Highlights of patient’s history

1. Highlights of patient’s history • 53 year old man with longstanding diabetes mellitus • One-week illness, characterized by: • Nausea, for 6 days • More nausea, vomiting, bloating, and crampy lower abdominal pain for 1 day • No BM for 2 days pta and for hospital days 1-5

2. Highlights of his physical exam • Temp 98.5, Resp 24 (depth?), BP 157/82, Pulse 103; tilt test ? • Oropharynx: slightly dry • Abdomen: slightly distended; mildly tender in the “lower abdomen” (RLQ?, LLQ?, suprapubic region?); “quiet” bowel sounds • Quiet. adj. making very little sound

3. Describing bowel sounds • Frequency • absent, present, increased (hyperactive) • Intensity • normal, loud • Quality • high-pitched, musical, tinkling • normal • rumbling, gurgling, rushes (borborygmi)

4. Physician accuracy: bowel sounds[Gade et al. Scand J Gastro 33:773, 1998] • Bowel sounds recorded from 4 normals, 6 pts. with obstruction [SBO(4), LBO(2)], and 2 pts. with peritonitis (perforated viscus) • Recorded sounds from these 12 people were amplified and transmitted through a dummy and listened to with a stethoscope by 100 physicians of different specialty and experience {normal vs. abnormal}

5. Physician accuracy: bowel soundsGade et al. Scand J Gastro 33:773, 1998 • NORMALS (n=400 ratings) • 25% were called abnormal [75% specificity] • OBSTRUCTION (n=600 ratings) • 64% abnormal (69% for surgeons, 50% for GIs) • PERITIONITIS (n=200 ratings) • 43% abnormal (50% for surgeons, 25% for GIs) Conclusion: Our patient’s bowel sounds are certainly compatible with SBO, LBO, and peritonitis with ileus.

6. Highlights of laboratory tests • WBC 15.9, with 94% neutrophils • Glucose 430’s • Anion gap 14; bicarbonate 22 • Urine + for glucose and ketones; no UTI • Lactate normal • LFTs, serum lipase/amylase normal • EKG, cardiac enzymes normal

7. Summary of clinical presentation (prior to his X-ray studies): • Middle-aged diabetic man with nausea and vomiting, constipation, lower abdominal pain, tenderness, and distention • Mild diabetic ketoacidosis

8. DIABETES ?  GI SYMPTOMS

9. OUTPATIENTS* Constipation 60% Abdominal pain 34% Nausea, vomiting 29% Dysphagia 27% Diarrhea 22% Fecal incontinence 20% None of the above 24% * Feldman and Schiller. Ann Int Med 1983 INPATIENTS, DKA “Abdominal pain, nausea and vomiting are common and may be caused by the ketoacidosis, but assoc-iated disorders such as pyelonephritis, pancrea-titis, or an acute abdomen must always be suspected.” GI Symptoms in Diabetics Williams textbook. Unger and Foster. 1998

10. Hospital course: days 1-5 • No BMs or flatus production • Abdominal distention did not resolve and instead increased despite NG suction • Diabetic ketoacidosis treated successfully with insulin, fluids and electrolytes

11. “ACUTE ABDOMEN”  DKA in a previously stable diabetic patient

12. FILM REVIEW: ADMISSION ABDOMINAL FILMS AND OF ARTERIOGRAMS

13. Summary of radiological exams • Plain films: dilated loops of small bowel and right colon, compatible with LBO or ileus • CT: same as above, with probabl”cut off” at the level of the transverse colon; “probable” filling defect in SMV; no abscesses or evidence of diverticulitis/ mass • Visceral arteriogram: normal vessels; dila-ted bowel as above

14. Separating pseudo- obstruction from true obstruction • Ileus of small bowel = intestinal pseudoobstruction [can mimic SBO] • Ileus of colon = Ogilvie’s syndrome [can mimic LBO] and can affect the right side prodominately • Ileus involving small and large intestine [can also mimic LBO] 

15. Conditions that may  pseudo-obstruction or ileus • Electrolyte disturbance, esp. hypokalemia • DKA can be a cause, but should improve with rx of DKA • Medications that suppress GI transit, especially anti-cholinergics and opiates • Neurological disease (CVA, Parkinson’s, dementia, CP), bedridden, institutionalized • Severe intra-abdominal inflammatory and infectious diseases: • pancreatitis - bowel ischemia/infarction • cholecystitis - bowel or GB perf., incl. perf. ulcer • diverticulitis - appendicitis • strangulated obstruction - peritonitis

16. Radiology workup of obstruction vs. ileus in acutely ill inpatients • Plain films: is there disproportionate bowel distention with gas or with gas/fluid levels? • CT with oral ± rectal contrast: is there a cut-off, transition point or site of blockage? • Water-soluble contrast enema (e.g., diatrizoate meglumine [HyapaqueR, GastrografinR])* * barium sulfate enema is relatively contraindicated

17. Typical SBO

18. Ileus involving small and large intestine

19. Hyapaque enema: complete sigmoid obstruction in patient with diverticulitis and obstipation

20. Hyapaque enema: complete obstruction to retrograde dye at the descending colon (Ca)

21. Differential Diagnosis, in order of likelihood • Intestinal Obstruction • MORE LIKELY, BASED ON HIS DRAMATIC XRAY STUDIES and that THIS IS A CPC “INTESTINAL OBSTRUCTION” • Ileus • LESS LIKELY, SINCE NO EVIDENCE FOR AN UNDERLYING PRECIPITATOR

