1.13 Ileus, Obstruction, Volvulus

Question 1

Describe the 3 major etiologies of bowel obstruction

Answer 1

• Mechanical
  
  • Adhesions
  • Tumors
  • Foreign bodies
  • Volvulus
  • Intussusception
  • IBD
• Ileus/Functional
  
  • Loss of peristalsis
    
    • Post-op ileus
    • Electrolyte deficiencies
      
      • Hypokalemia
    • Retroperitoneal hematoma from spine or pelvic fx
    • Pancreatitis
    • Megacolon
    • Opioid narcotics
• Infection
  
  • Abscess
  • Sepsis

Question 2

Describe cardinal signs/symptoms of small bowel obstruction

Answer 2

• Severe abd pain (complete obstruction)
• High pitched tinkling bowel sounds
• Peritoneal signs
  
  • Abd distention
  • Guarding
  • Rebound tenderness
• Nausea/vomiting
• Feculant odor
• Tachydardia, dehydration

Question 3

Describe diagnosis and management of SBO

Answer 3

• Diagnosis
  
  • Combination of HPI, pysical exam, and labs
    
    • Dehydration, skin turgor, oral mucous membranes, UO down and dark
    • KUB at minimum
  • Opthalmologic exam
  • Intraocular pressure measurement
• Management
  
  • Complete
    
    • Surgical emergency
    • Gastric decompression (NG/OGT)
    • IV fluid bolus and maintenance
    • Analgesia
  • Partial
    
    • Managed conservatively
    • NPO
    • NGT
    • IV fluids: bolus and maintenance
    • Electrolyte replacement
      
      • NGT to suction - Potassium
      • Mag and Phos

Question 4

Contrast these bowel obstructions:

Partial vs Complete

Simple vs. Strangulated

Answer 4

• Complete = nothing passes through
• Simple = blood flow intact
• Strangulated = blood flow prevented/necrosis

Question 5

Describe Cecal Volvulus:

Age

Risk factors

PMH

Presentation

When are you super concerned?

Answer 5

• Age: 30-60y
• Risks/predisposing factors:
  
  • Proximal colon mobile (11-25% of people)
  • Bowel movement restricted from adhesions, calcified lymph nodes, or abdominal mass
• PMHx
  
  • Atonic colon
  • Mass
  • Pregnancy
• Presentation
  
  • Abd pain
  • Abd distention
  • Vomiting
• Concerned
  
  • >13cm
  • Needs colonic decompression
  • Cecum has poor blood supply, volvulus can tamponade blood supply
  • Gangrenous gut

Question 6

What will you see on imaging for cecal volvulus?

What about Sigmoid Volvulus?

Answer 6

• Cecal
  
  • Arises to the Right Lower Quadrant
  • Extends towards the Epigastrum or Left Upper Quadrant
  • Colonic haustra visible
  • Distal colon usually collapsed and small bowel distended
• Sigmoid
  
  • Arises in pelvis (LLQ)
  • Extends twards RUQ
  • Ahaustral (less to notice)
  • Obstruction of proximal large bowel

Question 7

With all volvulus, what is your mgmt?

Answer 7

• First line
  
  • Decompressive colonoscopy
  • If fails…
• Surgery
  
  • Bowel resection
  • If gangrenous, perforated, fecal spillage, definite indication for surgery
  • May need colostomy formation