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A. MLA Map Paediatrics > Intestinal obstruction and ileus > Flashcards

Intestinal obstruction and ileus Flashcards

1
Q

What is an ileus?

1 - uncoordinated bowel movements
2 - lack of peristalsis
3 - increased peristalsis
4 - chronic diarrhoea associated with ileum

A

2 - lack of peristalsis

  • common effect following GIT surgery
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2
Q

What is a functional GIT obstruction?

1 - physical blockage of the GIT
2 - partial blockage of the GIT
3 - no blockage of GIT but no GIT movements
4 - increased GIT movements

A

3 - no blockage of GIT but no GIT movements

  • despite the obvious blockage, there is no movement of GIT contents
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3
Q

What is a mechanical GIT obstruction?

1 - physical blockage of the GIT
2 - partial blockage of the GIT
3 - no blockage of GIT but no GIT movements
4 - increased GIT movements

A

1 - physical blockage of the GIT

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4
Q

Is functional or mechanical blockage of the GIT more common?

A
  • mechanical
  • GIT obstruction causes proximal bowel distension and disruption of peristalsis, called paralytic ileus
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5
Q

The causes of intestinal obstruction can be subdivided into extrinsic, bowel wall problems or luminal problems. Which of the following is not a common cause of a luminal obstruction?

1 - gallstones
2 - caliculi
3 - foreign bodies
4 - phytobezoars (trapped mass of undigested food)
5 - trichobezoar (trapped mass of undigested hair)

A

2 - caliculi

  • kidney stones are normally isolated to the kidneys
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6
Q

The causes of intestinal obstruction can be subdivided into extrinsic, bowel wall problems or luminal problems. Which of the following is NOT a common cause of a intraluminal/bowel wall problem obstruction?

1 - tumours
2 - inflammatory/fibrotic strictures
3 - ischaemia
4 - crohn’s
5 - paralytic ileus

A

4 - crohn’s

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7
Q

The causes of intestinal obstruction can be subdivided into extrinsic, bowel wall problems or luminal problems. Which of the following is NOT a common cause of an extrinsic GIT obstruction?

1 - gallstones
2 - volvulus (twisting of bowels)
3 - hernia (small bowel)
4 - adhesions/scar tissue
5 - abdominal masses

A

1 - gallstones

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8
Q

What is the most common cause of a small bowel obstruction?

1 - ischaemia
2 - gallstones
3 - adhesions
4 - hernias

A

3 - adhesions

  • 80% associated with adhesions
  • 10-15% associated with hernias
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9
Q

The presentations of an obstruction depends on the completeness of an obstruction and where the obstruction is. Secreted/consumed fluid proximal to the obstruction can also cause what?

A
  • pain as bowels begin to distend proximally to obstruction
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10
Q

Although it can be hard to identify the location of the obstruction based on physical examination, the location of pain can be guided based on what?

1 - embryological development (fore, mid and hing gut)
2 - patients descriptions
3 - physical appearance of patients

A

1 - embryological development (fore, mid and hing gut)

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11
Q

If an obstruction is incomplete, or becomes a chronic incomplete obstruction what can happen to the bowel walls proximal to the obstruction?

1 - atrophy
2 - paralytic ileus
3 - hypertrophy and stronger peristalsis
4 - neoplasia

A

3 - hypertrophy and stronger peristalsis

  • also leads to pain
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12
Q

In an absolute obstruction is anything able to pass?

A
  • no
  • sign of complete obstruction is no wind or stool will be passed
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13
Q

If you have been able to identify that a patient has a bowel obstruction that is caused by adhesions, what % of these settle spontaneously?

1 - 9%
2 - 19%
3 - 49%
4 - 90%

A

4 - 90%

  • if malignant it will rarely settle
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14
Q

What is gastric outlet obstruction?

1 - obstructed lower oesophageal sphincter
2 - obstructed pylorus
3 - obstructed fundus
4 - obstructed antrum

A

2 - obstructed pylorus

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15
Q

Gastric outlet obstruction, which is when there is an obstruction of the stomach, most commonly at the pylorus. Is this more common in men or women?

