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Surgery > Intestinal obstruction and hernia > Flashcards

Intestinal obstruction and hernia Flashcards

1
Q

how do you classify bowel obstructions

A

mechanical vs non obstruction motility disorder

partial versus complete

low vs high grade

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2
Q

what are the most common causes of small bowel obstruction (SBO)

A
  1. post operative adhesions (nearly 75% of SBOs)
    - -5-30% patients develop SBO after abdo surgery
  2. hernia
  3. malignancy
    - -mets (i.e ovarian) rather than primary is most common
other--
IBD
abscess
intusussception
meckel's diverticulum
bezoar
gallstone illeus
volvulus
radiation enteritis
traumatic intramural hematoma
congenital abnormalities
SMA syndrome
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3
Q

what % of patients with SBO needs surgical intervention during index admission

A

up to 25% (though more likely 5-10%) of patients with SBO

patients without prior hx of abdominal surgery (“virgin abdo”) are far more likely to need surgery to resolve (because shouldnt be having problems like from adhesions etc)

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4
Q

classic SBO symptoms

A

colicky abdo pain (localized or diffuse)

nausea

emesis (bilious more concerning)

abdominal distension/bloating

obstipation (**but it is possible to have BMs if obstruction is more proximal)

?similar previous episodes of SBO

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5
Q

what might you find on exam of SBO patient

A

fever, tachy

distended abdo

tenderness to percussion or palpation

tympanic abdo

focal vs diffuse peritonitis

look for erythematous, tender bulges (groin, midline, umbilicus, previous surgical incision sites, parastomal)

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6
Q

what affects clinical presentation of SBO

A

anatomical site of obstruction

severity

time duration since onset of obstruction

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7
Q

how do you grade severity of SBO

A

complete
partial
open loop
closed loop

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8
Q

complete SBO

A

no distal passage of stool or gas

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9
Q

partial SBO

A

narrowing of passage with some matter going thru

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10
Q

closed loop SBO

A

more worrying

both proximal and distal segment of bowel loop are obstructed

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11
Q

open loop SBO

A

proximal decompression is achieved by nasogastric decompression

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12
Q

how sick is the patient? (what signs to look for…)

A

alert?
comfortable?
lethargic?

vitals/hemodynamic status?

emesis? (i.e 1L of bilious, multiple episodes?)

pain? opioid requirement?

blood work–WBC, BUN, Cr, lytes, lactate

imaging–>plain films vs CT abdo pelvis

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13
Q

what do you look for on plain film for SBO

A

more than 3 air fluid levels

caliber of small bowel more than 3 cm

step ladder pattern

*diagnostic only in 50-60% of cases and have high sensitivity only for high grade obstruction

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14
Q

what role does CT scan play in initial eval of SBO

A

go to imaging that completes initial eval

fast and relatively accessible, shows presence of obstruction

shows small vs large bowel

can show whether partial/complete/high/low grade

shows anatomical position and transition point and associated abnormalities

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15
Q

what role does CT scan play in initial eval of SBO

A

go to imaging that completes initial eval

fast and relatively accessible, shows presence of obstruction

shows small vs large bowel

can show whether partial/complete/high/low grade

shows anatomical position and transition point and associated abnormalities

*dont forget to check GFR before

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16
Q

intrinsic causes of SBO

A

IBD

neoplasias

vascular lesions

hematoma

intussusception

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17
Q

intraluminal causes of SBO

A

gallstones

bezoars

foreign bodies

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18
Q

extrinsic causes of SBO

A

adhesions

hernias

endometriosis

hematomas

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19
Q

what are the CT criteria for SBO

A

dilated small bowel loops (greater than 2.5 cm from outer wall to outer wall) proximally to normal caliber or collapsed loops distally

high grade–> 50% difference in caliber between proximal dilated bowel and distal collapsed bowel

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20
Q

how are most SBO manage

A

non operative

i.e for partial SBO
early post op period
crohns
hemodynamically stable 
no clinical deterioration
improvement within 12-24 hours 
motility related causes ie ileus 
manage with...
serial abdo exam
bowel rest
aggressive IVF rescus
electrolyte correction
NG tube decompression
serial abdo xray
abx?
TPB?
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21
Q

how does NG decompression work for SBO

A

allows edema in wall of bowel or adhesions to settle and allows affected area to heal

works in majority of people with partial obstruction

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22
Q

what are the endpoints of conservative SBO management

A

resolution of pain

distention

nausea/emesis

passage of flatus and stool

normalization of vital signs and bloodwork

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23
Q

what patients need operations for SBO

A

hemodynamic instability

fever, tachy, worsening leukocytosis

peritonitis

strangulation

evidence/suspicion bowel perf

no improvement with supportive care

virgin abdo

closed loop

non adhesive SBO

“dont let the sun rise and set on an SBO”…i.e do something if not improving

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24
Q

classification of LBO

A

partial or complete

extrinsic or intrinsic

mechanical or adynamic

competent ileocecal valve–> makes it a closed loop obstruction

*large bowel is less mobile than small bowel

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25
Q

causes of LBO

A

*more commonly require surgical intervention than SBO

neoplasm
volvulus
inflammatory (IBD, radiation, diverticulitis)
hernia
intussusception
adynamic (ogilvie's)
stricture
foreign body
fecal impaction
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26
Q

