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MET3a > Intestinal Obstruction > Flashcards

Intestinal Obstruction Flashcards

1
Q

Features present in all intestinal obstruction

A

Vomiting
Colicky abdominal pain
Distension
Constipation

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2
Q

What indicates severe case?

A 
High volume of vomit - thick, smelly
Degree of abdominal distention
Absolute Constipation - not passing anything
Shock
Constant pain - indicates perforation
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3
Q

First thing to do?

A 
ABCD
Urinary catheter
Fluids - K+ replace
NG tube as nil by mouth
Analgesia
Anti emetics
VTE prophylaxis
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4
Q

Venflon colours when used?

A

Blue - paediactrics
Pink - most common
Green - emergency
Grey and orange - breathing perfusely, immediate rapid infusion
Increase in size, reduce in gauge number, increase in water flow rate

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5
Q

Orange venflon

A

14G - largest
rapid blood transfusion
surgery

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6
Q

Grey venflon

A

16G
Rapid fluid replacement
Rapid blood transfusion

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7
Q

Green venflon

A

18G
Rapid fluid replacement
Trauma
Rapid blood transfusion

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8
Q

Pink venflon

A 
20G
Most infusions
IV Rapid fluid replacement
Trauma
Routine blood transfusions
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9
Q

Blue venflon

A 
22G
Neonate, pediatric
Older adults
Routine blood transfusion
Most infusions
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10
Q

What Ix

A

UBEXS
Urine - DM
Blood tests - FBC, U&E, urea, LFT, CRP, ABG
ECG - AF causing blood clots
CXR and abdo x-ray
Special tests = CT, gastrogafin (water soluble contrast)

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11
Q

Why do radiological tests?

A

Mechanical or functional obstruction

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12
Q

Functional obstructions

A

Pseudo-obstructions (oglivie’s syndrome)
Paralytic ileus - electrolyte imbalance, infected
Motility disorders - opiate abuse

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13
Q

Valvulae conniventes

A

Lines across small bowel
Go all the way across unlike haustra
Also called plicae circulares
Thinner than haustra

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14
Q

Haustra

A

Large bowel lines

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15
Q

Small bowel obstructions

A

normally central

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16
Q

Large bowel obsturctions

A

Peripheral

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17
Q

Pneumoperitoneum

A

Air inside peritoneal cavity

Hollow perforation risen up and is now under the diaphragm

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18
Q

Commonest cause of intestinal obstruction

A

Herniation

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19
Q

Other features of small bowel obstruction

A

Dehydration as proximal obstructed bowel fills with fluids
Vomiting exacerbates hypokaelaemia
Alkalosis as hydrogen ions lost in vomit and renal compensation results in hypokalaemia

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20
Q

Complications of obstruction

A 
Strangulation
Ischaemia
Infarction
Grangrene
Perforation
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21
Q

Signs of complications

A

Focal tenderness
Sepsis signs
Constant pain

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22
Q

Operative management

A

Laparotomy is operation of choice
If hernia is cause = repair this and get access to bowel for resection
Anastomoses with sutures/staples
Milk dilated proximal bowel contents through NG tube
Midline laparotomy incision/extend old scar if have one
Closure

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23
Q

Complications of surgical management

A 
Drains
Stomas
Prolonged hospital stay
Intensive care?
Pain, bleeding, anaesthetic risks
Anastomotic leak
Wound breakdown
Infection - UTI, to wound, intra-abdominal
DVT/PE
Adhesion formation
Scar problems
Incisional hernia
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24
Q

Most to least common causes of small bowel obstruction

A 
Adhesions
Neoplasm
Hernia
IBD
Volvulus
Others
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25
Q

Most to least common causes of large bowel obstruction

A 
Neoplasms
Volvulus
Hernia
Diverticular disease
Ischaemic colitis
Others
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26
Q

Closed loop obstruction

A

2 points along course of bowel obstructed forming a loop
Normally large bowel = volvulus
Incompetent ileo-caecal valve = small bowel obstruction as well

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27
Q

Define obstruction

A

Mechanical blockage due to structural abnormality

Physical barrier to progression of gut contents

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28
Q

Types of obstruction

A

Partial or complete

Simple or strangulated

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29
Q

How much fluid is received by the small intestines?

A

8L

Saliva, stomach, duodenum, pancreas, hepatobiliary

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30
Q

How much fluid is absorbed by the small intestines?

A

7L

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31
Q

How much fluid enters the large intestine?

A

2L

200ml excreted in faeces

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32
Q

How is there air in the bowel?

A

Swallow O2 and N2
Bacterial fermentation in colon = hydrogen, methane and CO2
- release 600ml flatus

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33
Q

Enteric bacteria

A

Coliforms
Anaerobes
Strep faecalis

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34
Q

Why do you get dehydration?

