Intestinal obstruction & ileus Flashcards

1
Q

What is intestinal obstruction

A

Mechanical disruption in the patency of the GI tract and flow of intestinal contents, resulting in a combination of emesis, absolute constipation and abdominal pain

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2
Q

What is ileus

A

slowing of gastrointestinal motility accompanied by distention, in the absence of a mechanical intestinal obstruction

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3
Q

What are the causes of small bowel obstruction

A

Duodenal atresia
Jejunal/ileal atresia or stenosis
Malrotation of the gut + volvulus
Meconium ileus
Intussusception
Strangulated inguinal hernia
Meckel’s diverticulum

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4
Q

What are the causes of large bowel obstruction

A

Meconium plug
Hirschsprung’s disease
Anorectal malformation: imperforate anus
Intussusception
Strangulated inguinal hernia

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5
Q

What are the causes of ileus

A

Paralytic ileus:
Gastroenteritis
Electrolyte imbalance e.g. hypokalaemia
Abdominal surgery
Reduced blood supply to intestines

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6
Q

What are the signs and symptoms of intestinal obstruction

A

Persistent bile stained vomiting
Delayed meconium passage
Abdominal distension
Abnormal bowel sounds

The more proximal the obstruction, the more prominent the vomiting and the sooner it becomes bile-stained (unless the obstruction is proximal to the ampulla of Vater)
The more distal the obstructions are more likely to cause significant abdominal distension

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7
Q

What investigations should be done for intestinal obstruction and ileus

A

Bedside: urine dip, stool culture, fecal calprotectin
Bloods: FBC, U&Es, CRP/ESR, calcium and bone profile, TFTs
Imaging: AXR

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8
Q

What do findings on AXR for obstruction suggest

A

Few dilated loops of bowel: proximal obstruction e.g. malrotation, jejunal atresia
Multiple dilated loops of bowel: distal obstruction e.g. ileal atresia, meconium ileus or plug, Hirschsprung’s or anal atresia

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9
Q

What is the management for intestinal obstruction

A
  1. IV fluid and electrolyte correction
  2. Treat the cause:
    Atresia/stenosis: duodenoduodenostomy or laparotomy with primary resection and anastomosis (Jejunal)
    Malrotation: Ladd’s proceudre
    Meconium ileus: gastrograffin contrast, surgical decompression
    Hirschsprung’s: rectal washout/bowel irrigation
    Necrotising enterocolitis: Conservative and supportive for non perforated cases, laparotomy and resection in cases of perforation of ongoing clinical deterioration
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10
Q

What are the complications of intestinal obstruction

A

Small Bowel Obstruction:
- Intestinal ischaemia → infarction → necrosis → perforation → peritonitis
- Sepsis
- Multi-organ failure
- Intra-abdominal abscess
- Short bowel syndrome

Large bowel:
- Intestinal ischaemia → infarction → necrosis → perforation → peritonitis
- Sepsis
- Death

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11
Q

What is the prognosis for intestinal obstruction

A

SBO is medical emergency, and those who are treated in a timely manner have a very good prognosis
SBO is a major cause of morbidity and mortality, and it can be fatal in untreated patients due to its progression to intestinal necrosis, perforation, sepsis, and multi-organ failure.

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12
Q

What are the features of duodenal atresia/stenosis and what investigations should be done

A

Associated with Down’s syndrome (1/3) and other congenital malformations
AXR: double bubble sign
Contrast study for diagnosis

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13
Q

What are the features of jejunal atresia/stenosis and what investigations should be done

A

Multiple atretic segments of the bowel
AXR: air fluid levels

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14
Q

What are the features of meconium plug and what investigations should be done

A

Plus of inspissated meconium causing lower intestinal obstruction
Usually passes spontaneously

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15
Q

What is meconium ileus and what investigations should be done

A

Thick inspissated meconium, putty-like consistency
Becomes impacted in the lower ileum
Associated with cystic fibrosis
Delayed passage of meconium and abdominal distension

AXR: no fluid levels as meconium is viscid
PR contrast studies: may be therapeutic
Sweat test to confirm CF

If no response to PR contrast and NG N-acetyl cysteine -> requires surgery to remove plugs

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16
Q

What is meckel’s diverticulum and its rule of 2s

A

Congenital malformation of the bowel which causes painless massive rectal bleeding in children 1-2yo

(1 to) 2-years-old
2% population
2x more common in boys
2 feet from ileocecal valve
2 inches long
2 different mucosae (gastric and pancreatic)

17
Q

What causes meckel’s diverticulum

A

2% of people have an ileal remnant of the vitello-intestinal duct (also known as omphalomesenteric duct)- a long narrow tube that joins the yolk sac to the midgut lumen of the developing foetus
It contains either gastric mucosa or pancreatic tissue i.e. can form gastric ulcers caused by acidity that bleed
The acid produced within the pouch can be released/ spilled causing ulcers or peritonitis

18
Q

What are the signs and symptoms of meckel’s diverticulum

A

Most asymptomatic
Rectal bleeding - severe (neither bright red or true melaena) -> may cuase haemodynamic instability
May have intractable constipation
Intussusception, volvulus, meckel’s diverticulitis (mimics appendicitis)
Bowel obstruction -> cramps, pain, tenderness
Nausea and vomiting

19
Q

What are the differentials for meckel’s diverticulum

A

Appendicitis - unlikely to have rectal bleeding, pt will be febrile & N+V
Intusception - peak age around 9m, will have colic pain and inconsolable crying
Anal fissure
Polyp
Clotting disorder
Peutz-Jeghers syndrome is a rare autosomal dominant disorder that is characterised by hamartomatous polyposis. Gastrointestinal symptoms first start becoming apparent at around 10 years of age. 

20
Q

What investigations should be done for meckel’s diverticulum

A

Abdo exam
Bedside: stool sample
Bloods: FBC
Imaging: USS, XR, Meckel’s scan
- A Technetium scan (Meckel’s Scan): increased uptake by ectopic gastric mucosa in 70% of cases
- Used if the child is haemodynamically stable with less severe or intermittent bleeding 

21
Q

What is the management for Meckel’s diverticulum

A

Asymptomatic (Incidental imaging finding)
NO treatment required
Detected during surgery for other reasons- prophylactic excision

Symptomatic
Bleeding- excision of diverticulum with blood transfusion (if haemodynamically unstable)
Obstruction- excision of diverticulum and lysis of adhesions
Perforation/ peritonitis- excision of diverticulum or small bowel segmental resection with perioperative antibiotics
Surgery usually performed laparoscopically

22
Q

What are the complications of Meckel’s diverticulum

A

Haemorrhage
Intestinal obstruction
Umbilico-ileal fistulas
Perforation

23
Q

What is the prognosis of Meckel’s diverticulum

A

Excellent if treated in a timely fashion
Most common complication is post-operative bowel obstruction (due to adhesions)