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GI > Mr Alay Tutorial 1 - Intestinal Obstruction > Flashcards

Mr Alay Tutorial 1 - Intestinal Obstruction Flashcards

1
Q

Define intestinal obstruction

A

Failure of downward passage of intestinal contents

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2
Q

What are the two subtypes of intestinal obstruction?

A

Dynamic

Adynamic

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3
Q

Define dynamic intestinal obstruction

A

Increasing peristalsis working against an obstructive agent

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4
Q

Define adynamic intestinal obstruction

A

Peristalsis is absent/ineffective and there are no effective propulsive waves
(no mechanical blockage)

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5
Q

Define simple intestinal obstruction

A

Obstruction of the intestinal lumen without interference with its blood supply

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6
Q

What is the commonest cause of simple intestinal obstruction?

A

Adhesions (usually due to prev. abdominal surgery)

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7
Q

What are causes of simple IO?

A

Lumen: gallstones, impacted faeces
Wall: strictures (neoplastic/inflammatory)
Outside wall: adhesions/tumours

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8
Q

What are causes of adhesions in the abdomen?

A

Usually due to surgery

Other: infections after surgery, infection due to primary pathology

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9
Q

What kind of obstructions do adhesions generally causes?

A

Small IO

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10
Q

How can you differentiate the most common cause of SBO based on the patients history?

A

Hx SBO + Hx abdominal surgery –> adhesions

Hx SBO = no Hx abdominal surgery –> tumour

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11
Q

What does simple OI look like above and below the obstruction?

A

Above obstruction - bowel dilates, inc. peristalsis to overcome blockage, food builds up, distension as fluid + gas builds up

Below obstruction: collapsed bowel (immobile + pale)

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12
Q

In IO what is the site between the collapse bowel and the dilated bowel known as?

A

Transition point - this is where the aetiology will be found

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13
Q

What can occur at the site of the obstruction in simple IO?

A

Perforation

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14
Q

What is the pathophysiology of simple IO?

A

Third space loss
Dehydration
Proliferation of bacterial proximal to obstruction
Impairment of barrier function of intestinal mucosa

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15
Q

What is third space loss in simple IO?

A

Normally fluid is in intravascular/extravascular spaces
But in IO above the obstruction there is a compartment where fluid is secreted by the GIT and cannot be reabsorbed due to the pathology

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16
Q

What is the clinical consequence of simple IO?

A

Dehydration

Patients require more fluid than you may think

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17
Q

Define third space loss

A

Fluid sequestration inside the body (cavity) that cannot be used by the systemic circulation

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18
Q

Explain why IO can lead to peritonitis

A

Bacteria above obstruction can proliferate and translocate (migrate) over the bowel wall into the peritoneum

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19
Q

Why does bacteria not usually translocate in healthy individuals?

A

Active protective mucosal barrier of GIT which is disrupted in IO

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20
Q

How long after the intestine becomes disrupted does translocation tend to occur?

A

Within 48h

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21
Q

If bacteria translocates in IO what can occur?

A

Peritonitis

Sepsis

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22
Q

What are causes of death in simple IO?

A

Fluid and electrolyte imbalance

Peritonitis

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23
Q

Define strangulation

A

Intestinal obstruction with persistent interference with the blood supply

(once BS starts to decrease, do not wait until it is completely diminished)

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24
Q

How long do you have to save the bowel before it dies in strangulation?

A

6h

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25
Q

Delay in the management of strangulation can lead to what?

A

Major resection of the bowel

Death

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26
Q

What should you do if in A and E you suspect someone to have strangulation?

A

Call surgical team - Ex, CT scan, theatre rapidly

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27
Q

What can cause strangulation?

A 
Strangulated hernia
Intussusception
Adhesive intestinal obstruction (late) 
Volvulus 
Vascular occlusions
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28
Q

What is the pathophysiology of strangulation?

A

Blockage of bowel also puts pressure on artery + vein supplying bowel
Vein low pressure and hence is blocked first –> venous return impaired so bowel appears dark and congested (as blood flows in but not out)
High venous pressure –> blood stained fluid (serosanguinous) filtration around bowel
Arterial supply impaired (bowel turns black)

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29
Q

What is serosanguinous fluid?

A

Blood stained fluid

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30
Q

What is serosanguinous fluid indicative of if found in the abdomen?

