Small Bowel Intestinal Obstruction

Question 1

Important to note

Answer 1

Medical emergency that requires early diagnosis and intervention

Question 2

CLINICAL FEATURES

Presentation

Answer 2

• Abdominal pain
• Bloating
• Vomitinng (particularly green bilous vomiting)
• Failure to pass flatus or stool

Question 3

CLINICAL FEATURES

Signs

Answer 3

• Abdominal mass
• Abdominal tenderness
• Abdominal distension
• Peritonitis

Question 4

AETIOLOGY

Common causes

Answer 4

• Previous surgery with formation of adhesions
• Inguinal hernia
• Crohns disease
• Intestinal malignancy
• Appendicitis

Question 5

What are the ‘big three’ causes to remember for obstruction

Answer 5

• Small bowel
  
  • Adhesions
  • Hernias
• Large bowel
  
  • Malignancy

Question 6

Key complication

Answer 6

• Third spacing
  
  • Water cannot reach colon and be reabsorbed
  • So fluid loss from intravascular space into GI tract causing hypovolaemia and shock

Question 7

INVESTIGATIONS

First choice

Answer 7

• Abdominal x-ray initial imaging - distended loops of bowel
• Contrast abdominal CT confirm diagnosis
• Full set of bloods (acute abdomen)

Question 8

ANATOMY

Parts of bowel observed on x-ray

Answer 8

• Valvulae conniventes
  
  • Mucosal folds in small bowel that form lines extending full widge
• Haustra
  
  • Pouches formed by muscles in wall of large bowel, form lines that do not extent full width

Question 9

INVESTIGATION

What are key things on bloods

Answer 9

• Electrolyte imbalance (U&Es)
• Metabolic alkalosis due to vomiting stomach avid (venous blood gas)
• Bowel ischaemia (raised lactate either by venous blood gas or laboratory sample)

Question 10

MANAGEMENT

General principles

Answer 10

• Resuscitation with ABCDE
• Full set of bloods as with any acute abdomen
• Conservative management in stable patients, surgical intervention second line

Question 11

MANAGEMENT

Options for surgical intervention

Answer 11

• Done laparoscopy or laparotomy
  
  • Exploratory surgery in patients where cause unclear
  • Adhesiolysis for adhesions
  • Hernia reapir
  • Emergency resection of obstructing tumour

Question 12

MANAGEMENT

Conservative

Answer 12

• Fluid resuscitation
• Bowel decompression
• Analgesia
• Consult general surgeon early

Question 13

What are adhesions

Answer 13

Pieces of scar tissue that bind abdominal contents together

Question 14

Main causes of intestinal adhesions

Answer 14

• Abdominal or pelvis surgery
• Peritonitis
• Abdominal or pelvic infections (eg pelvic inflammatory disease)
• Endometriosis