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Surgery M4 part 2 > Bowel Obstruction > Flashcards

Bowel Obstruction Flashcards

1
Q

What are the causes of dynamic bowel obstruction?

A

Outside wall

  • adhesions
  • hernia
  • volvulus
  • intussusception

In wall

  • tuberculous stricture
  • Crohn’s disease
  • Malignancy

In lumen

  • Gallstones
  • round worms
  • inspissated feces
  • meconium ileus
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2
Q

What are the causes of adynamic bowel obstruction?

A
  • cessation of peristalsis (paralytic ileus)
  • mesenteric ischemia
  • post-op
  • electrolyte imbalance (hypokalemia)
  • spinal injuries
  • uremia
  • diabetes
  • retroperitoneal hematomas & surgeries
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3
Q

What is the classification of types of obstruction?

A 
ACUTE -> small bowel 
CHRONIC -> large bowel 
ACUTE ON CHRONIC -> large bowel 
SUBACUTE -> Crohn's 
closed loop obstruction
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4
Q

What is the presentation depending on sites of obstruction?

A

PROXIMAL SMALL BOWEL -> vomiting
DISTAL SMALL BOWEL -> bilious vomitus -> feculent vomitus
LARGE BOWEL -> constipation

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5
Q

What is the pathogenesis of bowel obstruction?

A

PROXIMAL TO OBSTRUCTION collection of fluids from saliva,stomach, pancreas, & intestines

1) hyper peristaltic phase
2) anti peristaltic phase
3) flaccid, paralyzed, dilated bowel

DISTAL TO OBSTRUCTION
- collapsed

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6
Q

What causes a decrease in the absorption in the bowel?

A
  • edema & inflammation -> decreased absorption -> sequestration of fluids in lumen -> bacteria multiplies -> toxemia

this leads to severe dehydration & electrolyte imbalance

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7
Q

Air accumulates proximal to collected fluid from?

A
  • swallowed air (70%)
  • diffusion from blood into lumen (20%)
  • digested product & bacterial action (10%)
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8
Q

How does necrosis & gangrene develop in bowel obstruction?

A

dilation of bowel wall -> increase intraluminal pressure -> exceed bowel wall venous pressure -> ischemia -> further dilatation & ischemic injury -> blockage of arterial perfusion -> bowel wall necrosis & gangrene

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9
Q

What are the clinical features of bowel obstruction?

A
  • abdominal pain
  • vomiting
  • distention
  • absolute constipation
  • dehydration
  • features of toxemia & septicemia
  • abdominal tenderness
  • features of strangulation
  • fever -> inflammation hypothermia -> septicemia
  • borborygmi
  • empty, dilated rectum with tenderness
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10
Q

What is the character of abdominal pain in case of bowel obstruction?

A
  • initially colicky & intermittent ——-> continuous & severe
  • sudden & severe pain
  • colicky -> obstruction —————–> diffuse persistent -> strangulation
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11
Q

What is the character of vomiting in obstruction depending on location?

A
  • jejunal -> early & persistent
  • ileal -> recurrent bilious then faeculent
  • large bowel -> laaate vomiting
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12
Q

What are the exceptions of absolute constipation?

A
  • Richter’s hernia obstruction
  • gallstone obstruction (ball & valve)
  • mesenteric vascular obstruction
  • intestinal obstruction with pelvic abscess
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13
Q

What does dehydration lead to?

A

oligouria -> renal failure

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14
Q

What is the character of abdominal tenderness in obstruction?

A
  • initially localized then diffuse -> obstruction

- rebound tenderness & guarding -> strangulation

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15
Q

What are the features of strangulation?

A
  • continuous severe pain
  • shock
  • rebound tenderness (Blumberg’s sign)
  • guarding & rigidity
  • absence of bowel sounds
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16
Q

What are the investigations that should be done in suspected bowel obstruction?

A

1) X-RAY (supine & erect posture) > 3 fluid levels
- jejunum -> concertina
- ileum -> characterless
- large bowel -> haustrations

2) LAB
- hematocrit
- blood urea
- serum creatinine
- electrolytes
- leucocytic count

3) gastrograffin enema in mild or subacute CT
4) ultrasound abdomen
5) doppler US to detect strangulation

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17
Q

How is intestinal obstruction treated?

A

1) NGT to decompress
2) IV fluids & electrolytes
3) antibiotics -> ampicillin + metronidazole
4) if strangulated -> FFP
5) ICU till stabilized then laparotomy
6) CVP

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18
Q

How do you check for viability of bowel?

A
  • peristalsis
  • pulsations
  • bleeding in mesentery & bowel wall
  • friability in ischemic
  • color pink or black
  • serosal shining

if bowel is not viable -> resection & anastomoses + peritoneal wash + drainage of abdomen

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19
Q

What causes a pistol shot perforation?

A
  • closed loop obstruction -> increase pressure in the cecum -> ileocecal valve competence
20
Q

What is the most common cause of obstruction?

A

adhesions & bands

21
Q

What is the cause of adhesions?

A
  • previous surgery
  • infection
  • TALC powder from gloves
  • ischemia of bowel/sepsis
  • gynecological infections
  • bowel injury
  • radiation induced enteritis
  • Crohn’s disease
  • TB or malignancy
22
Q

How should adhesive obstruction be treated?

