Lower GI Surgery

Question 1

Bowel obstruction - What is complete obstruction?

Answer 1

Bowel lumen is completely
obstructed
* No distal passage of stool or air
* Can be only partial, meaning
the bowel lumen is narrowed
and there is some distal
passage of bowel contents

Question 2

What is Open Loop Obstruction?

Answer 2

when proximal decompression
is possible via emesis or
nasogastric tube (NGT)

Question 3

What is Closed - Loop Obstruction?

Answer 3

when both proximal and distal
bowels are obstructed; common
causes include bowel
incarceration in a hernia sac or
intestinal torsion

Question 4

Eg of closed loop obstruction?

Answer 4

Valvulus

Example is a sigmoid
carcinoma with a competent
ileocecal valve
* Both proximal & distal ends are
‘obstructed’ forming a ‘closed
loop’
* Runs the risk of perforation
usually at the caecum where
the bowel is thinnest and
widest; (more than12cm
requires urgent
decompression)

Question 5

What is a Strangulated Obstruction?

Answer 5

involves compromise of
blood flow with inevitable bowel
necrosis (pain is more severe)

• May present with signs & symptoms
  of peritonitis (board-like rigidity on
  abdominal palpation, fever,
  leucocytosis, etc…

Question 6

What is simple obstruction ?

Answer 6

no compromise
of blood flow to the bowel

Question 7

What are the causes of Small bowel obstruction?

Answer 7

• Postoperative adhesions
  -Strangulated inguinal hernia
• Small bowel volvulus
  -Small bowel neoplasms
• Miscellaneous

Question 8

What are the causes of Large Bowel Obstruction ?

Answer 8

Carcinoma of colon
* Volvulus (sigmoid)
* Diverticular disease

Others:

Crohn’s stricture, gallstone
ileus, intussusception,
foreign body

Question 9

What is the Clinical Presentation of

Answer 9

• Generalized abdominal pain
• Vomiting and abdominal distention (may
  depend on the level of obstruction)
• Inability to pass out gas or flatus
  (complete obstruction)
• Physical examination shows abdominal
  distention and ‘metallic’ tinkling sounds
  on auscultation
• When bowels become on-viable
  hypoactive bowel sounds

Always check the inguinal area which might be causing the obstruction

Question 10

What is the clinical presentation of proximal small bowel obstruction?

Answer 10

frequent, profuse vomiting, central abdominal pain, there may be minimal
distension

Question 11

What is the clinical presentation of Distal small bowel obstruction ?

Answer 11

Colicky abdominal pain, moderate vomiting (vomitus may be feculent),
moderate distension

Question 12

What is the clinical presentation of Large bowel obstruction?

Answer 12

abdominal distension, pain is more constant, minimal vomiting

Question 13

What is the diagnosis of bowel obstruction ?

Answer 13

Abdo x-ray
- Useful for identifying dilated loops of bowel
- Often includes supine and upright plain radiographs of the abdomen and an
upright chest radiograph

CT scan
-For non-specific and uncertain cases in which clinical and radiographic
findings are inconclusive

Question 14

What is the diagnosis for Small Bowel Obstruction ?

Answer 14

> 3cms; recognized by
the visible valvulae
conniventes
(arrowheads passing
across the width of the
lumen)
* The central position of
the loops is another
clue
* Presence of air fluid
levels (on upright x
ray

Question 15

What is the diagnosis of Large Bowel Obstruction ?

Answer 15

The colon can be identified by
its peripheral location
* If obstructed:
* >6cms in diameter with the
presence of haustral folds
that are widely spaced
* The caecal diameter is > 9
cms

Question 16

What is the management of Bowel obstruction ?

Answer 16

pt will be dehydrated - Resuscitation

Initial Assessment and Stabilization
* Resuscitation- should be stabilized with intravenous (IV) fluids to correct
dehydration and electrolyte imbalances.
* Nasogastric decompression: NGT may be required to decompress the bowel,
particularly in cases of vomiting or severe distension.
* Pain management: may start with intravenous analgesia.
* Blood exams: check for electrolyte imbalances, elevated WBCs which could indicate
infection or sepsis.
* Imaging: Initial diagnosis and confirmation of large bowel obstruction is typically
done with imaging (e.g., CT scan of the abdomen and pelvis)

Question 17

What is the Initial Non operative management of Bowel Obstruction ?

Answer 17

Can decompress bowels initially
* Decompress (insert NGT & monitor for character and amount of output)
* Nil by mouth
* Resuscitate with IVF (insert catheter; monitor I&O)
* Antibiotics
* Monitor for improvement or deterioration & treat accordingly

If the pain is much less on examination when you press on the abdo and if they have distended or detoriating

Question 18

What is the management of a Large bowel obstruction ?

Answer 18

Complete obstruction:
* Resection of the affected bowel segment (e.g., for cancer or ischemic bowel).
* Stoma creation: In cases of malignancy or where primary anastomosis is not feasible, a
stoma (e.g., colostomy) might be necessary.

• In cases of volvulus, an emergency endoscopic detorsion (e.g., for sigmoid
  volvulus) or surgery (if detorsion is not possible) is required.
• Resection of the tumour may be indicated if colorectal cancer is the cause,
  often combined with temporary or permanent stoma formation

Question 19

What is the surgery for Bowel Obstruction ?

Answer 19

Surgery in cases of Strangulation ( signs of vascular compromise)
Closed Loop obstruction
Generalized Peritonitis
Failure to improve despite conservative management