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GI #2 > Intestinal obstruction > Flashcards

Intestinal obstruction Flashcards

1
Q

caused by decreased intestinal blood flow causing ischemia and subsequent reperfusion damage that may progress to mucosal injury, tissue necrosis & metabolic acidosis

A

mesenteric ischemia

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2
Q

3 major GI arteries off the abdominal aorta

A

celiac axis
SMA
IMA

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3
Q

3 primary causes of mesenteric ischemia

A

arterial embolism
arterial thrombosis– in those w preexisting mesenteric artherosclerosis
non-occlusive etiology– severe systemic illness w/ systemic shock usually d/t reduced CO (hypovolemia)

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4
Q

symptoms include

  • severe, poorly localized, post-prandial abdominal pain w/ sorta normal abdomnial exam
  • not really relieved w/ opiods
  • N/V/D common
  • if chronic– wt loss & sitophobia
  • later dz– distention, ileus, melena, hematochezia
A

mesenteric ischemia

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5
Q

how to revascularize a mesenteric ischemia caused by embolism vs thrombosis vs venous thrombosis if WITHOUT peritoneal signs?

A
  • embolsim– early laparotomy w/ embolectomy
  • arterial thrombosis– bypass graft or basloon dilation angioplasty w/ stenting
  • venous thrombosis– systemic anticoag (heparin, warfarin)
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6
Q

if there are peritoneal signs or signs of perforation or gangrene, how are acute mesenteric ischemias treated?

A

emergent surgical exploration via laparotomy (after stabilization) to restore flow & resect nonviable bowel

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7
Q
  • transient impaired persistalsis in intestine causing gas & fluid accumulation in bowel
  • # 1 cause is post-op
  • typically resolves in 2-3 days; if longer then its post-op ileus
A

ileus (functional)

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8
Q

this is the pathophys of ileus

  • activation of inhibitory spinal reflex arcs– what prevents?
  • [insert word] stress generates endocrine & inflammatory mediators (promotes)
A
  • spinal epidural prevents
  • surgical stress promotes
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9
Q

other causes of post-op ileus

A

somatic & visceral trauma activating mast cells, etc
gut handling & anastomosis interferes w/ electromechanical coupling
fluid overload/ electrolyte abnormalities
opioid analgesia decreases motliti

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10
Q
  • slower onset of vague mild abd pain & bloating; N/V poor appetite; obstipation
  • NO CRAMPING
  • distended abdomen w/ tympany and decreased or no bowel sounds
A

ileus

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11
Q

expected imaging for ileus on plain film

A

nonspecific bowel gas pattern; increased gas

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12
Q

how can contrast help r/o mechanical SBO?

A

if the contrast does not reach cecum in 4 hrs then r/o mechanical SBO

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13
Q

how is ileus managed? (4)

A
  • Admit for watchful waiting & hydration
  • correct underlying cause
  • +/- NGT; NPO till resolved; gum chewing?
  • d/c meds (opiates)
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14
Q

general cause of FUNCTIONAL SBO

A

bowel wall or splanchnic nerve dysfunction

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15
Q

are adnesions, hernias, volulus aand neoplasms luminal, mural or extraluminal?

A

all are extraluminal except neoplasms which are mural

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16
Q

differentiate close vs open ended SBO in terms of movement. Which is typically luminal?

A
  • closed has 2 points and prevents any movement of contents; can affect blood supply
  • open has one point and affects with prograde movement; typically luminal
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17
Q

whats a complicated obstruction?

A

affects circulation with resultant ischemia, infarction and perforation

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18
Q

what are the 3 specific mechanical obstructions in SBO that we talked about

A

intussception
volvuus
gallstone ileus

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19
Q

invagination of segment of bowel into another causing triad of vomiting + abdominal pain + blood per rectum (currant jelly stools) in kids esp after viral infection

A

intussception

20
Q

axial twist of segment around its mesentery → closed loop obstruction and variable degree of vessel obstruction

A

volvulus

21
Q

pathophys of SBO; fill in the blank

  • obstruction causes progressive dilation of the intestine ____ to blockage while ____ to the blockage, it’ll decompress as luminal contents pass
  • air swallowed & bacterial fermentation cause gas accumulation
A

1st space: Proximal
2nd space: distal

22
Q

most common cause for SBO

A

adhesions

23
Q

distal vs proximal distention– which is more associated w/ vomiting? which is more associated with distention?

