Bowel!

1. Bowel! Puja Chopra PGY-1 Emergency Medicine

2. Case History: • 50 yo male complains of periumbilical and left lower quadrant abdominal pain that began earlier that day. • Intermittent and crampy pain, accompanied by anorexia and vomiting • Normal BM yesterday • No History of this pain has had prior abdominal surgery

3. …continued Physical Exam: • Afebrile • Moderate distress due to his abdominal pain • Bowel sounds present • Abdomen: mildly distended with periumbilical tenderness but no rebound

4. DDx

6. Small Bowel Obstruction

8. Definitions: • Mechanical obstruction: • Physical barrier to the flow of intestinal contents • Simple Obstruction: • Partial or complete occlusion, proximal intestinal distention, no compromise to blood flow • Closed Loop Obstruction: • Obstruction at two sequential sites, twisting around an adhesion or hernia, higher risk of ischemia

9. Strangulation: • Vascular compromise to the obstructed area • AdynamicIlleus • Disturbance in gut motility leading to a failure in flow of intestinal contents. Etiologies: abdominal trauma, infection (retroperitoneal, pelvic, intrathoracic), laparotomy, narcotics and other meds, metabolic disease (hypoK), renal colic, MSK inury

10. Etiology • Extraluminal Causes (Most common) • Adhesions • Post pelvic surgery, appendectomy, colorectal surgery • Hernia • Cancer • Intrinsic Causes: • Congenital (stenosis, atresia) • Neoplasm • Infection from chrones/colitis • Intuscception • Intraluminal Causes: • Gallstones • Foreign body • Barium • Cancer

11. Most common cause: • Adhesions • Most likely to lead to strangulation: • Hernia

12. Pathophysiology

13. Clinically • History: • Colicky abdominal pain q4-5minutes • Abdominal pain is worse with a proximal obstruction • Nausea and vomiting • Later: obstipation and constipation • Be aware of the pain that changes from intermittent and colicky to constant and severe: intestinal ischemia and perforation

14. Physical Exam: • Inspection: surgical scars, distended hernia, distended abdomen, peristalsis • Auscultation: early: you may hear high pitched bowel sounds, later you may hear no bowel sounds • Percussion: Tympany • Palpation: Masses • Look for any peritoneal signs

19. Complications of SBO • Hypovolemia • Intestinal ischemia and infarction • Peritonitis • Sepsis • Respiratory distress (due to diaphragm elevation) • Reoccurrence • Aspiration pneumonia • Perforation

20. Imaging

21. Plain Films • 1. Normal small bowel gas pattern: • Absence of small bowel gas or small amounts of gas with up to four variably shaped non-distended loops of small bowel (less than 2.5 cm in diameter) • 2. Abnormal but non-specific gas: • One loop of borderline or mildly distended small bowel (2.5 to 3 cm), with three or more air-fluid levels. • Normal colonic gas pattern • 3. Probable SBO: • Multiple gas or fluid filled loops of dilated small bowel with a moderate amount of colonic gas • 4. Definite SBO: • Dilated gas or fluid filled loops of small bowel in the setting of a gasless colon

22. Supine

24. Limitations to Abdominal Radiography • Negative and non-specific illeus patterns do not exclude the diagnosis • Can be too early thus the colon size and small bowel size are similar • Can be too proximal and thus only a small segment is dilated • Can be too fluid filled to see dilation

25. CT • Recommended when abdoxrays are non diagnostic • Detecting signs of ischemia and closed loop obstruction • When patients have failed conservative treatment • Can detect etiology – thus useful in patients that have not had previous surgery

27. CT for Ischemia

28. Ultrasound

29. ?Strangulation • Fevang et al. Early operation or conservative management of patients with small bowel obstruction • Strangulation diagnosed by physical signs and symptoms including fever, leukocytosis, peritonitis, tachycardia or metabolic acidosis is correct only 45% of the time

30. Strangulation vs Simple

33. On univariate analysis other factors that made one think of strangulation were: • Hypotension • Acidosis • Elevated BUN • But when put in multivariate analysis this was not proven

34. Management

35. Reoccurrence • There is about a 50% reoccurrence rate after the first small bowel obstruction • Gowen GF, 2003 • There is an 81% reoccurrence rate after 4 obstructive episodes • Fevang et al., 2004

36. Case 2

40. Facts • 7% lifetime risk of developing appendicitis • In the ED, 25% of patients younger than 60 yo with acute abdominal pain have appendicitis • In the ED, 4% patients older than 60 yo with acute abdominal pain have appendicitis • Incidence of perforation: 20% • 15 to 35% negative laparotomy rate, rises to 45% in females.

41. Etiology:

43. Typical Presentation Occurs in ????% of cases

44. Three Findings With a high positive likelihood ratio • RLQ pain: • Sensitivity: 81% • Specificity: 53% • LR+: 7.31, LR-: 0.20 • Rigidity: • Sensitivity: 27% • Specificity: 83% • LR+: 3.76, LR-: 0.82 • - Migration: • Sensitivity: 64% • Specificity: 82% • LR+: 3.18, LR-: 0.50

45. …Ruling out appendicitis? • Signs with Powerful Negative Likelihood Ratios: • Absence of RLQ pain • LR-: 0.20 • Presence of similar previous pain • LR-: 0.50 • Lack of migration of pain • LR-: 0.50

46. Other Symptoms

47. Other Signs…

48. McBurney’s Point

49. Rovsing Sign

50. Psoas Sign