 14

What is the most common cause of small bowel obstruction?

Answer 14

Adhesions, hernias

Question 15

How does small bowel obstruction present?

Answer 15

Abdo pain, vomiting (bilious)
, abdo distension,
absolute constipation (comes after the vomitting)

Question 16

What would be seen on examination for small bowel obstruction?

Answer 16

• tinkling bowel sounds,
• focal tenderness.

Question 17

What imaging would you do for small bowel obstruction? And what would you see?

Answer 17

AXR - see centrally dilated bowel >3cm. Valvulae conniventes are visible. Can do CT scan with IV contrast. Can do CXR - see pneumoperitoneum if perforated.

Question 18

What initial management options would you discuss for small bowel obstruction?

Answer 18

• Urgent fluid resus,
• catheter to monitor fluid output,
• pt NBM-insert NG tube to decompress bowel

Question 19

When is surgery indicated for small bowel obstruction?

Answer 19

Intestinal ishaemia,
closed loop bowel obstruction.
If hernia is present and strangulated - need surgical correction.

Question 20

What are complications of small bowel obstruction?

Answer 20

Bowel ischaemia, bowel perforation, dehydration and renal impairment

Question 21

What are most common causes of large bowel obstruction?

Answer 21

Malignancy
diverticular disease
volvulus

Question 22

What is seen on AXR of large bowel obstruction?

Answer 22

Peripherally dilated bowel. Haustral lines visible.

Question 23

How does a large bowel obstruction look on X-ray?

Answer 23

Peripherally dilated loops of bowel

Question 24

Sigmoid volvulus RF?

Answer 24

Older patients
Chronic constipation
Chagas disease
Neuro conditions- parkisons, Duchenne muscular dystrophy
psych conditions e.g. schizophrenia

Question 25

Clinical features of sigmoid volvulus?

Answer 25

• Constipation
• abdo bleeding
• abdo pain
• nausea and vomitting

Question 26

Axr of sigmoid volvulus?

Answer 26

Large bowel obstruction and coffee bean sign

Question 27

Management of sigmoid volvulus?

Answer 27

• Rigid sigmoidoscopy with rectal tube insertion

Question 28

Management of caecal volvulus?

Answer 28

• usually operative, right hemicolectomy is often needed

Question 29

abdominal pain, vomitting and bloating post bowel surgery?

Answer 29

post-operative ileus