A

Early

Proximal obstructed bowel fills with fluid

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35
Q

Why do you get hypokalaemia and alkalosis?

A

Hydrogen ions lost in vomit and renal compensation = hypokaelaemia

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36
Q

Signs of strangulation

A 
Focal tenderness
Sepsis signs (high temp and leucocytosis)
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37
Q

Signs of ischaemia/infarction/gangrene and perforation

A

Constant pain and clinical signs of peritonism

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38
Q

Luminal causes of small bowel obstruction

A

Foreign body
Gall stones
Food particles
A. lumbricodes

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39
Q

Mural causes of small bowel obstruction

A 
Neoplasms
Crohns
TB
Stricture
Congenital
Intussuception
40
Q

Extraluminal causes of small bowel obstruction

A

Post-op adhesions
Congenital adhesions
Hernias
Volvulus

41
Q

Most common cause for small bowel obstruction in developed world

A

Adhesions

42
Q

Most common cause for small bowel obstruction in developing world

A

Hernia

43
Q

Small bowel adhesions associations

A
  • haemorrhage
  • foreign bodies
  • sepsis
  • post-laparotomy 4 weeks (esp. colorectal)
  • peritoneal injury/platelet activation/fibrin activation
44
Q

Difference between small and large bowel obstruction

A 
Small
- central
- 5cm diameter max
- ileum may appear tubeless
- will see plicae circulares 
Large
- peripheral
- 8cm diameter max
- will see haustrations (thicker)
45
Q

CT role

A
  • IV contast, oral and rectal contrast
  • identify bowel wall/mesentery/mesenteric vessels and perionteum abnormalities
  • see level of obstruction
  • degree of obstruction
  • cause = volvulus, hernia, luminal, mural
  • degree of ischaemia
  • free fluid and gas
  • ensure no renal failure/allergy to iodine
46
Q

Role of Barium studies

A
  • not for patients with peritonitis
  • acute setting
  • barium enema
  • mechanical vs. non mechanical (also known as dynamic vs. adynamic)
47
Q

Role of gastrogafin studies

A
  • acute abdomen
  • diluted
  • recurrent/chronic obstruction
  • define level of obstruction
  • identify mural causes
48
Q

First line Ix

A 
FBC - high WCC, anaemia, platelets, Hct
Clotting
ABG
U&E
Group and save, cross match
ESR
CRP
49
Q

Radiological Ix

A 
X-rays
USS
CT
MRI
Contrast studies
50
Q

USS Role

A
  • free fluid
  • masses
  • mucosal folds
  • peristalsis patterns
  • solid organs
  • mesenteric vasculature
51
Q

Proximal small bowel obstruction features

A 
Rapid pain
Lots of vomiting
Vomit contains bile and jejunal content
Distention limited/localised
Rapid dehydration
52
Q

Distal small bowel obstruction features

A 
Central, colicky pain
Feculent vomiting
Severe distension
Visible peristalsis
Flatus and faeces passing may continue before absolute constipation
53
Q

Colonic obstruction features

A
  • colicky pain in lower abdomen
  • late vomiting
  • prominent distension
  • perhaps caecum distension
  • pre-existing bowel habit changes?
54
Q

What may persistent pain be a sign of?

A

Strangulation

55
Q

What to look for on general exam?

A 
Vitals
Dehydration
Anaemia
Jaundice
Lymph nodes
Vomitus inspect
Lung and Heart
56
Q

What to look for on abdomen exam?

A 
Distension pattern
Hernia?
Peristalsis visible?
Caecal distension
Tenderness/guarding/rebound
Organomegaly
Bowel sounds = high pitched/absent
Rectal exam
57
Q

Initial Management

A
  • conservative
  • DRIP AND SUCK
  • NBM, NG tube
  • IV fluids with K replacement
  • analgesia, anti-emetics, VTE prophylaxis
  • urinary catheter
58
Q

When would you not just stick to conservative management initially?

A
  • evidence of strangulation

- evidence of incarcerated hernia

59
Q

What would you do if there may be strangulation/incarcerated hernia?

A
  • serial assessment
  • AXR to evaluate bowel function restored?
  • Gastrogafin water soluble contrast to restore bowel function
  • If symptoms not settling revisit surgical option
60
Q

Extended Conservative Management

A
  • if multiple previous operations = extensive adhesions
  • consider operating
  • early parenteral nutrition via central line
61
Q

Operative Management

A
  • laparotomy is operation of choice

- not really if single band adhesion or high risk (bariatric patients)

62
Q

When is immediate surgery done?

A
  • strangulation

- peritonitis from perforation/ischaemia

63
Q

When is surgery done 24-48 hours?

