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Z Surgery

Bowel Obstruction

43y m w h/o abd lap, now 16h of int crampy abd pain & bilious vom. Sx's began 3h p lunch & bttr w vomiting, but ret 1-2h ltr. 1BM at onset. No flatus/stool since. Feb, tachy, inc BP, tachypnea, dist & tender abd, hypoBS, hi-pitch. mechanical SBO. also have Leuko w L shft, inc amylase. xray w dilated bowel & air-fluid levels.
If pt has s/s of high grade mechanical SBO, what is next step in management? NG tube to decompress stomach, IVF, Foley to monitor urine output to assess response to fluid resuscitation
complications of SBO (5) 1. strangulation, 2. bowel necrosis, 3. sepsis, 4. aspiration pneumonitis (if vomiting), 5. intravascular fluid loss (third-spacing and vomiting) --> prerenal azotemia and acute renal insuff
tx for mechanical SBO (6) CT scan, NPO, NG tube, IVF, foley to monitor fluid status. Then abx if signs of inflammation or going to OR. Exploratory laparotomy if nonresponsive to nonoperative tx or if severe at presentation.
what are the causes of persistent pain in SBO? (2) 1. severe bowel distension --> venous congestion, dec perfusion, necrosis), 2. strangulation --> ischemia
what is the most vital aspect of treatment in SBO? restore intravascular volume --> maintain organ perfusion (esp before general anesthesia)
Closed loop SBO. What is it and what is treatment? blockage at both proximal and distal end of bowel (ie bowel incarcerated in hernia, intestinal volvulus), more rapid progression to strangulation, unlikely to resolve without surgery
Ileus distension of small bowell and/or colon from nonobstructive causes (inflammation, infection, recent surg, meds)
gallstone ileus mechanical obstruction of small bowel due to large gallstone; stone in gallbladder enters adjacent duodenum --> intermittent bowel obstruction for several days until the stone lodges in the distal small bowel --> complete obstruction, constant
likely causes of SBO in child (6) 1. hernia, 2 . Malrotation, 3. meconium ileus, 4. Meckel diverticulum, 5. intussusception, 6. intestinal atresia
likely causes of SBO in adult (5) 1. adhesions, 2. hernia, 3. Crohn dz, 4. gallstone ileus, 5. tumor
Extraluminal causes of bowel obstruction (5) adhesions (75% of all bowel obstruction), hernias, carcinomas, abscesses (ie. s/p appendicitis), and volvulus
% of re-operation for adhesion lysis with symptomatic bowel obstruction 5-15% of abdominal surgery
intrinsic bowl wall causes of bowel obstruction most likely is cancer/tumor, more rare are inflammatory or radiation strictures and congenital abnormalities (duplication, atresia, stenosis)
Intraluminal causes of bowel obstruction (5) gallstones, enteroliths or meconium, foreign bodies, intussusception, or bezoars (hairballs)
sx's for SBO (5) 1. cramplike abd pain, 2. nausea, 3. bil vom -> all because obstr blocks intestinal cont; 4. BM at onset -> because of stim of peristalsis leading to evacuation of the distal GI contents; 5. abd exam with mild, diffuse tenderness, 6. labs - leuk w L shift
sx's for complicated SBO (6) 1. persistent pain, 2. fever, 3. tachycardia, 4. leukocytosis, 5. elevated serum amylase, 6. radiographic signs of high-grade SBO
tx for complicated SBO surgery
T/F Presence of BM effectively rules out bowel obstruction FALSE
In pt w frequent emesis, what acid/base abnlity is seen? Metabolic alkalosis
If pt has ischemic bowel, what acid/base disorder will they get? metabolic lactic acidosis
initial w/u for pts with suspected bowel obstruction (3) 1. labs (CBC with diff, chem7, amylase and lactate - both may be elevated in SBO), 2. UA, 3. KUB (dilated small bowel +/- colonic air), 4. ABG
If initial w/u (inc KUB) is suspicious for SBO, what is next step? (3) 1. If incarcerated hernia --> surg, 2. if h/o abd surg --> if no complications, then trial of nonoperative management, if complications, then IVF and surg, 3. if no h/o abd surg --> CT scan
