Lower G.I. 1

Question 0

45-year-old woman with three day history of nausea and crampy abdominal pain followed by vomiting and abdominal distention. Last bowel movement over three days ago. Crescendo-decrescendo bowel sounds. No stool in rectum. WBC count of 14,000 – suspected diagnosis? Test? (Expected Interpretation?)

Answer 0

Small bowel obstruction

Abdominal radiograph (upright and lateral) – multiple air fluid levels in small bowel but no air in colon or rectum

Question 1

Food/electrolyte status in small bowel obstruction? Mechanism? Treatment?

Answer 1

Dehydration (from vomiting and poor oral intake)

contraction alkalosis with hypokalemia (Alkalosis from increased hydrogen secretion stomach, and hypokalemia from retention of H at the expense of K I. Kidney)

IV fluids

Question 2

45-year-old woman with three day history of nausea and crampy abdominal pain followed by vomiting and abdominal distention. Last bowel movement over three days ago. Crescendo-decrescendo bowel sounds. No stool in rectum. Management?

Answer 2

Small bowel obstruction

1. NG tube drainage
2. IV fluids
3. Observe for signs of ischemia or perforation (leukocytosis, fever, acidosis, localized tenderness)

Question 3

45-year-old woman with three day history of nausea and crampy abdominal pain followed by vomiting and abdominal distention. Last bowel movement over three days ago. Crescendo-decrescendo bowel sounds. No stool in rectum. Treatment is begun. Patient improvements over the next several days, pain resolves, and appetite returns. Current management?

Answer 3

1. Remove NG tube

2. Begin feeding and if Patient tolerates food, discharge

Question 4

45-year-old woman a one day history of nausea and crampy abdominal pain followed by vomiting and abdominal distention. Last bowel movement over three days ago. Crescendo-decrescendo bowel sounds. No stool in rectum. Suspected diagnosis?

Answer 4

If one day duration of symptoms, suspect more proximal obstruction (no change in management)

Question 5

45-year-old woman with three day history of nausea and crampy abdominal pain followed by vomiting and abdominal distention. Last bowel movement over three days ago. Crescendo-decrescendo bowel sounds. No stool in rectum. History of prior appendicitis. Presumptive diagnosis?

Answer 5

Small bowel obstruction due to Adhesions secondary to prior appendectomy

Question 6

45-year-old woman with three day history of nausea and crampy abdominal pain followed by vomiting and abdominal distention. Last bowel movement over three days ago. Crescendo-decrescendo bowel sounds. Diagnoses higher on differential if Heme positive stool in rectum?

Answer 6

Obstructing tumor or ischemic bowel

Question 7

45-year-old woman with three day history of nausea and crampy abdominal pain followed by vomiting and abdominal distention. Last bowel movement over three days ago. Crescendo-decrescendo bowel sounds. No stool in rectum. Passing of flatus. Suspected diagnosis? Less likely complications?

Answer 7

Partial small bowel obstruction

Ischemia, perforation

Question 8

45-year-old woman with three day history of nausea and crampy abdominal pain followed by vomiting and abdominal distention. Last bowel movement over three days ago. Crescendo-decrescendo bowel sounds. Small amount of diarrhea. Suspected diagnosis? Differential?

Answer 8

Partial obstruction; fecal impaction, severe constipation

Question 9

45-year-old woman with three day history of nausea and crampy abdominal pain followed by vomiting and abdominal distention. Last bowel movement over three days ago. Crescendo-decrescendo bowel sounds. No stool in rectum. Presence of inguinal hernia – management?

Answer 9

Urgent laparoscopic repair and relief of bowel obstruction

Question 10

Most common tumor that metastasizes to the intestine?

Management of tumor related obstructions?

Answer 10

Melanoma

Do not resolve with nonoperative management – must get surgery

Question 11

45-year-old woman with three day history of nausea and crampy abdominal pain followed by vomiting and abdominal distention. Last bowel movement over three days ago. Crescendo-decrescendo bowel sounds. No stool in rectum. Previously excised ovarian cancer – suspected diagnosis? Management?

Answer 11

Local recurrence of cancer or peritoneal stunning

Debulking if incurable cancer

Question 12

45-year-old woman with three day history of nausea and crampy abdominal pain followed by vomiting and abdominal distention. Last bowel movement over three days ago. Crescendo-decrescendo bowel sounds. No stool in rectum. Signs that warrant surgical intervention? Why?

Answer 12

Peritonitis! Leukocytosis, fever, acidosis, localized tenderness

indicates series complication (closed loop obstruction, perforation, ischemia, abscess)

Question 13

Patient with suspected small bowel obstruction. Sign that can warrant urgent exploration or mesenteric arteriography?

Answer 13

Metabolic acidosis (indicating ischemic or necrotic bowel)

Question 14

30 year old woman with small bowel obstruction and no evidence of complications. Test history of appendicitis. Past history of appendicitis. Place NG tube, and correct fluid/electrolyte abnormalities. Partial improvement with some flatus and one small bowel movement. Upon removing NG tube, becomes nauseated and distended. Next step? Most likely finding? Management?

Answer 14

Exploratory laparotomy

Adhesive band scar tissue from the appendicitis

Lysis of adhesions

Question 15

46-year-old woman who presents with signs and symptoms of small bowel obstruction. Radiograph shows closed loop obstruction – physiology? Locations? management?

Answer 15

Adhesive band occludes inlet and outlet of loop of bowel – accumulates secretions and air. Can become ischemic or can perforate.

Exploration.

1. Determine whether bowel is viable (if not, resect and re-anastomose)
2. If unsure, second look operation 24 hours later

Question 16

46-year-old woman who presents with signs and symptoms of small bowel obstruction. Has crampy abdominal pain and free air in peritoneal cavity. Suspected diagnosis?

Answer 16

Surgical exploration Due to likely perforation

Question 17

46-year-old woman who presents with signs and symptoms of small bowel obstruction. Evidence of herniation. Management options?

Answer 17

Urgent exploration after resuscitation

1. If stable patient, exploration through hernial incision is growing
2. If ill, midline abdominal incision

Question 18

60-year-old man with small bowel extraction and dense adhesions. During lysis, enter bowel lumen. Management? Post operative problems?

Answer 18

It’s small, primary repair. If big, may require resection

Postoperative leak or small bowel fistula

Question 19

49-year-old man recovering from pneumonia. Abdominal distention, nausea, crampy abdominal pain develops – differential? How to confirm diagnosis?

Answer 19

1. Small bowel obstruction
2. Air swallowing
3. Constipation
4. Paralytic ileus

Upper G.I. series with barium swallow