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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
causes of LBO
*more commonly require surgical intervention than SBO ``` neoplasm volvulus inflammatory (IBD, radiation, diverticulitis) hernia intussusception adynamic (ogilvie's) stricture foreign body fecal impaction ```
26
what is the significant of the ileocecal valve in an LBO
essentially makes an LBO a closed loop obstruction competent valve causes pressure to build up cecum is thus at highest risk for necrosis/perforation
27
what is normal colon diameter
less than 6 cm more than 9cm is dilated
28
what is ogilvie's syndrome
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
29
what is paralytic ileus
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.
30
classic symptoms of paralytic ileus
abdo distension, pain, nausea, vomiting with or without obstipation with or without resp distress (from distenstion)
31
tx for paralytic ileus
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 ```
32
groin mass ddx
``` hernia lymphadenopathy hydrocele/spermatocele hematoma/femoral artery aneurysm undescended testes/testicular torsion psoas abscess neoplasm ```
33
how do you classify hernias
anatomical location ``` epigastric umbilical incisional inguinal femoral spigelian lumbar richter's ```
34
define spigelian hernia
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
define richters hernia
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
maydl's hernia
REDUCTION CONTRAINDICATED "w" through the internal inguinal ring
37
littre's hernia
herniation of meckel's diverticulum
38
amyand's hernia
vermiform appendix herniation
39
hesselbach's triangle boundaries
lateral--> inferior epigastric BVs medial--> rectus abdominis inferior--> inguinal ligament
40
pantaloon hernia
both direct and indirect hernia at the same time
41
why do we care about hesselbach's triangle
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
why do we care about hesselbach's triangle
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
indirect hernia
lateral to epigastric vessels secondary to patent processus vaginalis, pass through internal inguinal ring
44
direct hernia
medial to epigastric vessels direct hernia's protrude through the floor of hesselbach's triangle due to weakness of transversalis fascia
45
what is the most common type of hernia
indirect in males
46
what is the most common general surgical procedure in north america
inguinal hernia
47
define femoral hernia
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
risk factors for inguinal hernia
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
reducible hernia
spontaneous or manual return of hernia sac content into abdo cavity
50
incarcerated hernia
inability to reduce the contents
51
strangulated hernia
incarcerated with signs of bowel compromise
52
how should you examine a patient for a hernia
standing position can be difficult to distinguish direct or indirect on exam
53
do you need imaging to dx hernia
no, not if clinical presentation clearly consistent with reducible inguinal hernia obese/patients without history might need imaging any dx uncertainty--image
54
who gets surgery for a hernia
all females with grain hernia femoral hernia symptomatic hernia incarcerated or strangulated hernia (emergent)
55
when should you NOT try manual hernia reduction
if there are any signs of bowel compromise--do not want gangrenous piece of bowel in peritoneal cavity
56
how to reduce a hernia
place patient in trendelenburg position and apply constant pressure to the bulge until returns to peritoneal cavity
57
no surgical management of inguinal hernia
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
sliding hernia
part of the wall is composed of part of another organ (i.e bowel plus bladder)
59
what is the ddx of groin pain and/or mass
inguinal hernia femoral hernia muscle strain adenopathy
60
how do inguinal hernia patients often present (on history)
intermittent groin discomfort or "heaviness" that is more prominent with activity and after standing for long periods of time
61
what test should be ordered to confirm a femoral hernia
CT pelvis
62
how do you approach treatment of an acutely incarcerated femoral hernia
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
define indirect inguinal hernia
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
define direct inguinal hernia
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
define femoral hernia
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
define umbilical hernia
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
define a Little hernia
any hernia that contains a meckel's diverticulum
68
define Amyand's hernia
inguinal hernia that contains the appendix
69
define de garengoet's hernia
femoral hernia that contains the appendix
70
define richter's hernia
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
define spigelian hernia
hernia just lateral to the rectus sheath and located at the semi-lunar line or the lower limits of the rectus sheath
72
define obturator hernia
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
define sliding hernia
indirect inguinal hernia with hernia sac containing either sigmoid colon or cecum sac will contain the attachment of the intestines
74
what is incarceration
trapping of the abdominal contents within the hernia sac (does not spontaneously reduce)
75
what is strangulation
blood supply to the trapped intra-abdominal contents becomes compromised leading to ischemia, necrosis, and ultimately perforation
76
what are the boundaries of hesselbach's triangle
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
what is cooper's ligament
aka pectineal ligament fibrous structure that extends from the pubic tubercle mediallyand extends posteriotly to the femoral vessels
78
define the boundaries of the femoral canal
between the inguinal ligament, cooper's ligament, femoral vein
79
what is the rate of inguinal hernia incarceration over 2 years for those with asymptomatic hernias
0.18% (and no strangulations) **about 1/3 patients with FEMORAL hernias developed acute events requiring emergency surgery so dont wait for them**
80
which is better in hernia repair--suturing native tissue closed or using mesh prosthetic and plug?
mesh prosthetic plus plug has lower recurrence rates
81
what presentation of a hernia is most concerning for strangulation
hard and tender hernia when palpated

Surgery (20 decks)

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