If initial w/u (inc KUB) is suspicious for large bowel obstruction, what is next step? CT scan. If confirms LBO, then treat. If no LBO or SBO, then treat ileus.
Why low grade fever and tachycardia in bowel obstruction pt? dehydration and inflammation - will show leukocytosis w L shift
What should you be thinking if suspected bowel obstruction pt continues to be tachy after restoration of intravascular volume? Unresolved inflammation from small bowel ischemia or necrosis
What should you be thinking if suspected bowel obstruction pt continues to have leukocytosis after restoration of intravascular volume? suspicion of complicated SBO, may need early surgical intervention
What should you be thinking if fever in pt with suspected bowel obstruction? (2) bowel ischemia and/or pulm complications due to aspiration of gastric contents
Pt suspected of SBO with non-specific tenderness on abd exam that does not improve after decompression by placement of NG tube Can still be SBO; uncomplicated SBO may show improvement with NG tube decompression
What should you consider if pt suspected of bowel obstruction has localized tenderness? severe distension or bowel ischemia, this pain is not specific for ischemia
What would you expect on DRE of pt with bowel obstruction? DRE often reveals little or no stool in rectal vault because of continued peristalsis and evacuation of stool from distal bowel
What would you think if DRE of suspected SBO pt revealed large amt of stool in the rectum? suggests ileus rather than SBO as cause of distension
why do pts with SBO lose intravascular volume? (4) 1. reduced absorp -> fluid acc in bowel (edema -> dec absorp), 2. local inflam & ven conges -> fluid shift, 3. trans fluid loss into periton, 4. vomiting (sterile bowel contents overgrown w bacteria->emesis, met alk (hypoCl, hypoK), & worse hypovol)
what is the danger of decreased intravascular volume in SBO pt? risk of hypoperfusion and remote organ dysfxn
What is the difference in sx's of pt with proximal vs. distal SBO? proximal - more frequent vomiting; distal - more distension
In pt with SBO, what does feculent vomitus suggest? long-standing distal SBO with bacterial overgrowth
KUB showing dilated small bowel +/- colonic air SBO OR ileus
what can you see on CT of SBO pt that is diagnostic for mechanical obstruction? transition from dilated to decompressed bowel
What studies besides KUB can you use to diagnose SBO? upper GI with small bowel follow through AND CT scanning
What to do if pt develops SBO within 30 d of abdominal operation? What is the cause? narrowing of lumen or ileus --> nonoperative observation. CT scan to r/o infxn.
initial tx for pts with uncomplicated partial SBO from adhesions (4) trial of nonoperative therapy: 1. NPO, 2. NG tube, 3. IVF, 4. follow w exam, labs, imaging
for pts with uncomplicated partial SBO treated nonoperatively, when shld pts demonstrate improvement? 6 to 24h after initiation of tx
How can you tell that a pt with uncomplicated SBO is responding to nonoperative tx? (3) 1. dec in abd discomfort and distension, 2. dec in volume of NG aspirate, 3. radiographic resolution of bowel distension
What should you do if pt with uncomplicated SBO is not responding to nonoperative tx? CT scan or UGI/SBFT to confirm dx or further define obstruction for surg
What is surgical tx for SBO? ID and removal of obstruction, lysis of adhesions, resect ischemic or necrotic bowel
What are you looking for on CT in pt with suspected SBO? Obstruction (mechanical vs. ileus; quantify degree of obstruction), possible malignancy, gallstone ileus, internal hernia
If SBO pt has anion gap acidosis, what does it mean and what should you do? probably ischemia or severe fluid depletion --> build up of lactic acid; if intra-abd sepsis or high-grade obstruction on CT --> surgery
In which SBO pts would you NOT need CT imaging? 1. pts with simple SBO 2/2 adhesions, 2. absense of indicators of complicated SBO
when is it appropriate to tx SBO nonoperatively partial SBO
Created by: christinapham



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