Obstruction/Rectal Dz Flashcards
Divisions of small intestines? (3)
1) Duodenum (pylorus to ligament of Treitz)
2) Jejenum
3) Ileum
Vascular supply of small intestines?
SMA
Primary role of small intest?
absorption
Components of large bowel? (8)
1) Cecum
2) Ascending colon
3) Hepatic Flexure
4) Transverse colon
5) Splenic flexure
6) Descending colon
7) Sigmoid
8) Rectum
Vascular supply for large bowel?
SMA
IMA
Primary role of large bowel?
Absorb H2O, e-
Store feces
Causes of small bowel obstruction (SBO)? (5)
1) POST-OP ADHESION (primary cause, 80% self-resolve)
2) Malignancy
3) Hernia
4) Strictures (Crohn’s, NSAIDS, radiation, ischemia)
5) Tumors
Intussusception epidemiology?
Sxs?
(U) kids, benign, self-limiting
Adults (U) a/w tumors
Currant jelly stool
W/ SBO, intestinal dilation seen where?
Exacerbated by?
proximal to obstruction
swallowed air, intest secretion
Dilation from SBO leads to?
↑ peristalsis ->
compressed lymphatics ->
swelling in lumen ->
↑pressure drives fluid into peritoneum (3rd spacing)
or
necrosis -> leaks bacteria
SBO signs/sxs? (5)
1) Abd pain (intermittent initially, then constant)
2) Distention (more C w/ distal obstr)
3) N/V (more C w/ distal obstr)
4) Constipation (pass gas but not stool)
5) Obstipation (can’t pass gas or stool)
SBO sxs that are “bad signs”? (2)
Constant pain
Obstipation
Important SBO hx? (5)
1) Prior abd surgery?
2) Hernia?
3) CA?
4) N/V/D/C? If so, how long?
5) Pain ↓ or ↑?
Important SBO physical exams? (3)
1) VITAL SIGNS (tachy w/ hypoTN = SHOCK/strangulation/sepsis)
2) Bowel sounds (Early = high-pitched w/ rushes, Late = silent)
3) Abdominal palpation (diffuse tenderness)
(Rebound + very still pt = advanced dz)
SBO lab findings:
Electrolytes?
BUN/Cr?
WBC?
Hct?
LDH?
Electrolytes = altered
BUN/Cr = elevated (dehydration)
WBC = (U) elevated (late)
Hct = increased if hemoconcentration (late)
LDH = elevated if tissue breakdown (late)
SBO imaging studies? (3)
1) Plain films: supine and upright
2) CT scan w/o contrast
3) UGI w/ small bowel follow through
SBO findings on plain films?
Dilated bowels
Air-fluid levels
Free air if perforated
30% false negatives
CT w/o contrast indicated for SBO when?
Plain films are negative
Do CT first if high clinical suspicion
If very high suspicion for SBO, first action should be?
call surgeon (let him decide imaging)
SBO management? (7)
1) Volume resuscitation
2) Decompress w/ nasogastric tube
3) NPO
4) Abx
5) Correct e- imbalance
6) Watch vitals
7) Reassess for next 3 days
Paralytic Ileus is?
↓ bowel motility with NO obstruction
Paralytic Ileus caused by? (6)
1) intra-abd surgery
2) opiates
3) bedrest
4) trauma
5) e-
6) sepsis
Paralytic Ileus presentation? (5)
1) No BS
2) Less severe abd pain
3) (P) massive distention
4) N/V
5) Normal vitals
Paralytic Ileus diagnositcs?
Findings on plain films?
Same as SBO (ruling this out)
Dilation of small AND large bowels
Paralytic Ileus management? (6)
1) Assess for vol restriction
2) Decompress w/ NG tube if N/V
3) NO abx
4) NPO
5) AMBULATE
6) If > 4 days, (P) feeding tube?
Large Bowel Obstruction (LBO) caused by? (4)
1) Adenocarcinoma (most C)
2) Stricture from diverticulitis/ischemia
3) Volvulus (malrotation)
4) IBD, FB, fecal impact
LBO presentation? (5)
1) Cramping pain
2) Distention
3) Constipation/Obstipation
4) N/V
5) High-pitched bowel sounds
Important LBO hx? (5)
1) Chronic rectal bleeding/black stool/∆ in caliber? (signs of CA)
2) Recent bloody stool w/ diarr? (ischemia)
3) LLQ pain w/ diarr? (diverticulitis)
4) How long? (rapid onset = volvulus)
5) Chronic narcotic use or chronic constipation? (compaction)
LBO labs? (3)
CBC
CMP
LDH
LBO imaging?