A

Ischaemic/necrotic bowel

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31
Q

How does the third space loss in strangulation differ from simple IO?

A

Blood + fluid are lost
Blood is trapped due to venous congestion
This is blood lost from the systemic circulation and hence in strangulation more likely to present as unwell + shocked

Dehydration is big issue!

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32
Q

Why is translocation of bacteria much faster in strangulation as compared to simple IO?

A

Ischaemic bowel is easier for the bacteria to translocate over

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33
Q

What are causes of death in strangulation?

A

Peritonitis due to perforation
Hypovolaemic shock
Sepsis

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34
Q

At how many points is the bowel usually obstructed?

A

1

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35
Q

If the bowel is obstructed at 2 points what is this known as?

A

Closed loop obstruction

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36
Q

Give examples of closed loop obstructions

A

Hernias
Volvulus
Competent ileocaecal valve + sigmoid obstruction

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37
Q

Explain why sigmoid obstructions can lead to a closed loop obstruction

A

In most people the ileocaecal valve is competent + allows things only to move from SB –> LB
And therefore in sigmoid blockage this is a normal physiological blockage that leads to a closed loop obstruction

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38
Q

What % of people have a competent ileocaecal valve?

A

75%

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39
Q

How do sigmoid tumours often present?

A

Closed loop obstruction

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40
Q

In sigmoid tumours where is the most common place for a perforation to occur and why?

A

Caecum

CLO forms and the wall at the caecum is thinnest

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41
Q

When the caecum is ____cm there is eminent risk of perforation of the caecum.

A

10cm

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42
Q

What are the only two kinds of operations done during the night?

A

L + L

Life saving and limb saving

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43
Q

What are the 4 clinical features of IO?

A

Pain
Vomiting
Abdominal distension
Absolute constipation

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44
Q

What can the timing of the symptoms tell you about where the obstruction is in IO?

A

If order of onset of symptoms is pain –> vomiting –> distension –> constipation = small IO

and if opposite = large IO

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45
Q

What kind of pain is experienced in IO?

A

Generalised colicky abdominal pain

Attacks of pain lasting a few min with periods of relief

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46
Q

What happens to the pain as time progresses in IO?

A

Attacks of pain become longer, more painful and less spread out

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47
Q

What causes colicky pain?

A

Obstructed bowel, ureter, gallbladder

Is due to peristalsis

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48
Q

How can you tell where the obstruction is in IO based on the timing of the vomiting?

A

Jejunal - early vomiting, vomiting with each attack

Ileal - delayed for a few hours, vomiting with each attack

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49
Q

What does bile stained vomiting suggest?

A

Jejunal contents are in the vomit

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50
Q

What is faeculent vomit?

A

Dark brown, v. offensive vomit

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51
Q

What does faeculent vomit suggest?

A

Partly digested food from the TERMINAL ileum

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52
Q

If the obstruction in IO is higher up why do you get more vomit as compared to if it is lower down?

A

The higher up the obstruction, the less time there is for fluids (both ingested + secreted) to be absorbed hence there is a higher volume of vomit

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53
Q

What is the most important point about vomiting in IO to remember?

A

The higher the level of obstruction, the more SEVERE and EARLY the vomiting is

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54
Q

Why don’t people normally vomit faeces if they have a large IO?

A

Ileocaecal valve usually is competent

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55
Q

What type of constipation do you get in complete obstruction?

A

Absolute

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56
Q

Define absolute constipation

A

Inability to pass stools and flatus

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57
Q

What kind of constipation would you get in partial obstruction?

A

Continued passage of flatus +/or stools beyond 6-12h after onset of symptoms

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58
Q

What type of constipation is more indicative of IO?

A

Complete

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59
Q

What kind of abdominal distension do you get in jejunal obstruction?

A

Minimal

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60
Q

What kind of abdominal distension do you get in ileal obstruction?

A

Central

Flanks complete collapsed

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61
Q

What kind of abdominal distension do you get in large bowel obstruction?

A

Flanks

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62
Q

What types of IO may lead to generalised abdominal distension?

A

Distended small bwel + colon, e.g. LBO with incompetent ileocaecal valve

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63
Q

Give examples where IO presents without absolute constipation

A

Ritcher’s hernia
Gallstone ileus
Mesenteric vascular occlusion
Intestinal obstruction associated ith a pelvic abscess

64
Q

Define Richter’s hernia

A

Bowel caught in v small hernia so that a section of it is strangulated but not full circumference of bowel is in hernia so there isn’t a complete obstruction

65
Q

What is the issue with Richter’s hernia?