A
  • Proximal SBO: acute colicky pain with bilious vomiting
  • distal SBO: progressive with distention (distal-distention)
24
Q

PE of distention, hyperactive high-pitched BS (early), hypoactive BS later, fever, tachycardia, TTP

A

SBO

25
Q

what is the uright XR finding for SBO? when do you get a CT?

A

plain film– increased air or multi-height air fluid level (flat straight lines ladder)
CT if patient has fever, tachycardia, leukocytosis, or localized abd pain

26
Q

how is SBO managed?

A
  • ADMIT
  • aggressive fluid resus
  • analgesia and antiemetic tx PRN
  • NGT (aka bowel decompression)
  • early surgical consult
  • abx prophylaxis
  • NPO
  • ambulation and close observatoin
27
Q

what is this? how is it treated?

  • happens when inflammation & adhesions after cholecystitis causes choleocystenetic fistula via which gallstones enter the bowel and goes to either stomach or down the SB.
  • makes up a quarter of the nonstrangulating SBO in over 65yo;
  • most happen at the terminal ileus
A

gallstone ileus
surgically corrected

28
Q

functional obstruction causing massive acute colonic dilation in absence of any mechanical obstruction, usually at the cecum or right hemicolon with mortality rate of 40%

A

acute colonic pseudo-obstruction (Ogilvie’s Syndrome)

29
Q

explain laplace’s law & which condition it’s the most relevant to. What are 4 things it could cause?

A
  • the intraluminal pressure needed to stretch the wall of a hollow tube & the diameter of that same tube are inversely related
  • most relevant to Ogilvie’s syndrome
  • implications– ischemia, serosal splitting, herniation, perforation
30
Q

3 etiologies of ogilvie’s syndrome

A

retroperitoneal trauma
serious infection
cardiac dz (MI or CHF)

31
Q

most common presentation of ogilvie’s syndrome

A

debilitated, hospitalized patient w/ multiple medical problems and history of many surgical conditions.

32
Q

what do you need to diagnose ogilvies? (3)

A

signs & sx; history
CBC, CMP
plain films of adomen

33
Q

first thing to do when managing ogilvies

A

r/o mechanical obstruction!
- need to see colonic air in all segments; if not visible, get barium enema!
- aggressive management of underlying issues & stop narcotics

34
Q

how is < 9 cm cecum ogilvie’s managed? give 4 examples

A

conservatively
- prevent consipation
- NPO, decompression, correct lytes, tx infection, etc

35
Q

if conservative tx isn’t working what are 3 ways to treat ogilvies?

A
  1. sympathetic blocker (ocretotide) then cholinesterase inhibitor (neostigmine)
  2. colonsocopic decompression to reduce perforation risk
  3. surgery for perforations or mechanical obstructive risk
36
Q

what is the condition?

radiological finding: marked isolated large bowel dilation (likely R side), diaphragm elevated

A

ogilvie’s

36
Q

what is the condition?

radiological finding: marked isolated large bowel dilation (likely R side), diaphragm elevated

A

ogilvie’s

37
Q

PE findings with ogilvie’s is most similar to what other condition?

A

SBO

38
Q

if patient with sx of SBO is not clinically stable what do you do? if they are stable then what?

A
  • unstable– laparotomy
  • stable– XR or CT
39
Q

if person w/ sx of SBO shows signs of vascular compromise or perforation on imaging, what next? what if it shows complete or partial obstruction instead?

A
  • vascular comp or perf– laparotomy
  • any obstruction– NPO, NGT, IV fluids
40
Q

what happens if person with partial obstruction doesn’t resolve in 1-2 days? what if its complete that doesnt resolve?

A
  • unresolving partial– upper GI/SB follow-thru or enteroclysis (if it doesnt resolve then laparotomy)
  • unresolving complete– laparotomy
41
Q

which lab is essential in SB infarction or acute mesenteric ischemia?

A

lactate/lactic acid (NOT LDH)

42
Q

most common, but still rare neuroendocrine tumors from enterochromaffin cells that mostly happen in GI tract of kids; tend to be incidental findings

A

carcinoid tumor

43
Q

what is the classic carcinoid traid?

A

diarrhea, flushing & wheezing respiration
(also PERIODIC abd. pain, tachycardia, hypotension)

44
Q

best screening test for carcinoid tumors? how is it treated?

A

screen: 24hr urinary 5-HIAA
treatment: surgery, chemo for carcinoid syndrome

GI #2 (9 decks)

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