22. Intestinal Obstruction (SBO/LBO) • Common cause for admission to hospital (20% of acute admissions to surgical services are for SBO) • SBO and LBO can be either partial or complete • Strangulation (ischemic infarction of the bowel) is the most dreaded and lethal consequence • SBO and LBO have many causes, making a specific diagnosis of the cause challenging • Ideal therapy is dictated by knowledge of the cause, although this is often not known at the time of surgery

23. Clinical features of Intestinal Obstruction • Crampy abdominal pain in waves (intestinal colic) • Nausea • Bilious or feculent vomiting • Abdominal distention • Constipation with decreased flatus production • High pitched (musical, tinkling) hyperactive bowel sounds • Symptoms and signs of intravascular volume depletion due to external losses, reduced oral intake, and 3rd space losses into the bowel wall and/or abdominal cavity

24. Common causes of SBO/LBO • Adhesions are most common cause of SBO, but are rare cause of LBO. • Hernia is a common cause of SBO, but rearely LBO. • Neoplasm is most common cause of LBO, and accounts for 10% of SBO. • Volvulus and diverticulitis are common causes of LBO, but rarely SBO. (SBO) (LBO)

25. Atresia/stenosis/ bands IBD (Crohn’s) Radiation injury Ischemic stricture Endometriosis Anastomotic stricture Intussusception Gallstones Foreign body/bezoar Meconium Meckel’s diverticulum Intra-abdominal abscess [Children, young adults] S [History of fever, diarrhea] S [History of cancer/XRT] S,L [Vascular disease] L,S [Premenopausal female] S,L [Prior anastomosis] S,L [Children > adults] S>>L [Biliary colic;pneumobilia] S [Ingestion history] S [Neonate, cystic fibrosis] S,L [Male, young, recurrences] S [Fever, chills, ? mass] S>L Miscellaneous causes of SBO/LBO

26. Historical/demographic factors which aid in assessing the etiology of SBO and LBO • Age and gender of the patient • History of abdominal or pelvic surgery • History of intra-abdominal disease • History of recent abdominal surgery/trauma • History of abdominal radiotherapy • History of overt rectal bleeding/ weight loss • History compatible with undiagnosed IBD

27. If obstruction, SBO or LBO? • Pain before nausea/vomiting is typical in SBO • History of prior surgery or abdominal trauma would favor SBO over LBO • Bilious vomiting favors SBO; feculent vomiting favors LBO • No mass on digital exam excludes distal rectal cause of LBO, but not high rectal/colon obst’n • Right colon distention on radiographs favors LBO, especially as there is a distinct cut-off  • Periumbilical pain (SMA distribution ) favors SBO, while suprapubic pain favors LBO 

29. LBO (adults) • Neoplasms (60%) • Adenocarcinoma • Others • Volvulus (20%) • sigmoid • cecal (SBO) • others are rare • Diverticulitis with stricture (10%) • Sigmoid, descending colon • Cecal • Others are rare • Miscellaneous causes (10%)

30. Annular adenocarcinoma of the colon, the “apple core”

31. Sigmoid diverticulitis can mimic colon cancer

32. BE: complete retrograde obstruction at the rectosigmoid junction due to diverticulitis

33. Distal small bowel obstruction 2º to cecal volvulus

34. LBO from sigmoid volvulus

35. Atresia/stenosis/ bands IBD (Crohn’s) Radiation injury Ischemic stricture Endometriosis Anastomotic stricture Intussusception Gallstones Foreign body/bezoar Meconium Meckel’s diverticulum Intra-abdominal abscess [Children, young adults] S [History of fever, diarrhea] S [History of cancer/XRT] S,L [Vascular disease] L,S [Premenopausal female] S,L [Prior anastomosis] S,L [Children > adults] S>>L [Biliary colic;pneumobilia] S [Ingestion history] S [Neonate, cystic fibrosis] S,L [Male, young, recurrences] S [Fever, chills, ? mass] S>L Miscellaneous causes of SBO/LBO

36. Final diagnosis • Most likely: large bowel obstruction due to adenocarcinoma of the colon • “He has not seen a PCP in over 4 years and has never had a colonoscopy.” • Less likely: • Diverticular stricture (pro:mom;con:age/history) • Another 1º colonic malignancy (e.g., lymphoma) • Sigmoid or (less likely) or cecal volvulus

37. What was the diagnostic procedure? • PREFERRED: Flexible sigmoidoscopy or colonoscopy following enema preparation • ACCEPTABLE ALTERNATIVES: Diatrizoate meglumine (not barium) enema or CT with rectal contrast • LESS ATTRACTIVE APPROACH (at this point -may do later for therapy): Laparoscopy or exploratory laparotomy

38. MEDICAL NPO fluid and electrolyte support NG decompression analgesia p.r.n. meds. for underlying disease, if indicated e.g., steroids for Crohn’s disease 48-72 hour trial with frequent bedside exams SURGICAL laparoscopy laparotomy OPTIONS INCLUDE: adhesiolysis resection/ anastomosis stricturoplasty removal of intraluminal obturation (FB, stone) bypass untwist volvlus/ “pexy” “open and close” Therapy of Intestinal Obstruction 