A
  • men
  • 3-4 times more likely
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16
Q

Gastric outlet obstruction, which is when there is an obstruction of the stomach, most commonly at the pylorus. What is the most common cause, accounting for 50-80% of obstructions?

1 - peptic ulcers
2 - malignancy
3 -foreign bodies
4 - crohns stricture
5 - gastric volvulus
6 - pancreatitis
7 - gastroparesis (motility issues)

A

2 - malignancy

  • peptic ulcers account for 5%
  • the rest can cause the problem but are rare
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17
Q

If a patient presents with vomiting, early satiety, weight loss and succession splash, where the the obstruction most likely to be?

1 - proximal to 2nd part of duodenum
2 - pylorus of stomach
3 - jejunum
4 - ileum

A

1 - proximal to 2nd part of duodenum

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18
Q

What is the imaging modality of choice can be used to diagnosis and therapy in a patient with suspected gastric outlet obstruction?

1 - CT
2 - endoscopy
3 - MRI
4 - interventional radiology

A

2 - endoscopy

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19
Q

In a patient with suspected gastric outlet obstruction what might we expect to see from an ABG?

1 - metabolic acidosis with hyperkalaemia
2 - reduced ph
3 - metabolic alkalosis with hyperkalaemia
4 - increases HCO3-

A

3 - metabolic alkalosis with hyperkalaemia

  • due to vomiting
  • in addition kidneys secrete K+ in an attempt to retain H+ due to alkalosis
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20
Q

In a patient with confirmed gastric outlet obstruction, why is an NG tube useful?

1 - can take samples to help diagnose
2 - aspirate gastric contents and reduce pain
3 - useful if patient needs feeding
4 - helpful in taking biopsies

A

2 - aspirate gastric contents and reduce pain

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21
Q

In a patient with confirmed gastric outlet obstruction, which of the following is NOT part of initial treatment?

1 - NBM
2 - IV fluids (due to dehydration)
3 - fluid output monitoring
4 - NSAIDs
5 - high dose PPI
6 - endoscopic balloon dilation
7 - Helicobacteria pylori

A

4 - NSAIDs

  • can have a detrimental effect
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22
Q

If a conservative approach to treating gastric outlet obstruction fails, what are the 2 main surgical alternatives?

1 - resection
2 - gastric stoma
3 - bypass surgery
4 - percutaneous removal of blockage

A

1 - resection
3 - bypass surgery

  • stenting may also be an option
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23
Q

What is the incidence of small bowel obstruction?

1 - 1-2/100,000
2 - 10-20/100,000
3 - 100-200/100,000
4 - 1000-2000/100,000

A

2 - 10-20/100,000

  • more common in patients who have previously had surgery, likely due to adhesions
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24
Q

In a patient with confirmed Crohns disease, do they have an increased or decreased risk of small bowel obstruction?

A
  • increased
  • 250 / 100,000 compared to 10-20 / 100,000 in non-Crohns patients
  • patients are likely to have multiple strictures
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25
Q

What is the most common cause of small bowel obstruction, accounting for 80-90% of cases?

1 - adhesions
2 - hernias
3 - paralytic ileus
4 - gallstones ileus
5 - tumours
6 - small bowel strictures (seen in Crohns disease)

A

1 - adhesions

  • hernia is next most common, accounting for 10-15% of cases
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26
Q

When investigating a patient who is vomiting, why is it important to ask about the contents and colour of the vomit?

1 - infers severity of obstruction
2 - helps identify where obstruction is
3 - helps identify if malignancy is likely
4 - infers if adhesions is cause

A

2 - helps identify where obstruction is

  • green bile = duodenum
  • undigested food = stomach
  • stool like = colon
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27
Q

In a patient with suspected small bowel obstruction, where is the pain likely to be located?

1 - left or right lumbar region
2 - epigastric
3 - umbilical region
4 - colicky across central abdomen

A

4 - colicky across central abdomen

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28
Q

There are large volumes of secretions into the GIT each day. What volume is secreted on average?

1 - 100ml
2 - 1L
3 - 5L
4 - 10L

A

4 - 10L

  • this is why patients can continue to vomit even if they are NBM
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29
Q

When palpating a patients abdomen would we expect the abdomen to be tender in a patient with suspected obstruction?

