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GI (Semester 4) > Intestinal obstruction and perforation > Flashcards

Intestinal obstruction and perforation Flashcards

1
Q

How can intestinal obstruction be broadly classified?

Compare these

A

Mechanical: physical obstruction (increased peristalsis)

Non-mechanical: reduced or absent peristaltic

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2
Q

List 4 causes of mechanical intestinal obstruction

A
  1. Adhesions (small bowel)
  2. Hernias (small bowel)
  3. Malignancy (large bowel)
  4. Volvulus (large bowel)]

+ diverticular disease, strictures (2o Crohn’s), Intussusception

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3
Q

List 3 causes of Non-mechanical intestinal obstruction

A
  1. Paralytic ileus
  2. Colonic Pseudo-obstruction (Ogilvie’s syndrome)
  3. Neuromuscular
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4
Q

Pathophysiology of obstruction?

A
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5
Q

How does intestinal obstruction present?

A
  1. Green bilious vomiting
  2. Diffuse abdominal pain and distention
  3. Absolute constipation and lack of flatulence
  4. Abnormal bowel sounds
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6
Q

What is bilious vomiting?

A

Containing bright green bile

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7
Q

Describe the bowel sounds heard in mechanical obstruction

A

Can be high pitched and “tinkling” early in the obstruction and absent later

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8
Q

Initial imaging for suspected bowel obstruction

What will this show?

A

Abdominal X-ray showing distended loops of bowel

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9
Q

What are the normal diameters of the small bowel, colon and caecum?

A
  • 3 cm small bowel
  • 6 cm colon
  • 9 cm caecum
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10
Q

How do we differentiate between a small vs large bowel obstruction on X-ray

A

Small bowel obstruction:

  • Dilated bowel (>3cm)
  • Central abdominal location
  • Valvulae conniventes (lines completely cross width of the bowel)

Large bowel obstruction:

  • Dilated bowel (> 6cm, or > 9 cm at caecum)
  • Peripheral location
  • Haustral lines (lines do not completely cross bowel width)
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11
Q

Gold standard imaging to confirm bowel obstruction?

A

A contrast abdominal CT scan

To confirm diagnosis and establish the site and cause

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12
Q

Initial management of intestinal obstruction?

A

ABCDE approach and “drip and suck”

  1. Nil by mouth
  2. IV fluids
  3. NG tube with free drainage
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13
Q

What blood findings must we look out for in bowel obstruction?

What do these indicate

A
  1. Electrolyte imbalances (U&Es)
  2. Metabolic alkalosis due to vomiting stomach acid (VBG)
  3. Bowel ischaemia (↑lactate)
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14
Q

What is the definitive management of bowel obstructions?

A

Surgery (either laparoscopy or laparotomy) to correct the underlying cause

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15
Q

List 4 complications of bowel obstruction?

A
  1. Hypovolaemic shock
  2. Bowel ischaemia
  3. Bowel perforation
  4. Sepsis
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16
Q

How does bowel obstruction lead to shock?

A

Due to fluid stuck in the bowel rather than the intravascular space (third-spacing)

Leads to Hypovolaemic shock

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17
Q

List 4 causes of Closed-Loop Obstruction

A
  1. Adhesions that compress two areas of bowel
  2. Hernias
  3. Volvulus
  4. Single point of obstruction in the large bowel, with a competent ileocaecal valve
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18
Q

What is meant by a Closed-Loop Obstruction?

A

Where there are two points of obstruction along the bowel; meaning the middle section is sandwiched between

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19
Q

What is the risk of an untreated close-loop obstruction?

A

Will inevitably expand, leading to ischaemia and perforation

Requires emergency surgery

20
Q

What are Bowel adhesions?

A

Scar tissue that bind the abdo contents together → causes kinking/squeezing of the bowel, leading to obstruction

21
Q

Are adhesions more common in the small or large bowel?

A

small

22
Q

List 4 causes of bowel adhesions

A
  1. Abdominal or pelvic surgery
  2. Peritonitis
  3. Abdominal or pelvic infections (eg. PID)
  4. Endometriosis
23
Q

What is a volvulus?