1) Plain films: supine, upright
2) CXR (for perf air)
3) Gastrograffin Enema
4) CT (only if dx still unclear)
Possible LBO findings: Plain films? (5)
1) Proximal colon distention
2) Rectal air = ileus or PSBO (partial sm bowel)
3) Intraluminal air = ischemia
4) Competent ileocecal valve = higher chance of perf
5) Loss of haustral markings = volvulus
Possible LBO findings/uses: Gastrograffin Enema?
Uses:
X-Ray unclear,
Identify PSBO vs Obstruction
Localization for surgery
Findings:
“bird beaks” = volvulus
Partial LBO management? (5)
If Pseudo-obstruction?
1) IV fluids, NPO
2) ABX
3) Decompress if vomiting
4) Slow bowel cleanse
5) No narcotics or anticholinergics
If pseudo-obstr:
neostigmine + decompression
Complete LBO management:
Cancer?
Complete Stricture?
Sigmoid Volvulus?
Cecal Volvulus?
Fecal Impaction?
Intussusception?
Depends on cause:
Cancer = resection
Complete Stricture = resection
Sigmoid Volvulus = sigmoidoscopy w/ reduction
Cecal Volvulus = resection
Fecal Impaction = H2O/mineral oil enema
Intussusception = barium enema
Rectum anatomy?
Dentated line at anorectal jxn:
Above = insensate
Below = sensate
Super/Inferior hemorrhoidal veins
Hemorrhoids are?
Normal hemorrhoid plexus important for?
swollen cluster of vv, aa, CT
protection of vasculature,
sensory (e.g. liquid vs gas)
Hemorrhoids (P) cause what? (3)
1) allows fecal leakage -> pruritis ani
2) exposes vasculature
3) tissue prolapse
Hemorrhoid presentation?
bright red blood per rectum,
pain,
itching
Important Hemorrhoid hx? (6)
R/O other rectal path:
1) qty of blood?
2) color of blood?
3) blood mixed w/ stool? (IBD)
4) recent diar/constip?
5) severe pain w/ BMs? (fissure)
6) d/c or mucus? (IBD, infection)
Hemorrhoid diagnostics? (4)
1) Rectal (feel for ulcers, fissures, abscess)
2) CBC to eval bleeding
3) Anoscope (visualize)
4) Flexible Sigmoidoscopy (standard of care)
Perianal Infections caused by?
Obstruction of perianal glands ->
stasis -> infection
(common a/w fistulas)
(U) e coli, anaerobes
Perianal infection presentation?
Locations?
rectal pain, fullness, fever/chills
Perianal (most C)
Ischiorectal
Intersphincteric
Supralevator
Perianal infection diagnostics?
Digital rectal
(P) CT/MRI
Perianal infection management?
I & D w/ anesthesia
(P) drain placement
(P) abx based on culture
Fistulas related to rectal dz are?
inflammatory tracts connecting abscesses to the skin
Fistulas caused by? (3)
1) Open/ruptured abscesses
2) Crohn’s
3) Diverticulitis
Fistula in Ano is?
connection b/w anal canal and skin
Fistula presentation?
chronic drainage of pus and (P) stool from opening in skin
Fistula diagnostics?
Exam under anesthesia
MRI if complex/recurrent
Colonoscopy if IBD possible
Fistula management?
unroofing of fistula tract to allow healing
Anal Fissures are?
trauma-caused linear tears in lining of anal canal BELOW dentate line
(U) on posterior wall (lowest blood supply here)
Anal Fissures are concerns why?
Tear causes mm spasm ->
↓ blood flow ->
poor healing
Repeat injury from BMs
Anal Fissure presentation?
1) Severe rectal pain w/o BM
2) Fear of having BM
3) Rectal bleeding
Anal Fissure diagnostics?
(U) felt on digital rectal
(P) flex sig/colonoscopy
Anal Fissure management?
Stool softener Sitz baths Nitroglycerine ointment (↓spam/↑blood flow) Botox Surgery if not healed in 3 wks
Rectal Prolapse is?
protrusion of rectal tissue through anus
Rectal Prolapse caused by?
Unknown
(P) a/w chronic straining, neuro dz, preggos
Rectal Prolapse presentation?
mass protruding thru anus,
may start w/ BM and retract
Rectal Prolapse exam?
Pt strain on toilet to reproduce
Rectal Prolapse diagnostics?
Defecography (X-ray to see shape/position of emptying rectum)
Anal Manometry if unclear (measure of strength of anal mm)
Rectal Prolapse management?
all need surgery
Rectocele is?
rectum bulges into/against vagina