A
  • no
  • if tender then suggests strangulation and/or perforation
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30
Q

When percussing a patients abdomen would we expect the abdomen to be resonant in a patient with suspected obstruction?

A
  • yes, but only central as gas moves to most non-dependent point
31
Q

When auscultating a patients abdomen would we expect to hear normal bowel sounds in a patient with suspected obstruction?

A
  • no
  • sounds would be louder and potentially tinkly in nature
32
Q

Although not specific, what imaging modality is useful for identifying if the bowel is distended due to an obstruction?

1 - ultrasound
2 - supine chest X-ray
3 - MRI
4 - PET scan

A

2 - supine chest X-ray

  • distension will be proximal to obstruction
33
Q

When we see distended bowels from an imaging modality, what do the small intestines contain that helps us identify the distended bowels are small intestines?

1 - haustra
2 - tenia coli
3 - valvulae conniventes
4 - tenia libera

A

3 - valvulae conniventes

  • they cover the whole diameter of the small bowels
34
Q

When we see distended bowels from an imaging modality, what do the small intestines contain that helps us identify the distended bowels are large intestines?

1 - haustra
2 - tenia coli
3 - valvulae conniventes
4 - tenia libera

A

1 - haustra

  • only cover partially the diameter of the colon
35
Q

Although supine X-ray is useful when trying to identify an obstruction in a patients GIT, what is the gold standard for identifying the obstruction and the potential cause?

1 - ultrasound
2 - CT scan
3 - MRI scan
4 - PET scan

A

2 - CT scan

  • can also rule out other mechanical causes
36
Q

A contrast enema using water soluble gastrogrfin is sensitive to identify the obstruction site. However, what the main limitation of this approach?

1 - exposed to iodine and radiation
2 - expensive and specialist training needed
3 - only covers the rectum, sigmoid and colon
4 - lots of contraindications, limiting their use

A

3 - only covers the rectum, sigmoid and colon

  • BUT some evidence to show this can resolve some bowel obstructions
37
Q

In patients with Crohns and strictures, which 2 imaging modalities are useful for identifying the level of strictures, the absence of inflammatory disease and other causes?

1 - CT and ultrasound
2 - plain and contrast CT
3 - CT and PET scan
4 - CT and MRI

A

4 - CT and MRI

38
Q

Is surgery always required in small bowel obstructions?

A
  • no
  • 90% of adhesion causes obstructions relieve themselves
  • hernia, malignancy, IBD, structures all need surgery, which could include dissection
39
Q

If a patient has a small bowel obstruction that is suspected to be due to adhesions, we use a conservative approach as 90% of cases relieve themselves in around 4 days. Which of the following is NOT a part of conservative management?

1 - NBM
2 - IV fluids
3 - NG feeding
4 - fluid balance monitoring
5 - NG aspiration

A

3 - NG feeding

40
Q

What is the normal urine output, which is important when assessing a patients fluid levels?

1 - 0.1ml/kg/hour
2 - 0.3ml/kg/hour
3 - 0.5ml/kg/hour
4 - 0.7ml/kg/hour

A

3 - 0.5ml/kg/hour

41
Q

Following surgery, how long can an ileus generally last?

1 - 1-2 days
2 - 1-4 days
3 - 1-8 days
4 - 1-14 days

A

4 - 1-14 days

  • can also occur in critically ill patients such as renal failure, peritonitis, abdominal trauma
42
Q

Although the exact cause is unknown, what is the most likely cause of an ileus?

1 - adrenergic stimulation
2 - cholinergic stimulation
3 - atrophy of muscularis externa
4 - adrenergic inhibition

A

1 - adrenergic stimulation

  • this is activated during fight of flight, which normally reduces bowel movements
43
Q

What is the gold standard for diagnosing an ileus?

1 - ultrasound
2 - CT scan
3 - PET scan
4 - MRI

A

2 - CT scan

44
Q

If a patient has a suspected ileus we use a conservative approach. Which of the following is NOT a part of conservative management?

1 - NBM
2 - IV fluids
3 - NG feeding
4 - fluid balance monitoring
5 - NG aspiration

A

3 - NG feeding

45
Q

What is a gallstone ileus?

