1 / 12

Bowel Obstruction

Bowel Obstruction. Tad Kim, M.D. UF Surgery tad.kim@surgery.ufl.edu (c) 682-3793; (p) 413-3222. Overview. Case ABC & Resuscitation History Physical Labs & Imaging Differential Diagnosis Management Indications for emergent surgery. Case.

kyria
Download Presentation

Bowel Obstruction

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Bowel Obstruction Tad Kim, M.D. UF Surgery tad.kim@surgery.ufl.edu (c) 682-3793; (p) 413-3222

  2. Overview • Case • ABC & Resuscitation • History • Physical • Labs & Imaging • Differential Diagnosis • Management • Indications for emergent surgery

  3. Case • 50yo male p/w abd pain, distension, bilious emesis • Think “bowel obstruction” • What else could kill the patient? • Ischemic bowel, perforated viscus (ulcer) • Acute appendicitis, diverticulitis, pancreatitis • Acute cholecystitis or cholangitis • Could be an atypical presentation of MI • Other possible causes, i.e. medical? • Acute hepatitis, gastroenteritis, food poisoning

  4. ABC & Resuscitation • Vomited 5x past 4 hrs, oliguric, dry mucous membranes, looks “ill”, distended • VS: Pulse 110, BP 100/60 • Clinically hypovolemic, needs fluid boluses • ABC, 2 large bore IV’s, Foley, monitor • Isotonic fluid bolus 1-2 Liters, repeat until clinically appropriate response • Bowel obstrux patients need resuscitation

  5. History • Colicky, intermittent mid-abd pain (SBO) • Obstipation = no BM or flatus • Prior surgeries, esp pelvic (adhesions) • History of CA, unexplained weight loss • History of hernias • History of Crohn’s or Crohn’s flare-ups • Any similar prior episodes of abd pain • ROS for other causes of acute abdomen

  6. Physical Exam • Vitals: hopefully more stable if ABC’s done • Is patient “toxic” appearing? (get to OR) • Feculent emesis = bad (dead bowel) • Signs of dehydration • Mucous membranes, skin turgor, oliguria • Examine abdomen for peritoneal signs • Check for hernias (groins or ventral) • Rectal for impaction, mass, fluctuance

  7. CBC w diff Left shift more telling than elevated WBC BMP Correct electrolytes BUN/Cr>20 (hypovol) Amylase Ischemic/perf bowel UA spec grav > 1.030 means dehydrated Flat & Upright KUB Free air Air-fluid levels Dilatation/obstruction CT scan Partial vs complete “transition point” of obstruction Find cancers/hernias Signs of diverticulitis Free air or free fluid Ischemia/necrosis Labs & Imaging

  8. Differential Diagnosis of SBO • #1 Adhesions (60%) • #2 Cancer (20%) • #3 Hernias or Bulges (10%) • Crohn’s disease – strictures (5%) • Gallstone ileus (rare) • Erosion of gallstone from gallbladder to small bowel (cholecystoenteric fistula) & obstruction • Other: abscess, radiation stricture, foreign body, tuberculosis • Just remember the top 4

  9. Management • NPO, NGT, Foley (No Abx unless perf) • Resuscitation IVF at 1.5x maintenance • Most partial obstructions will resolve • Complete obstructions need OR urgently • Signs strangulation/ischemia→ OR stat • Leukocytosis, left shift, fever, tachycardia • Unrelenting or constant, noncramping pain • Origin of “Never let the sun set on a SBO”

  10. Management of SBO • In general, failure of non-operative management is an indication for surgery • Adhesions → NGT vs OR for adhesiolysis • Hernias → reduce hernia versus OR if incarcerated or strangulated (stat) • Crohn’s → Treat Crohn’s flare-up vs OR to resect the strictured segment • Cancer → NGT vs ex-lap/resection vs ex-lap & bypass the obstructing cancer

  11. DDx & Management of LBO • Cancer (colon or rectum) • Dx by colonoscopy & biopsy • Some data for stenting before surgical resection • Volvulus (torsion of a segment of GI tract) • Sigmoid volvulus (emesis less common) • Tx: Sigmoidoscopic reduction if no gangrene • Surgery recommended w ‘pexy’ or resection • Cecal volvulus (Like SBO p/w N/V distension, obstipation). Tx: Surgery (scope won’t work) • Diverticulitis (at some point, need to r/o cancer) • Tx w surg if complicated or medical tx fails

  12. Take Home Points • Always start with ABC, resuscitation • Includes 2 large bore IV, Foley, NGT, monitor • DDX is simple: • SBO: Adhesions, Bulges, Cancer, Crohn’s • LBO: CANCER, Volvulus, Diverticulitis • Labs to assess dehydration & leukocytosis • Imaging to assess obstruction & etiology • If hypoTN/shock, “toxic”, or signs of strangulation or ischemia, resusc & OR stat • Otherwise, for SBO, NGT & treat etiology • LBO is different: really must rule out cancer, colonoscopy plays a larger role than w SBO

More Related