A

Torsion of the colon around it’s mesenteric axis resulting in compromised blood flow and closed loop obstruction

Affected bowel can become ischaemic rapidly leading to bowel necrosis and perforation

24
Q

List 4 risk factors for a volvulus

A
  1. Parkinson’s
  2. Elderly
  3. Chronic constipation
  4. High fibre diet
  5. Pregnancy
  6. Adhesions
25
Q

List 2 locations where a volvulus tend to occur

Highlight the most common

A
  1. Sigmoid colon
  2. Caecum
26
Q

Initial investigation for a suspected volvulus?

Classic finding?

A

Coffee bean sign - indicative of sigmoid volvulus

27
Q

Investigation of choice to confirm diagnosis of sigmoid volvulus?

A

Contrast CT

28
Q

Initial management of a sigmoid volvulus?

A

‘Nil by mouth’ and ‘Drip and suck’

29
Q

Conservative management of a sigmoid volvulus?

A

endoscopic decompression (only if there is NO peritonitis)

30
Q

Surgical management of a volvulus?

A
  1. Laparotomy
  2. Hartmann’s procedure (sigmoid volvulus)
  3. Ileocaecal resection or right hemicolectomy (caecal volvulus)
31
Q

What is paralytic ileus?

A

Condition affecting the small bowel, where normal peristalsis temporarily stops

32
Q

List 4 common causes of Ileus

A
  1. Injury to the bowel
  2. Handling of the bowel during surgery
  3. Inflammation or infection
  4. Electrolyte imbalance (e.g., hypokalaemia or hyponatraemia)
33
Q

How may the presentation of Ileus (non-mechanical) differ from mechanical obstruction?

A

Presentation is the SAME except there are absent bowel sounds (as opposed to the “tinkling” bowel sounds)

34
Q

Management of Ileus

A
  1. Nil by mouth
  2. NG tube if vomiting
  3. IV fluids
  4. Mobilisation - helps stimulate peristalsis
  5. Total parenteral nutrition
35
Q

Compare structures involved in an upper vs lower GI perforation

A

UGI perforations

UGI: eosophagus - small bowel (jejunum, ileum)

LGI: caecum - rectum)

36
Q

How does GI perforation typically present?

A
  1. Sharp, rapid onset abdominal pain
  2. Systemically unwell
  3. Pain worse with breathing and moving
  4. Malaise, vomiting, and lethargy
37
Q

What is the importance of diagnosis in GI perforation

A

Delay in resuscitation and management → septic shock, multi organ dysfunction, and death

Immediate ddx in anyone presenting with acute abdominal pain

38
Q

List 4 causes of Upper GI perforation

A
  1. PUD
  2. Small bowel tumours
  3. Endoscopy
  4. Foreign body
39
Q

How does a perforation in the thoracic region present?

A
  1. Pain in chest, neck or radiating to the back
  2. Worse on inspiration
  3. Vomiting
  4. Respiratory symptoms.
40
Q

List 4 causes of Lower GI perforation

A
  1. Crohn’s disease
  2. Colon cancer
  3. Colonoscopy
  4. Diverticular disease
41
Q

What classification system is used to assess severity of acute diverticulitis?

A

Hinchey

  • I para-colonic abscess
  • II pelvic abscess
  • III purulent peritonitis
  • IV faecal peritonitis
42
Q

What may be seen on chest X-ray of bowel perforation?

A

Air under the diaphragm in pneumoperitoneum

43
Q

What 2 signs may be seen on an abdominal X-ray of bowel perforation?

A
  1. Rigler’s sign (both sides of bowel visible *image) or
  2. Psoas sign (loss of sharp delineation of the psoas muscle border)
44
Q

Gold standard imaging to confirm bowel perforation?

A

A contrast abdominal CT scan

To confirm diagnosis and establish the site and cause

45
Q

Management of GI perforation?

A
  1. ABCDE
  2. Broad spectrum antibiotics
  3. Nil by mouth, NG tube, IV fluid resuscitation
  4. Analgesia
  5. Surgery

GI (Semester 4) (19 decks)

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