Surgical bowel disorders

Question 1

Ischemic Bowel Disease

Answer 1

● Ischemic Bowel Disease (also known as Mesenteric Ischemia) occurs when blood supply to the intestine is decreased or cut off.
● It could be an acute problem or a
chronic problem (acute versus chronic
mesenteric ischemia).
● Because of the close association with
atherosclerotic disease, chronic is considered a condition of the elderly

Question 2

Pathophysiology of Ischemic Bowel Disease

Answer 2

■ Embolism- Arterial blood clot becomes lodged.
■ Thrombosisatherosclerotic disease or
dissection or SMV clot
■ Low Flow- Insufficient blood pressure to
maintain adequate blood flow can occur with CHF, shock, or vasoconstrictive Rx (digoxin)
● Aka nonocclusive mesenteric ischemia

Question 3

Ischemic Bowel Disease S&S (Chronic vs. Acute)

Answer 3

Chronic: presents similarly to “angina,”
where significant pain starts 10-30 minutes after eating food
Acute: comes on suddenly
Both:
○ Abdominal pain out of proportion to the physical exam findings in an elderly patient is classic.
○ Later in the process, involuntary guarding, rebound tenderness, and bloody stool may be positive.
○ A gangrenous bowel can rupture and result in hemodynamic shock

Question 4

Ischemic Bowel Disease diagnosis:

Answer 4

○ Plain film X-rays may reveal dilated loops
of bowel and free air
○ CTA of the abdomen can rule out other
causes of severe abdominal pain, but may
also reveal the bowel distention and
intestinal edema of ischemic injury.
○ Mesenteric Angiography (arterial access) can provide very precise anatomic diagnosis
(and treatment) of vascular compromise.
(Gold Standard)

Question 5

Gold standard testing for Ischemic Bowel Disease

Answer 5

Mesenteric Angiography (arterial access)

Question 6

Ischemic Bowel Disease Management - ACUTE

Answer 6

○ Acute ischemia requires emergent Tx.
■ IV hydration is an important therapy.
■ Most patients require extensive bowel
resection of the diseased bowel.
■ Open laparotomy is preferred

Question 7

Ischemic Bowel Disease Management - Chronic

Answer 7

○ Chronic ischemia with viable intestine may
be candidates for Angioplasty with
Revascularization. (consult vascular)
■ Anticoagulation is sometimes needed

Question 8

Postoperative adhesions are the most common etiology of

Answer 8

Small Bowel Obstruction

Question 9

Etiology of Small bowel obstruction

Answer 9

● Small bowel obstruction is relatively common and can occur
secondary to multiple processes.
● Postoperative adhesions are the most common etiology.
● The second most common etiology is incarceration and strangulation
of a hernia.
● Tumors, intussusception, and volvulus are less-common causes.

Question 10

Common hernia locations:

Answer 10

● Umbilical
● Inguinal
● Ventral
● Incisional

Question 11

Small Bowel Obstruction pathophysiology

Answer 11

■ Obstruction of intestinal motility, which leads to intestinal dilation and potential for perforation
■ Strangulation of intestinal tissue, which can lead to ischemic injury and the potential for necrosis and perforation

Question 12

Small Bowel Obstruction S&S

Answer 12

○ Nausea and vomiting (60-80%)
○ Obstipation
○ Initial abdominal cramping followed by constant severe pain when necrosis is occurring.
○ Cramping abdominal pain often has a
“crescendo-decrescendo” pattern, classically.
○ Distention, diarrhea, inability to flatulate
○ High-pitched bowel sounds are common early
○ GU exam: check for hernias and rectal bleeding

Question 13

Diagnosis of a Small Bowel Obstruction

Answer 13

○ Upright Chest/ Abdomen X-ray is the most
common 1st diagnostic study. (75% sens)
● Abdomen/Pelvis CT w/ IV and PO
contrast (if tolerated)

Question 14

When is emergency surgery needed in a small bowel obstruction

Answer 14

Pneumoperitoneum is seen on CT

Question 15

Small bowel obstruction Management-Nonsurgical (3Ns)

Answer 15

■ Change to NPO diet-bowel rest
■ IV hydration Normal Saline
■ NG tube for gastric decompression

Question 16

Management-Surgical of small bowel obstructions - When do we do surgery?

Answer 16

■ Signs of ischemic bowel/sepsis
■ Possibility of perforation
■ No improvement after 3-7 days
○ Monitor labs daily
■ CBC
■ CMP
■ Glucose q6
○ Consider TPN (total parenteral nutrition)

Question 17

Causes of large bowel obstructions:

Answer 17

○ Tumors
○ Volvulus
○ Adhesions
○ Strictures
○ Foreign objects

Question 18

Volvulus

Answer 18

● Volvulus is the twisting or malrotation of the intestine, small intestine most common in children.
● This is a similar concept to testicular torsion, where the twisting may produce ischemia.
● Bowel obstruction also may occur.
● In adults, most commonly occurs in the sigmoid area of the bowel, followed by cecal region.
● Ischemic injury and bowel perforation are the two largest and significant concerns.