A

Progresses v. quickly to gangrene

As very small hernia, no vomiting, constipation etc. may mistakenly think it is fine to leave it

66
Q

What is NEVER normal for a hernia?

A

For it to be painful/tender

67
Q

What should you do if a patient has a tender/painful hernia?

A

Refer to surgery immediately

68
Q

What is the commonest presentation of a Richter’s hernia?

A

Small femoral hernia in elderly women that is not fully obstructed (i.e. no vomiting, constipation)

69
Q

What will you see on general examination on someone with IO?

A

Dehydration

Tachycardia + shock (may indicate strangulation)

70
Q

Why are patients with IO dehydrated?

A

Third space loss

Vomiting

71
Q

What should you look for on inspection of the abdomen in suspected IO?

A

Scars for prev. surgeries (adhesions)
Visible non-reducible hernia
Visible peristalsis
Step ladder appearance due to distended loops of bowel over each other

72
Q

What must you always check for in patients with suspected IO?

A

Hernias

i.e. check groin for femoral hernias

73
Q

What will tenderness/rigidity on palpable in suspected IO indicate?

A

Strangulation (do not get tenderness/rigidity in simple IO)

74
Q

What will you ascultate in early IO?

A

Loud and frequent intestinal sounds

75
Q

What will you ascultate in late IO?

A

Silent abdomen (ileus/peritonitis)

76
Q

What other examination should you always do in suspected IO?

A

PR

77
Q

What will PR in IO show in most cases?

A

Empty rectum (they have cleared the faeces and it is now empty due to the occlusion)

78
Q

What may PR reveal in IO if the rectum is not empty?

A

Rectal tumour, faecal impaction etc.

79
Q

What signs/symptoms should make you suspect strangulation as opposed to simple IO?

A

Pain - more severe, background pain in between attacks
Shock - present + progressive
Tenderness + rigidity
NG suction for 1-2h fails to relieve the pain (unlike in simple IO)

80
Q

What causes the background pain in strangulation?

A

Ischaemia

81
Q

What are the two types of strangulation?

A

Internal - inside chest/abdominal cavity

External (hernia)

82
Q

What features of a hernia should make you think it has strangulated?

A

Tense, tender, irreducible, no expansible impulse on cough

83
Q

What investigations should be done for suspected IO?

A 
(fiBloods - FBC, UE, LFTs, ?ABG
AXR
CT
Water soluble oral contrast/enema
Erect CXR
84
Q

What useful information can be derived from the FBC in suspected IO?

A

Hb - anaemic (if elderly think colon cancer as colon tumours bleed)
WCC - if high early - could be strangulation, if high after day or 2 could indicate strangulation

85
Q

If an elderly patient presents with SBO and anaemia where is the tumour most likely to be and why?

A 
Right side (caecal tumour) 
Blood mixes with the faeces and hence pt doesn't know they are bleeding and present late and by this point are anaemic

L sided tumour present with rectal bleeding and hence present earlier before anaemia has occured

86
Q

What useful information can be derived from the U+E in suspected IO?

A

Dehydration puts pt at risk of AKI

Check eGFR and also K level (fix hypokalaemia ASAP as pt cannot be anaesthesised if hypokalaemic

87
Q

Why should you do LFTs in a pt with IO?

A

To see what drugs anaesthetist can use

If abnormal LFTs in certain pts may indicate liver mets

88
Q

Why do you do an erect CXR in suspected IO?

A

To check for free air (perforations)

89
Q

How can you differentiate between the large bowel and small bowel on AXR?

A

Small bowel - complete lines over circumference of bowel (valulae conniventes)

Large bowel - incomplete lines (haustrations)

Terminal ileum is featureless tube

90
Q

What is the sensitivity of AXR in picking up IO?

A

60-90%

91
Q

Why is use of AXR in IO limited?

A

Cannot reliably find site/cause of obstruction

Normal AXR does not exclude IO (may have to do CT)

92
Q

Summarise the clinical presentation of a high proximal SBO

A

Early vomiting
Minimal distension
Minimal small bowel loops on AXR

93
Q

Summarise the clinical presentation of a low (distal) SBO

A

Pain + distension
Vomiting late
Dilated small bowel loops on AXR

94
Q

Summarise the clinical presentation of a high LBO

A

Marked distension
Pain + vomiting late
Dilated large bowel loops on AXR

95
Q

What is CT used for in IO?