A

if good general condition -> conserve for 48-72hrs
-ryle

if patient doesn’t get better & doesn’t pass stool

  • open surgical adhesiolysis using fingers
  • laparoscopic adhesiolysis
23
Q

What is the commonest site of volvulus?

A

sigmoid colon 65% -> anticlockwise (has long mesentry & is loaded by stool)
- common in patients with chronic constipation with laxative abuse
cecum second commonest -> clockwise

24
Q

What are the clinical features of volvulus obstruction?

A
  • marked abdominal distention
  • intestinal obstruction
  • TYRE LIKE FEEL (diagnostic)
  • features of peritonitis due to impaired blood supply
25
Q

What is the DD of volvulus?

A
  • Ogilves’ syndrome
  • faecal impaction
  • carcinoma rectosigmoid
  • idiopathic megacolon
26
Q

What are the investigations that should be done for volvulus diagnosis?

A

1) X-ray
- OMEGA SIGN
- CAR TIRE SIGN
- COFFEE BEAN SIGN

2) contrast enema -> line of transection
3) CT for difficult cases

27
Q

How is volvulus treated?

A
  • admit patient
  • IV fluids catheterization
  • antibiotics
  • flatus tube or rigid sigmoidoscope -> try to detorte
  • if detortion doesn’t occur -> Sigmoidopexy
    - > Hartmann’s operation -> colostomy 3 months -> prepare & anastomose

right colon resection -> immediate anastomoses
left colon resection -> colostomy
-> open table preparation

28
Q

What is acute intussusception?

A

gut becomes invaginated in adjacent segments & stretched blood supply

  • hyperplasia of Peyer patches could cause it
  • most common in children (3-9 months)
  • if it occurs in adults -> polyp, submucosal lipoma, tumor
29
Q

most common strangulating obstruction by acute intussusception?

A

ileocecal

30
Q

What is the clinical picture of acute intussusception?

A
  • severe attacks of pain (lasting minutes)
  • RED CURRANT JELLY STOOL
  • sausage shaped lump -> empty RIF -> SIGN DE DANCE
  • p/r -> blood stained stool
  • later -> vomit & distention
31
Q

What investigations should be done for acute intussusception?

A
  • x ray -> absent cecal gas
  • barium enema -> CLAW SIGN
  • CT -> target sign
32
Q

How should acute intussusception be managed?

A
  • hydrostatic reduction with enema

- operative reduction -> fixation by appendectomy or to cecal wall

33
Q

Failure of neuromuscular mechanisms (Auerbach’s & Meissner’s plexus) leads to?

A

Paralytic ileus

34
Q

What are the causes of paralytic ileus?

A
  • peritonitis
  • hypokalemia
  • abdominal surgery
  • spine injury
35
Q

What are the clinical features of paralytic ileus?

A
  • no passage of flatus
  • no bowel sounds
  • marked abdominal distention
  • vomiting large volumes of fluid
  • high pitched tinkling note
  • dull abdominal pain (NOT COLICKY)
36
Q

What investigations should be done for paralytic ileus?

A

rule out

  • uremia
  • hypokalemia
  • diabetes
  • DYNAMIC OBSTRUCTION
37
Q

How should paralytic ileus be treated?

A

CONSERVING is better than opening if patient has good general condition

  • don’t stimulate peristalsis
  • NPO
  • NGT
  • measure abdominal girth
  • decompress by flatus tube if possible

recovery in 3-6 days most probably

38
Q

What are the causes of mesenteric vessel ischemia?

A
  • embolism
  • thrombosis -> in portal hypertension & OCP use -> atherosclerosis
  • hypotension/hypoperfusion
39
Q

What pathological features occur in mesenteric vessel ischemia?

A
  • bowel & mesentery edematous, friable, discolored, & collected with fluid & blood
  • within 3 hours mucosa sloughs -> ulcerates -> bleeds in lumen -> bacteria in bloodstream -> whole thickness -> exudates serosanguinous fluid in peritoneum -> functional obstruction
  • can lead to extensive gangrene or focal ischemia
40
Q

What is the clinical picture of mesenteric ischemia?

A
  • acute abdominal pain (doesnt respond to narcotics or NGT)
  • vomiting & obstruction like symptoms
  • BLEEDING PER RECTUM
  • sepsis
  • shock
  • signs of peritonitis (BOARD LIKE RIGIDITY)
41
Q

What investigations should be made to diagnose mesenteric ischemia?

A
  • X-ray -> increase air fluid levels
  • ultrasound - CT
  • arteriography
  • amylase elevated
  • doppler
42
Q

How should mesenteric vessel ischemia be treated?

A

EMERGENCY LAPAROTOMY

  • patient presents after 24-48 hours -> gangrene -> resection & anastomosis
  • within 6 hours -> salvage bowel

Emergency SMA angiography
Heparin or thrombolytics
CLOSE MONITORING for possibility of gangrene formation
Broad spectrum antibiotics

43
Q

What is the cause of chronic ischemia of mesenteric vessels?

A

atherosclerosis at the mouth of superior mesenteric artery

- in old males

44
Q

postprandial abdominal pain starting 15 mins after meal & lasting for an hour is a sign of?

A

chronic ischemia

  • abdominal angina
  • loss of weight (afraid of eating)
  • upper abdominal bruit
45
Q

How should chronic ischemia be diagnosed and treated?

A

US, CTA & MRA

ENDARTERECTOMY (coring out thickened intema) or BYPASS GRAFT

Surgery M4 part 2 (36 decks)

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