what is the significant of the ileocecal valve in an LBO

A

essentially makes an LBO a closed loop obstruction

competent valve causes pressure to build up

cecum is thus at highest risk for necrosis/perforation

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27
Q

what is normal colon diameter

A

less than 6 cm

more than 9cm is dilated

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28
Q

what is ogilvie’s syndrome

A

adynamic bowel

only LARGE BOWEL

exact pathophys is poorly understood

end result is disruption of colon motility, leading to distention

can lead to ischemia and perf if untreated

commonly seen in trauma, severe infection and cardiac disease

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29
Q

what is paralytic ileus

A

adynamic bowel

*dilatation of ENTIRE GI TRACT

people become massively distended

commonyl seen post abdo/ortho/obgyn procedures

onset around POD4

predisposing factors–> manipulation of bowels, meds (opioids, anticholinergics), immobilization, electrolyte abnormalities etc.

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30
Q

classic symptoms of paralytic ileus

A

abdo distension, pain, nausea, vomiting

with or without obstipation

with or without resp distress (from distenstion)

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31
Q

tx for paralytic ileus

A

aggressive supportive care

bowel rest
NG/rectal tube or lower scope decompression
IV fluids
correct lytes
minimize opioids, anticholinergics
mobilize
treat underlying illness
gentle bowel protocol
neostigmine or methylnaltrexone
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32
Q

groin mass ddx

A 
hernia
lymphadenopathy
hydrocele/spermatocele
hematoma/femoral artery aneurysm
undescended testes/testicular torsion
psoas abscess
neoplasm
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33
Q

how do you classify hernias

A

anatomical location

epigastric
umbilical
incisional
inguinal
femoral
spigelian
lumbar 
richter's
34
Q

define spigelian hernia

A

lateral aspect of rectus along the semicircular line of douglas–transition of two layers to one layer of rectus

high risk for complication

hard to detect

35
Q

define richters hernia

A

10% of strangulated hernias

not a full thickness of bowel hernia –no actual obstruction but ongoing ischemia in the wall

ileum most common place –herniation of antimesenteric wall without compromise of entire lumen

progress more quickly to gangrene

36
Q

maydl’s hernia

A

REDUCTION CONTRAINDICATED

“w” through the internal inguinal ring

37
Q

littre’s hernia

A

herniation of meckel’s diverticulum

38
Q

amyand’s hernia

A

vermiform appendix herniation

39
Q

hesselbach’s triangle boundaries

A

lateral–> inferior epigastric BVs

medial–> rectus abdominis

inferior–> inguinal ligament

40
Q

pantaloon hernia

A

both direct and indirect hernia at the same time

41
Q

why do we care about hesselbach’s triangle

A

it is where the direct hernias occur –> direct hernia’s protrude through the floor of hesselbach’s triangle due to weakness of transversalis fascia

result of increased abdo pressure (cough, COPD, constipation, obesity)

42
Q

why do we care about hesselbach’s triangle

A

it is where the direct hernias occur –> direct hernia’s protrude through the floor of hesselbach’s triangle due to weakness of transversalis fascia

result of increased abdo pressure (cough, COPD, constipation, obesity)

43
Q

indirect hernia

A

lateral to epigastric vessels

secondary to patent processus vaginalis, pass through internal inguinal ring

44
Q

direct hernia

A

medial to epigastric vessels

direct hernia’s protrude through the floor of hesselbach’s triangle due to weakness of transversalis fascia

45
Q

what is the most common type of hernia

A

indirect in males

46
Q

what is the most common general surgical procedure in north america

A

inguinal hernia

47
Q

define femoral hernia

A

below inguinal ligament and medial to femoral vein

more common on right than left

elderly women more common

need to repair due to high risk of strangulation

48
Q

risk factors for inguinal hernia

A

males

family history

genetic–immature type III:type I collagen

aneurysmal disease, collagen disease, hiatal hernia, sleep apnea, smoking

increased intra abdo pressure

older age

49
Q

reducible hernia

A

spontaneous or manual return of hernia sac content into abdo cavity

50
Q

incarcerated hernia

A

inability to reduce the contents

51
Q

strangulated hernia

A

incarcerated with signs of bowel compromise

52
Q

how should you examine a patient for a hernia

A

standing position

can be difficult to distinguish direct or indirect on exam

53
Q

do you need imaging to dx hernia

A

no, not if clinical presentation clearly consistent with reducible inguinal hernia

obese/patients without history might need imaging

any dx uncertainty–image

54
Q

who gets surgery for a hernia

A

all females with grain hernia

femoral hernia

symptomatic hernia

incarcerated or strangulated hernia (emergent)