A

Confirm diagnosis

Identify level of obstruction, find cause, ischaemia, perforations

96
Q

What agent is used in water soluble oral contrast scans?

A

Gastrografin (orally or via NG tube)

97
Q

What is predictive of a non-surgical resolution of adhesive small bowel obstruction?

A

Contrast in caecum within 6h of giving gastrografin (i.e. it can be therapeutic!)

98
Q

What can water soluble enemas be used for?

A

Confirming diagnosis of LBO (rarely)

99
Q

What are the most common causes of IO in newborns?

A

Imperforate anus
Congenital atresia
Stenosis of the gut
Volvulus

100
Q

What are the most common causes of IO in 2-3m olds?

A

Strangulated hernias

101
Q

What are the most common causes of IO in 3-12m olds?

A

Intussusception

102
Q

What are the most common causes of IO in young adults?

A

Strangulated hernia

Post-op adhesions

103
Q

What are the most common causes of IO in older adults?

A

Strangulated hernias
Post-op adhesions
Colon cancer
Colonic volvulus

104
Q

What are the general principles of treatment of IO?

A

NG tube
Reus - IV fluids
Early surgery in some cases

105
Q

What are indications for early surgery in IO?

A 
Obstructed hernia
Suspected strangulation
SBO in virgin abdomen
Failure of conservative Rx in adhesive SBO
Obstructing tumours on CT
106
Q

What does a virgin abdomen mean?

A

Abdomen that has never been operated on

107
Q

Why do you want to do surgery early on a virgin abdomen in IO?

A

Likely to be tumour

108
Q

Why do you want to use an NG tube in all patients with IO?

A

Avoid risk of aspiration

109
Q

What are the two types of intussusception?

A

Adult

Paediatric

110
Q

Define intussusception

A

Invagination of an intestinal segment into adjacent loop

111
Q

What are causes of intussusception in adults?

A

Polyp, submucosa lipoma, polypoidal tumours, inverted Meckle’s diverticulum

(protrusion invites intussusception)

112
Q

What is the difference between adult and paediatric intussusception?

A

Adult - always an underlying cause + hence req. surgery

Children - no cause, avoid surgery

113
Q

What is the treatment of adult intussusception?

A

Laparotomy, resection +/- anastomosis

114
Q

How does intussusception present in paediatrics?

A

Dying spells - recurrent episodes of screaming + drawing legs up
Vomiting
Redcurrant jelly stools
O/e - sausage shaped mass

115
Q

What investigations are usually done for intussusception?

A

USS - target sign

116
Q

How is intussusception managed in paediatrics?

A

Air enema reduction

Surgery if failed reduction/suspected strangulation

117
Q

Define volvulus

A

Axial rotation of the gut

i.e. bowel twisted on itself

118
Q

What are the 4 types of volvulus?

A

Volvulus Neonatorum
Volvulus of Small Intestine in Adults
Volvulus of the Caecum
Sigmoid Volvulus

119
Q

What causes volvulus of small intestine in adults?

A

Post-op adhesions between the intestine and anterior abdominal wall which acts as an axis for the bowel to twist on

120
Q

What occurs in caecal volvulus?

A

Usually caecum covered on front and sides by mesentery

In 10% individuals it is covered on all surfaces and this means the caecum can twist on itself

121
Q

How is caecal volvulus managed?

A

R hemicolectomy +/- ileo-colic anastomosis

122
Q

Why do you not just untwist the bowel in caecal volvulus and leave it?

A

Recurrence is v. high

123
Q

Who is sigmoid volvulus most common in?

A

Elderly females

124
Q

What is the typical presentation of sigmoid volvulus?

A

Sudden L sided abdominal pain

Abdominal distension, absolute constipation

125
Q

What do you see on AXR in sigmoid volvulus?

A

Dilated colon - ‘coffee bean sign’

126
Q

How is sigmoid volvulus managed?

A

Emergency - endoscopic decompression

May do sigmoid resection in fit pts but most of these pts v. frail and will just req. frequent decompressions

127
Q

How are adhesive IO managed?

A 
NG tube
IV fluids
Pain relief 
Gastrografin
Give bowel time for symptoms to calm down itself
128
Q

What is the issue with doing surgery for adhesive IO?