Question 19

S&S of a volvulus

Answer 19

-Majority present with acute presentation
○ Tachycardia, fever, and constant severe pain accompany ischemia (with concern for necrosis)

Question 20

Diagnosis of a volvulus

Answer 20

○ Abdominal X-ray is the initial diagnostic
study of choice.
■ Reveals intestinal distention
■ Often described as “double bubble”

Question 21

What is this?

Answer 21

Pneumoperitoneum - surgical emergency

Question 22

Volvulus diagnosis

Answer 22

○ Barium Enema-used if no evidence of
peritonitis and inconclusive x-ray
○ CT usually not needed unless suspect
cecal volvulus or pneumoperitoneum
not apparent on x-ray
○ Labs not conclusive, but can point to
complications:
■ CBC: check WBC
■ CMP: check electrolytes

Question 23

Management of a Volvulus

Answer 23

○ Regardless, definitive treatment is
surgery either elective or emergent
○ Emergent surgical intervention as an open laparotomy is usually
indicated, with reduction of the rotation and resection.

Question 24

Indications for emergent volvulus surgery

Answer 24

○ Cecal volvulus as endoscopic
decompression unlikely
○ Unsuccessful endoscopic sigmoid
decompression
○ Evidence of ischemia/peritonitis

Question 25

Intussusception

Answer 25

The invagination of one segment of the bowel into a segment adjacent
to it- Appropriately called “telescoping.”
● 95% of cases occur in young children, and the cause is not discernible
○ When it occurs in adults, the cause
is almost always colon cancer

Question 26

______ intussusception is most
commonly seen in children ages 3
months to 3 years- condition of the
infant

Answer 26

Idiopathic

Question 27

Main concern with intussusception

Answer 27

Necrosis of the involved portion of
bowel

Question 28

Signs and Symptoms of Intussusception

Answer 28

○ Nearly all infants present with an acute onset of colicky abdominal
pain with crying and possibly vomiting
○ A “sausage-like” abdominal mass may be palpated on examination .
○ The classic “Currant Jelly stools” are a characteristic finding in late disease

Question 29

Diagnosis of intussusception

Answer 29

○ Barium/air enema can be diagnostic and
therapeutic for infants.
○ CT is the Dx tool of choice in adults

Question 30

Management of Intussusception

Answer 30

○ All patients with suspected
intussusception should be hospitalized.
○ Air or barium enema is often times
completely curative for infants
○ Surgery is usually required for children
older than 3 and all adults. Can be open or
laparoscopic

Question 31

Toxic Megacolon

Answer 31

Toxic Megacolon is the pathologic distention of the colon with accompanying clinical signs of toxicity
○ Sometimes called Toxic Colitis +/- megacolon

Question 32

The most common causes of toxic megacolon

Answer 32

○ Ulcerative Colitis
○ Crohn’s Disease
○ Acute Colitis (C diff)

Question 33

Pathophysiology of toxic megacolon

Answer 33

○ The pathophysiologic mechanism of development is not fully understood, but seems to be related to intestinal immobility
○ Results in severe non-obstructive dilation of the colon- Could be a segment or the entire length of the colon.

Question 34

S&S of Toxic Megacolon

Answer 34

○ The patient often appears “toxic,” almost as if septic.
○ Clinical presentation may include:
■ Fever
■ Prostration (lying down/weak)
■ Severe abdominal pain/distension
■ AMS
■ Tachycardia
○ Abdomen may be rigid with rebound
tenderness.

Question 35

Toxic Megacolon Diagnosis

Answer 35

○ Abdominal plain-film X-rays- Reveals significant colonic distention, often
greater than 6 cm in the transverse colon.

○ Three of the following as well:
■ Fever > 38C (100.4F)
■ Tachycardia (usually >120 bpm)
■ Leukocytosis (usually > 10.5)
■ Anemia (due to bloody diarrhea)

○ PLUS one of these: Electrolyte abnl,
AMS, hypotension, or dehydration

Question 36

Treatment of toxic megacolon includes 3 main goals

Answer 36

○ Reduce colonic distention to prevent perforation
○ Correct fluid/electrolyte disturbances
○ Treat toxemia and underlying
etiology

Question 37

Management of toxic megacolon

Answer 37

○ NPO diet and NG tube for gastric
decompression. (Bowel Rest)
○ Broad-spectrum IV antibiotics
should be initiated.
○ Urgent decompression of the
colon, usually by surgical
resection, is usually necessary.
■ Open Laparotomy
■ May be entire colectomy

Question 38

Ostomy care includes

Answer 38

○ Send with supplies and HH/wound care referral
○ Order PT
○ Possible reversal after 3-6 months
○ THIS IS A BIG DEAL FOR PATIENTS