1 - bile becomes thick and blocks small bowel
2 - gall stone forms, gallbladder adheres to small bowel, erodes the wall and becomes lodged in small bowel
3 - gall stone forms and blocks ampulla of vator
4 - gall bladder becomes blocked and intestines become blocked with undigested food

A

2 - gall stone forms, gallbladder adheres to small bowel, erodes the wall and becomes lodged in small bowel

  • stone is normally >2cm
  • causes cholecystitis (cholecyst = gall bladder and itis = inflammation)
46
Q

Is a gall bladder ileus more common in men or women?

A
  • women
  • 70% occur in women
  • more common in elderly
47
Q

A patient with gall bladder ileus is likely to experience what type of pain?

1 - right hypochondriac
2 - epigastric
3 - left hypogastric
4 - depends where gall stone is

A

1 - right hypochondriac

  • typical cholecystitis symptoms in 30-80% of patients
48
Q

Riglers triad is used to identify if a patient has gallstone ileus. Which of the following is not part of this triad seen on imaging?

1 - pneumobilia
2 - small bowel obstruction
3 - fistula
4 - ectopic calcified gallstone (C)

A

3 - fistula (normally very difficult to see on imaging

Pneumobilia (A)
Small bowel obstruction (B)
Ectopic calcified gallstone (C)

49
Q

How is a gallstone ileus generally treated?

1 - conservatively
2 - surgically to remove stone
3 - endoscopically
4 - colonoscopy

A

2 - surgically to remove stone

  • gall bladder not normally removed
  • laparotomy or laparoscopy
50
Q

What is Ogilvie’s syndrome?

1 - mechanical blockage of large bowel
2 - mechanical blockage of small bowel
3 - functional obstruction of small bowel
4 - pseudo obstruction of large bowel with no known mechanical obstruction

A

4 - pseudo obstruction of large bowel with no known mechanical obstruction

51
Q

Ogilvie’s syndrome is a pseudo obstruction of large bowel with no known mechanical obstruction. Which of the following is NOT generally considered a risk factor for Ogilvie’s syndrome?

1 - critical illness
2 - recent major surgery
3 - obesity
4 - post-partum
5 - medications (clozapine)

A

3 - obesity

52
Q

In a patient with Ogilvie’s syndrome, which is pseudo obstruction of large bowel with no known mechanical obstruction can be treated conservatively (NBM, IV fluids with monitoring). If this fails we can use neostigmine, which acts how?

1 - ACh antagonist
2 - ACh agonsit
3 - cholinesterase inhibitor
4 - cholinesterase agonist

A

3 - cholinesterase inhibitor

  • means more ACh, so idea is to increase peristalsis contractions
53
Q

Neostigmine can be used in patients with Ogilvie’s syndrome, which is pseudo obstruction of large bowel with no known mechanical obstruction. What is the main thing that needs to be monitored if a patient is given this?

1 - Na+ levels
2 - cardiac monitoring
3 - respiratory function
4 - fluid levels

A

2 - cardiac monitoring

  • if conservative and neostigmine fail then surgery is required
54
Q

What % of GIT obstruction are due to large bowel obstruction?

1 - 0.25%
2 - 2.5%
3 - 25%
4 - 50%

A

3 - 25%

0.2 - 0.6 cases /100,00/year

55
Q

Where does 75% of large colon obstruction most likely to occur?

1 - caecum to hepatic flexure
2 - hepatic flexure to splenic flexure
3 - distal to splenic flexure
4 - rectum

A

3 - distal to splenic flexure

56
Q

75% of large colon obstruction most likely to occur distal to the splenic flexure, why?

1 - large calibre bowels means peristalsis isn’t as strong
2 - small calibre bowels, and cancer and diverticular disease is more common here
3 - rigid walls so more likely for things to get stucj

A

2 - small calibre bowels, and cancer and diverticular disease is more common here

57
Q

75% of large colon obstruction most likely to occur distal to the splenic flexure because the of the small calibre bowels compared to the proximal colon. Although everything below can cause an obstruction, what is the most common cause?

1 - colon cancer
2 - diverticular disease
3 - volvulus
4 - intussusception (bowel folds onto itself
5 - acute colonic pseudo obstruction (Ogilvie’s syndrome)

A

1 - colon cancer

  • diverticular disease accounts for 20%
58
Q

Why do symptoms generally present more slowing in a patient with a large colon obstruction compared to a small bowel obstruction?