A

More surgery = more adhesions

129
Q

What are indications for surgery in IO?

A

Suspected strangulation

Failure of conservative treatment (48h - risk of bacterial translocation)

130
Q

What is an ABG likely to show in strangulation and why?

A

Severe metabolic acidosis

Bowel undergoing anaerobic respiration and producing large amounts of lactic acid

131
Q

What is the pathophysiology of gallstone ileus?

A

Gallbladder sits on jejunum
LARGE stone causes pressure necrosis through wall of gallbladder and jejunum
Large stone passes into jejunum and causes blockage in SBO

132
Q

What does gallstone ileus ALWAYS result from?

A

Cholecystoduodenal fistula

133
Q

Why can small stones passing through the CBD not cause gallstone ileus?

A

Stone passing through CBD would be too small to cause a SBO

134
Q

What signs will you see on AXR in gallstone ileus?

A

SBO
Air in biliary tree
Stone may be seen

135
Q

Why do you get air in the biliary tree in gallstone ileus?

A

Due to fistula between gallbladder and jejunum

136
Q

How is gallstone ileus managed?

A

Enterotomy + removal of gallstone (enterolithotomy)

137
Q

Should you do a cholecystectomy in gallstone ileus?

A

No - do as minimal as possible in emergency situations

138
Q

What is the aetiology of mesenteric vascular occlusion?

A

Occlusion of the superior (rarely the inferior) mesenteric vessels or one of its branches

139
Q

What are causes of mesenteric vascular occlusion?

A 
Arterial embolism (e.g. in AF, SBE)
Arterial thrombosis (e.g. polycythaemia, artherosclerosis, COCP)
Venous thrombosis (portal HTN)
140
Q

What patients tend to get mesenteric vascular occlusion?

A

Elderly

Those with an aetiological RF (cardiac hx)

141
Q

What is a classical presentation of mesenteric vascular occlusion?

A

Sudden onest severe pain out of proportion with physical signs
May get passage of blood/mucous per rectum
Shock
Abdominal tenderness/ridigity

142
Q

Why is the pain of mesenteric vascular occlusion out of keeping with the physical signs?

A

No peritonitis yet (happens after about 6-8h)

143
Q

What is the prognosis of mesenteric vascular occlusion?

A

Very poor

Usually a life ending event

144
Q

How do you investigate suspected mesenteric vascular occlusion?

A

ABG if severe metabolic acidosis then do -

CT angiogram

145
Q

How should you manage mesenteric vascular occlusion?

A

Discussion with pt/family re options

Can do GI suction, IV fluids, antibiotics
laparotomy (embolectomy if early case)
Late case may be treated by resection

146
Q

Define paralytic ileus

A

Cessation of peristalsis due to failure of neuromuscular mechanism of intestine

147
Q

What does paralytic ileus lead to?

A

Accumulation of gas + fluid in intestine –> distension, vomiting, failure of pass flatus, absent intestinal sounds

148
Q

What are causes of paralytic ileus?

A 
Post-abdominal surgery 
Perionitis
Reflex following spinal fracture/retroperitoneal haemorrhage
Uraemia
Hypokalaemia
149
Q

What electrolytes should you check in paralytic ileus?

A

K, Mg, Ca

150
Q

What is a typical presentation of paralytic ileus?

A 
Hx underlying disorder
Vomiting/increased NG tube output
Absolute constipation
NO PAIN
False shifting dullness
Dead silent abdomen
151
Q

What do you see on AXR/CT in paralytic ileus?

A

Dilated small bowel loops

No transition point

152
Q

How do you treat paralytic ileus?

A

NG tube
Restoration of fluid and electrolyte balance
Mx underlying cause

153
Q

Define large bowel pseudo-obstruction (Ogilvie syndrome?

A

Signs, symptoms + AXR appearance of LBP bit with no identifiable mechanical obstruction

154
Q

Who does Ogilvie syndrome tend to occur in?

A

Elderly patients +/- recent surgery

155
Q

What are associated features/causes of Ogilvie syndrome?

A 
Severe pulmonary or CV disease
Severe electrolyte disturbance: 
Hyponatraemia
Hypokalaemia
Hypomagnesaemia
hypo/hypercalcaemia
Malignancy
Systemic infection
Medications: 
Opioids, anticholinergics, clonidine, amphetamines, phenothiazines, steroids

GI (8 decks)

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