A
  • clear that there is no resolution of obstruction

- diagnosis is unclear

64
Q

Intermediate stage/timing of surgery >48 hrs

A
  • cause diagnosed and patient stabilised
65
Q

When would you not operate?

A
  • poor outcome
  • paralytic ileus/pseudo-obstruction
  • SBO single adhesion conservative management
66
Q

Laparotomy Procedure

A
  • optimise pre-op
  • incision through midline
  • divide adhesions, identify transition points
  • milk dilated proximal bowel contents through NG tube
  • primary anastomosis with sutures/staples
  • examine whole length of small bowel
  • closure/laparostomy
67
Q

Examples of operations

A

Right hemicolectomy
Extended right hemicolectomy (right + part of transverse)
Transverse
Left
Sigmoid
Hartmann’s procedure = tumour obstruction in rectosigmoid

68
Q

Types of stomas

A 
Ileostomy - spouted
Colostomy - non spouted
Both either loop or end
Loop means bring loop out then cut so 2 openings next to each other
Mucous fistula
Ileal Conduit - spouted, for urine
69
Q

Immediate surgical complications

A

Pain
Bleeding
need stoma
Anaesthetic risk

70
Q

Early surgical complications

A

Anastomotic leak
Wound breakdown
Infection - wound, intra-ab, chest, UTI
DVT/PE

71
Q

Late surgical complications

A

Adhesions form
Scar problems
Incisional hernias
Stoma complications

72
Q

Define paralytic ileus

A
  • inactivity of small bowel
  • differentiate from mechanical obstruction
  • 2-3 days post op
  • lasts 2-3 days
  • no pain
  • distension
  • no bowel sounds
  • large amounts from NG tube
73
Q

Causes of paralytic ileus

A
  • post laparotomy
  • intra-peritoneal infection
  • ischaemia
  • chest infection, MI
  • hypothyroidism, diabetes
  • spinal/pelvic fractures
  • retro-peritoneal haematoma
  • bed ridden
  • drugs = TCA, Ca blockers, morphine
  • low K, Na, Mg
  • uraemia
74
Q

Diagnosis of paralytic ileus

A

X- ray

- gas diffusely through intestine

75
Q

Management of paralytic ileus

A
  • rule out mechanical causes
  • drip and suck
  • 2-4 days resolves
76
Q

How to differentiate paralytic ileus from obstruction?

A
  • other cause?
  • distended abdo but not tenderness
  • no bowel sounds
  • gas In rectum
  • improves on conservative Tx
77
Q

Pseudo-obstruction

A

Ogilvie’s syndrome

  • elderly and very sick
  • symptoms and signs of obstruction
78
Q

RF of pseudo-obstruction

A
  • chest infection
  • MI
  • cerebrovascular event
  • renal failure
  • electrolyte disturbances
79
Q

Define simple bowel obstruction

A

Intestinal blockage without peritonitis

80
Q

Define complicated bowel obstruction

A

Surgical obstruction

Obstruction progresses to ischaemia/gangrene/perforation

81
Q

What is the most common cause of large bowel obstruction?

A

Colorectal cancer

82
Q

Define volvulus

A

Torsion of colon around mesenteric axis = compromised blood flow and closed loop obstruction

83
Q

Sigmoid Volvulus

A

Sigmoid colon twists around mesocolon

  • most common
  • sometimes also in caecum but caecum mostly retroperitoneal so not as much risk
84
Q

Who gets sigmoid volvulus?

A
  • older
  • adhesions
  • pregnancy
  • chronic constipation
  • neurological conditions/psychiatric
85
Q

Gastric Volvulus main features

A

Borchadt’s triangle

  • severe epigastric pain
  • retching
  • inability to pass an NG tube
86
Q

Volvulus features

A
  • constipation
  • bloating
  • pain
  • nausea/vomiting
87
Q

Diagnosis of volvulus

A
  • X-ray
88
Q

What does a sigmoid volvulus look like on X-ray?

A

Large bowel obstruction so:

  • large
  • dilated loop of colon
  • air and fluid levels

And coffee bean sign

89
Q

What does caecal volvulus look like on x-ray?

A
  • small bowel obstruction
90
Q

Management of sigmoid volvulus?

A

Right sigmoidoscopy with rectal tube insertion

91
Q

Caecal volvulus Management

A

Operative

Right hemicolectomy

92
Q

Signs of peritonism

A 
Abdominal tenderness/distension
Chills
Fever
Fluid in abdomen
Not passing urine/less
Difficulty passing gas/bowel movement
Vomiting
93
Q

Define peritonism

A

Symptoms of peritonitis without inflammation of peritoneum

94
Q

Is small or large bowel obstruction more common?

A

Small! - 80%

95
Q

Define adhesions

A

Fibrous bands forming between tissues and organs
Often due to surgery injury
Scar tissue like

MET3a (38 decks)

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