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Bowel Obstruction

Bowel Obstruction. Tad Kim, M.D. Connie Lee, M.D. Definitions. Ileus = obstruction 2/2 dysfunctional motility of bowel Mechanical obstruction = 85% SB, 15% large bowel Simple obstruction Closed loop obstruction Strangulation. SBO: Etiology.

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Bowel Obstruction

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  1. Bowel Obstruction Tad Kim, M.D. Connie Lee, M.D.

  2. Definitions • Ileus = obstruction 2/2 dysfunctional motility of bowel • Mechanical obstruction = 85% SB, 15% large bowel • Simple obstruction • Closed loop obstruction • Strangulation

  3. SBO: Etiology • Adhesion #1 (80-90% of SBO in pt’s w/prior abdominal surgery) • Hernia #2 overall - #1 cause of SBO in pts w/o prior abdominal surgery • Tumor • Abscess • Hematoma • Annular pancreas • SMA syndrome • Congenital lesions • Gallstone ileus • Intussusception • Foreign body (bezoars, worms, etc) • Meconium ileus • Malrotation

  4. Colonic Obstruction: Etiology • Cancer #1 (60%) • Volvulus (sigmoid > cecum) • Adhesions • Hernia • UC • Diverticulitis • Congenital lesions • Fecal impaction • Adynamic ileus • Hirschsprung’s • Meconium ileus • Foreign body

  5. Age & DDx • Age matters! • Neonate: meconium ileus, Hirschsprung’s, malrotation, atresia • Child: intussusception, Hirschsprung’s • Adult: hernia, IBD, CA, diverticular disease • Elderly: CA, diverticular disease, Ogilvie’s

  6. History & DDx • Proximal obstruction: early bilious vomiting, +flatus/BM • Distal obstruction: obstipation, distension, vomiting feculent material (2/2 bacterial overgrowth of SB contents) • Pain w/obstruction: begins as cramping pain, changes to continuous severe pain w/strangulation & peritonitis • PMHx: remember to ask about cardiac history (arrhythmias, prior MI, Afib - think about intestinal ischemia), IBD, gallstones, cancer • PSHx: remember to ask about ostomy output • Meds: narcotics (ileus), antipsychotics (ileus), diuretics (hypoK a/w ileus) • ROS: recent weight loss (CA, SMA syndrome)

  7. PE • Start with ABCs • Look for surgical scars • Bowel sounds • Distention: distal obstruction >> proximal • Localized tenderness: think peritonitis • Look for hernias/masses • Do a rectal exam

  8. Labs • WBC (nml in uncomplicated SBO) • CBC (anemia w/CA) • BMP (hypoK) • Alkalosis (a/w proximal obstruction) • Acidosis (a/w bowel infarction) • Amylase (may be elevated in SBO)

  9. Studies • Upright CXR: look for free air • Flat and upright/left lateral decubitus: look for dilated bowel loops, air-fluid levels • Note: if cecal diameter >12cm, there is a risk of perforation. At 12-14cm, the wall tension > perfusion pressure, increasing risk of necrosis • Barium enema • UGI series w/SB follow-through • CT scan

  10. SBO: Management • NPO, NGT, Foley, IVF • Electrolyte replacement • Many partial obstructions will resolve • “Don’t let the sun set on a (complete) SBO” • Complete bowel obstruction w/concern for strangulation/perforation requires immediate operative intervention (resuscitate first)

  11. A 72-year-old woman presented with a 2-day history of abdominal pain associated with nausea and vomiting Dedouit F and Otal P. N Engl J Med 2008;358:1381

  12. A 48-year-old healthy woman presented with anorexia of 2 days' duration and abdominal pain in the right lower quadrant Liu K and Lin B. N Engl J Med 2007;356:1152

  13. A 60-year-old woman presented to the outpatient clinic with vague abdominal discomfort that had developed over the previous several weeks Jang M and Lee K. N Engl J Med 2008;358:e16

  14. A 68-year-old man with alcoholic cirrhosis, portal hypertension, ascites, and an umbilical hernia presented to the emergency department after an episode of coughing that was followed by a rush of fluid and fat from the umbilicus Miryala R and Neilan R. N Engl J Med 2009;360:e32

  15. Ingested magnets Avolio L and Martucciello G. N Engl J Med 2009;360:2770

  16. A 68-year-old man with chronic dysuria and increased urinary frequency presented with three weeks of weakness and fever Rosmarin D and Tan C. N Engl J Med 2006;355:601

  17. Radiographic Findings in Body Packers Traub S et al. N Engl J Med 2003;349:2519-2526

  18. An 83-year-old woman was hospitalized with nausea, vomiting, and obstipation Graham J and Rothwell B. N Engl J Med 2004;351:1119

  19. A previously healthy 102-year-old woman was admitted with abdominal pain and a 3-day history of vomiting Chan D. N Engl J Med 2006;355:1714

  20. A 64-year-old woman with ulcerative colitis presented with abdominal pain Kurer M and Chintapatla S. N Engl J Med 2007;356:1656

  21. 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

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