1 - larger capacity
2 - haustra do not encircle whole wall so can distend more
3 - longer that small intestines

A

1 - larger capacity

59
Q

What does it mean for the ileocaecal valve to be competent?

1 - valve allows one way movement of GIT contents
2 - valve allows 2 way movement of GIT contents
3 - valve allows no movement of GIT contents

A

1 - valve allows one way movement of GIT contents

  • in normal physiology the ileocaecal valve only allows GIT contents to move from SI to LI
60
Q

A competent ileocaecal valve allows one way movement of GIT contents to move from SI to LI, whereas an incompetent ileocaecal valve allows fluid to move back into the SI. This is called a closed loop obstruction. Is it better to have a competent or incompetent ileocaecal valve better?

A
  • incompetent
  • if colon is blocked fluid can move back into SI, can be aspirated or cause vomiting
  • if valve is competent then colon will dilate and be at risk of perforation
61
Q

In a large bowel obstruction, which part of the colon is most likely to perforate and rupture?

1 - caecum
2 - appendix
3 - transverse colon
4 - sigmoid

A

1 - caecum

  • wide diameter with thin walls increase risk
  • this is called Laplaces law
62
Q

What % of ileocaecal valves become incompetent in patients with a large bowel obstructions?

1 - 1%
2 - 5%
3 - 25%
4 - 50%

A

4 - 50%

63
Q

Why can sepsis be caused by a large bowel obstruction?

1 - stool becomes stagnant and contaminated
2 - stool leaks into circualtion
3 - colovesical fistula forms
4 - no fluid absorbed due to block colon causing hypovolaemia

A

1 - stool becomes stagnant and contaminated

64
Q

If a patient has a complete large bowel obstruction causing constipation, does this always present immediately?

A
  • no
  • if obstruction is distal, bowels have a large capacity and can fill
65
Q

If a patient has a suspected large bowel obstruction and right iliac fossa pain, what must we be aware of?

1 - appendicitis
2 - peritonitis
3 - caecal perforation
4 - UTI

A

3 - caecal perforation
- vomitting may not be present if ileocaecal valve is patient

66
Q

If a patient has a suspected large bowel obstruction, what must we ask in the history taking?

1 - family history
2 - medications
3 - previous medical history of bowel problems
4 - alcohol and smoking intake

A

3 - previous medical history of bowel problems

  • known bowel cancer
  • previous volvulus
  • diverticular disease
  • IBD causing a stricture
67
Q

If a patient has a suspected large bowel obstruction, what is often the first imaging modality to confirm the presence of an obstructed bowel?

1 - ultrasound
2 - X-ray
3 - CT scan
4 - MRI

A

2 - X-ray

68
Q

f a patient has a suspected large bowel obstruction, what is often the gold standard imaging modality to confirm the site and cause of an obstructed bowel?

1 - ultrasound
2 - X-ray
3 - CT scan
4 - MRI

A

3 - CT scan

69
Q

If a patient has a large bowel obstruction that is closed loop, what treatment is required?

1 - surgery
2 - fluids and antibiotics
3 - analgesia
4 - NG aspiration

A

1 - surgery

  • this is a medical emergency requiring decompression
70
Q

If a patient has a large bowel obstruction that is due to cancer, what is the most important questions surgeons need to ask themselves?

A
  • will surgery be curative
  • staging and planning are important
71
Q

If a frail or advanced cancer patient has an obstruction that is not curative, will they receive surgery?

A
  • depends on the patient
  • may be palliative surgery including stents or stomas
72
Q

is it easy to distinguish the difference between a stricture caused by diverticular disease and cancer?

A
  • no
  • cannot see difference on imaging
73
Q

If a patient presents with a large bowel obstruction due to diverticular disease that presents as an acute obstruction then surgery is most often needed. Which of the following is not commonly performed for long term management?

1 - stoma
2 - resection
3 - anastomosis
4 - stents
5 - stents

A

5 - stents
- not long term option for diverticular disease

A. MLA Map Paediatrics (75 decks)

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