SBO/LBO, Pancreatitis, Perforated Viscus

Question 1

distended bowel

Answer 1

-diaphragm goes up -> hyperventilation -> respiratory alkalosis -> respiratory acidosis -> MI
-can lead to perforation

-tx- NG tube to relieve distention -> otherwise can vomit and aspirate
-if distended volvulus -> NG tube prior to surgery

Question 2

55 yo
epigastric pain for past 5 years and worsening
9/10 pain
N/V
sickle cell, cholelithiasis
pleural effusion

Answer 2

-BISAP tool
-pancreatitis
-high mortality

Question 3

SBO

Answer 3

-step laddering
-high pitch sound -> less -> absent

Question 4

volvulus

Answer 4

-twisting loop of bowel
-leads to necrosis and perforation
-sigmoid > cecum
-older age pts
-constipation
-distention and sudden onset
-check lactate for potential bowel ischemia

-def dx- CT = whirl sign
-x ray- coffee bean sig

-fluid resuscitation
-NG tube to decompress
-sigmoidoscope decompression

Question 5

LLQ cancer

Answer 5

-can cause such an obstruction that pt is vomiting stool
-backflow at ileocecal valve

Question 6

mallory weiss syndrome

Answer 7

-high pitch
-metallic quality- change in a can sound
-ascites -> intravascular department becomes depleated -> hypotensive
-crampy abdominal pain
-no BM or flatus
-previous surgery
-hypoactive/hyperactive bowel sounds

Question 8

mechanisms of fluid loss

Answer 8

-within bowel lumen
-within bowel wall
-weeping
-ascites
-N/V- measure its ouput via NG tube or kidney basin

Question 9

labs to order

Answer 9

-BUN/Creat- elevated -> prerenal azotemia (> 20:1)
-hypernatremia
-urine lytes- low Na
-hemoconcentration- Hct can be high due to ratio
-acidosis- from anaerobic metabolism -> lactate
-leukocytosis - leukopenia can also occur if its bad
-FNa-
-if given a diuretic- Fractional excretion of urea

Question 10

Answer 10

markings go across the bowel
-this is small bowel

Question 11

Answer 11

-air fluid levels
-step laddering
-SBO

Question 12

Answer 12

-distended loops of bowel
-SBO
-give water soluble contrast -> high osmolality -> pt must be awake, alert, and able to swallow
-if not -> give NG tube otherwise…
-if it gets into their lungs -> pulmonary edema -> death

-barium - if it leaks in peritoneal cavity due to perforation -> chemical peritonitis -> DONT GIVE THIS

Question 13

SBO approach

Answer 13

-Make diagnosis
-Aggressive management
-IV fluids- wt in kg + 40 for maintenance
-for resuscitation- 200cc/hr, monitor BP
-“Never let the sun rise and set on a SBO”

Question 14

surgery

Answer 14

-resuscitation prior to surgery -> anesthetic are cardiopulmonary suppressors -> BP must be high enough -> FLUID

-Exploratory laparotomy
-Lysis of adhesions
-Resection?
-Handle tissue carefully- adhesions form easily
-Role for conservative Tx? - pts with multiple past surgerys -> try NG tube

Question 15

long NG tubes

Answer 15

-goes down into the jejunum to decompress
-rarely used
-conservative tx
-Abbot-Miller tube!

-Radiation enteritis- you dont want to operate on this -> very friable
-Repeat offenders- multiple obstructions/surgeries

Question 16

pediatric SBO

Answer 16

-Crohn’s disease
-Meckel’s diverticulum- lead point for RLQ intussusception, rule of 2’s (children under age 2, 2 cm, 2 ft from ileocecal valve, affects 2 layers of tissue: gastric and pancreatic )

-Pyloric outlet obstruction- projectile vomiting, olive sized mass, fixed easily via surgery
-Intussusception- sausage shaped mass -> resect it

Question 17

Ogilvie’s syndrome

Answer 17

-Trauma
-Infection
-CHF
-distended large bowel
-no BM
-acute colonic pseudo obstruction, adynamic ileus w/out mechanical obstruction
-MASSIVE dilation of cecum & right colon
-pts have decreased propulsion of GI tract especially colon
-AIR IN RECTUM WITH DISTENDED CECUM AND RECTUM
trauma, hip surgery, CHF, intra abdominal infection
-tx with neostigmine

Question 18

bezoar

Answer 18

-ball of swallowed foreign material
-eat extreme amount of fiber or objects(linens)
-buildup of solid indigestible material and causes a blockage
-hair one (Trichobezoar)→ MUST DO SURGERY
-MC dementia or psychotic pts

Question 19

cathartic medication

Answer 19

-never give in SBO
-perforates small bowel
-instead give mirolax, colase -> prevents stool accumulation

Question 20

pancreatitis

Answer 20

-alcoholism
-biliary stones
-gall stone moves down to bile duct -> zymogens (protealytic enzymes) backflow -> pancreatic inflammation -> pancreatitis
-high leuks, amylase high, lipase high, hyponatremic
-AST and ALT can be high if alcohol is the cause
-= 30% burn pt -> suponification of Ca (hypocalcemia)
-aggressive resuscitation -> 30% x 4 = 120
-60kg x 120 = 7200 -> 7.2L fluid for resuscitation
-% area burn x 4 x wt in kg = fluid to resuscitate
-lipase attacks surfactant -> hypoxemia
-hypertriglyceridemia can cause pancreatitis

Question 21

Answer 21

-different grey scaling
-fluid around it
-swollen
-edematous
-pancreatitis

Question 22

Question 23

Answer 23

-air in it
-pancreatic abscesses
-give antibiotics

Question 24

pancreatitis tx

Answer 24

-RESUSCITATION
-IV Fluids:Aggressive hydration with normal saline.
-Pain Management:Administered opioids for severe abdominal pain.
-NPO Status:Patient was kept NPO (nothing by mouth) to rest the pancreas or postpyloric feeding.
-Monitoring:Close monitoring of vital signs and laboratory values.
-Nutrition: As soon as feasible- titer tube -> feed pt past/distal the pancreas
-make sure have stool prep to pass stool easily
-NO ANTIBIOTICS unless complex (abscess, WBCs) -> penams

Question 25

LDL

Answer 25

-intracellular enzyme
-high -> cells are dying somewhere

Question 26

BISAP score

Answer 26

Question 27

balthazar score

Answer 27

-based on looking at the CT

Question 28

Answer 28

-inflamed
-fluid inside
-irregular
-pancreas

Question 29

Answer 29

-acute pancreas
-due to STONE
-fluid around the gallbladder

Question 30

chronic pancreatitis

Answer 30

-no amylase, lipase
-burn out exocrine and endocrine function
-enzymes to digest food, no insulin (hyperglycemia)
-tx- pancreatic enzymes (prion)