55
Q

when should you NOT try manual hernia reduction

A

if there are any signs of bowel compromise–do not want gangrenous piece of bowel in peritoneal cavity

56
Q

how to reduce a hernia

A

place patient in trendelenburg position and apply constant pressure to the bulge until returns to peritoneal cavity

57
Q

no surgical management of inguinal hernia

A

watchful waiting acceptable for men with minimal symptoms or asymptomatic inguinal hernia (incarceration is 0.3-3% per year)

weight reduction

smoking cessation

educate about sx of incarceration and strangulation

58
Q

sliding hernia

A

part of the wall is composed of part of another organ (i.e bowel plus bladder)

59
Q

what is the ddx of groin pain and/or mass

A

inguinal hernia
femoral hernia
muscle strain
adenopathy

60
Q

how do inguinal hernia patients often present (on history)

A

intermittent groin discomfort or “heaviness” that is more prominent with activity and after standing for long periods of time

61
Q

what test should be ordered to confirm a femoral hernia

A

CT pelvis

62
Q

how do you approach treatment of an acutely incarcerated femoral hernia

A

expeditious exploration and repair of the hernia

use an open incision above the inguinal ligament that allows the surgeon to go through the inguinal floor to identify the femora canal and address the contents of the hernia

once reduced, use a McVay type repair (Cooper’s ligament repair) with placement of prosthetic mesh

63
Q

define indirect inguinal hernia

A

inguinal hernia in which abdominal contents protrude through the internal inguinal ring through a patent PROCESSUS VAGINALIS into the inguinal canal

in men, hernia sacs follow the spermatic cord and may descend into the scrotum

in women–may present as labial swelling

64
Q

define direct inguinal hernia

A

inguinal hernia that protrudes through the HESSELBACH TRIANGLE and MEDIAL to the ipsilateral inferior epigastric vessels

develop initially as tears to the abdominal well within hesselbach’s triangle (transversus abdominis musculature)

65
Q

define femoral hernia

A

hernia that protrudes through the femoral canal, which is bound by the INGUINAL LIGAMENT superiorly, FEMORAL VEIN laterally and PYRIFORMIS and PUBIC RAMUS medially

femoral hernia is BELOW inguinal ligament

66
Q

define umbilical hernia

A

hernia that results from improper closure of the abdominal wall defect where the umbilical cord was in utero

80% will close spontaneously by 2 years of life

can also be acquired–subclinical defects increase in size due to increased intra-bdbominal pressures (pregnancy, ascites, excess weight gain)

67
Q

define a Little hernia

A

any hernia that contains a meckel’s diverticulum

68
Q

define Amyand’s hernia

A

inguinal hernia that contains the appendix

69
Q

define de garengoet’s hernia

A

femoral hernia that contains the appendix

70
Q

define richter’s hernia

A

herniation of part of the bowel wall through any hernia defect

unique in that it may or may not be associated with intestinal obstruction–often smaller and more difficult to diagnose

area of incarcerated intestine can develop ischemia and necrosis when not dx

71
Q

define spigelian hernia

A

hernia just lateral to the rectus sheath and located at the semi-lunar line or the lower limits of the rectus sheath

72
Q

define obturator hernia

A

herniation along the obturator canal alongside the obturator vessels and obturator nerve

most common in women (esp multiparous women) with history of recent weight loss

mass palpable in medial thigh

howship-romberg sign associated with 50% of patients with obturator hernias–> pain along inner thigh induced by hip flexion, abduction, internal rotation or external rotation

73
Q

define sliding hernia

A

indirect inguinal hernia with hernia sac containing either sigmoid colon or cecum

sac will contain the attachment of the intestines

74
Q

what is incarceration

A

trapping of the abdominal contents within the hernia sac (does not spontaneously reduce)

75
Q

what is strangulation

A

blood supply to the trapped intra-abdominal contents becomes compromised leading to ischemia, necrosis, and ultimately perforation

76
Q

what are the boundaries of hesselbach’s triangle

A

edge of RECTUS MUSCLE medially, the INGUINAL LIGAMENT inferiolaterally, and INFERIOR EPIGASTRIC VESSELS superiolaterally–> this is where direct hernias are found

(indirect hernias as lateral to this)

77
Q

what is cooper’s ligament

A

aka pectineal ligament

fibrous structure that extends from the pubic tubercle mediallyand extends posteriotly to the femoral vessels

78
Q

define the boundaries of the femoral canal

A

between the inguinal ligament, cooper’s ligament, femoral vein

79
Q

what is the rate of inguinal hernia incarceration over 2 years for those with asymptomatic hernias

A

0.18% (and no strangulations)

about 1/3 patients with FEMORAL hernias developed acute events requiring emergency surgery so dont wait for them

80
Q

which is better in hernia repair–suturing native tissue closed or using mesh prosthetic and plug?

A

mesh prosthetic plus plug has lower recurrence rates

81
Q

what presentation of a hernia is most concerning for strangulation

A

hard and tender hernia when palpated

Surgery (20 decks)

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