Intestinal Obstruction Laila Tavazo, REM. Case A 50 year old man presents with abdominal pain,...
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Transcript of Intestinal Obstruction Laila Tavazo, REM. Case A 50 year old man presents with abdominal pain,...
Intestinal ObstructionLaila Tavazo, REM
Case• A 50 year old man presents with
abdominal pain, distension and absolute constipation. With repeated episodes of vomiting.• Vital sign were stable, abdomen
distended with diffuse tenderness but minimal peritonism. Bowel Sounds are hyperactive.• The plain abdominal xray was taken
on admission.
Definition
• Lack of transit of intestinal contents is called intestinal obstruction• Intestinal obstruction is a very common problem encountered in the
ED, accounting for up to 15% of all emergency admissions for abdominal pain.
Classification
Lesions Causing Small Bowel ObstructionRelative to the Intestinal Wall
Causes of Adynamic Ileus
Differentiating SBO from Paralytic Ileus
SBO Ileus
Etiology Patient with prior surgery weeks to years prior
Recent (hours) post-operative patient
Pain Colicky Not a prominent featureAbdominal distension Frequently prominent Sometimes not apparent
Bowel sounds Usually increased Usually absentSmall bowel
dilatation Present Present
Large bowel dilatation Absent Present
Intestinal obstruction
Colicky abdominal pain, vomiting, constipation (absolute), abdominal distension.
Proximal small bowel•Pain is rapid•Vomiting copious and contains bile jejunal content•Abdominal distension is limited or localized•Rapid dehydration
Distal small bowel•Pain: central and colicky•Vomitus is feculunt•Distension is severe•Visible peristalsis•May continue to pass flatus and feacus before absolute constipation
Colonic• Pre-existing change in bowel habit•Colicky in the lower abdomen•Vomiting is late•Distension prominent
Clinical Findings 1. History
General
•Vital signs: P, BP, RR, T, Sat•dehydration•Anaemia, jaundice, LN•Assessment of vomitus if possible•Full lung and heart examination
Abdominal
•Abdominal distension•Previous surgical scar•Hernia•Visible peristalsis•Cecal distension•Tenderness, guarding and rebound•Organomegaly•Bowel sounds
–High pitched–Absent
•Rectal examination
Others
Systemic examination If deemed necessary.•CNS•Vascular•Gynaecological•muscuoloskeltal
Clinical Findings 2. Examination
Diagnostic•Lab:•CBC (leukocytosis, anemia, hematocrit, platelets)•Clotting profile•Arterial blood gasses•BUN, Crt, Na, K, Amylase, LFT and glucose•CPK, LDH, I-FABP•Optional (ESR, CRP, Hepatitis profile)
Diagnostic
Plain radiographs can diagnose SBO in 50 to 60% of cases but usually cannot identify the cause of the obstruction. CT scanning is much better for determining the cause and is also very useful in identifying strangulation complicating SBO.
Diagnosis of small bowel obstruction
Diagnosis of large bowel obstruction
Normal Ileus
Sigmoid volvulus Cecal volvulus Bird’s beak volvulus
IBDGall stone IleusIntussusception
Other causes
Hernia
multiple fluid-filled and dilated loops of small bowel (white arrows) and collapsed right colon (red arrow)
String of pearl sign
Coffee bean sign Whirl sign
Ogilvie’s Syndrome
Ogilvie’s syndrome, or acute colonic pseudo-obstruction, is a rare clinical entity that usually accompanies other medical or surgical conditions. It usually responds to non-operative therapy, but occasionally requires surgical intervention. Sir Heneage Ogilvie, first described Ogilvie’s syndrome, or isolated colonic pseudo-obstruction, in 1948 in the British Medical Journal. He postulated that the colonic ileus was secondary to an imbalance between parasympathetic and sympathetic innervation caused by metastatic disease to the celiac plexus.
Treatment
A. Resuscitation.B. Conservative treatment
1. Previous surgery.2. Incomplete obstruction.3. Advanced malignancy.4. Uncertain diagnosis.
C. Indications for surgery 1. Generalized or
localized peritonitis.
2. Perforation.3. Irreducible hernia.4. Palpable mass.5. Closed loop6. Failure to improve.
Treatment
Thank you for your attention