Bowel obstruction

Question 1

Causes of bowel obstruction?
common (3)
less common (bonus - 6)

Answer 1

adhesions, followed by tumors and hernias

Bonus - strictures, intussusception, volvulus, Crohns Disease, foreign bodies, and gallstones

Question 2

Classic symptom history for bowel obstruction

Answer 2

Abdo pain
Nausea and vomiting
Feel distended
No bm 
Not passing flatus

Question 3

Classic physical exam findings for SBO
simple (2)
more severe (3)

Answer 3

looks distended, firm maybe
diffusely tender to palpation
Could be peritonitic, gaurding, rebound if perfed

Question 4

Imaging for SBO

Answer 4

Xray - Abdo and CXR to assess for perf, air fluid levels

CT abdo - if need to further characterize or assess for complications like abscess formation

Question 5

Which patients are in need of emergent surgical intervention or surgical consultation?

Answer 5

All patients with SBO need surgical consult

More emergent if strangulated, signs of necrosis, perforation

Question 6

Most common cause of large bowel obstruction?

Answer 6

malignancy

Question 7

Four terms important to communicate obstruction..
Degree of obstruction (2)
Most severe (1)

Answer 7

Partial or complete
- gas or liquid stool can pass vs no substance

Strangulated
- perfusion compromised and necrosis ensues, leads to to perforation, peritonitis

Question 8

Potential immediate interventions for patient with bowel obstruction who presents with copious vomiting…
vitals - HR 130, BP 95/65, RR 24, Sats 90-93%, T 36

ABC’s - airway considerations

Answer 8

Airway

• consider intubation for airway protection if copious emesis and not mentating well
• consider NG tube to control vomiting (and antiemetics obv)

Question 9

Potential immediate interventions for patient with bowel obstruction who presents with copious vomiting…
vitals - HR 130, BP 95/65, RR 24, Sats 90-93%, T 36

ABC’s - breathing considerations

Answer 9

Breathing - supplemental oxygen as necessary

Question 10

Potential immediate interventions for patient with bowel obstruction who presents with copious vomiting…
vitals - HR 130, BP 95/65, RR 24, Sats 90-93%, T 36

ABC’s - circulation considerations

Answer 10

Circulation - large bore IV x2 if worried, tachycardia or hypotension administer a fluid bolus and drip

Question 11

What symptoms on history might be more prevalent in proximal SBO?

Answer 11

nausea and vomiting

Question 12

Character of abdo pain in obstruction?

Answer 12

Simple obstruction - crampy and intermittent

Strangulation or ischemia - development to severe pain

Question 13

Explain how a patient with an bowel obstruction might have a 12-24 hour history of diarrhea?

Answer 13

Diarrhea early in the course of bowel obstruction is possible as the distal portion of the bowel empties which then progresses to an inability to pass flatus and obstipation

Question 14

Patient with a diagnosed bowel obstruction with no history of abdo surgery, what should you think about?

Answer 14

• underlying cause might be tumor or hernia

Question 15

Important PMHx questions when you suspect bowel obstruction? (2)

Answer 15

• any abdo surgeries b/c adhesions

- GI diseases like Crohns or Colitis

Question 16

Two reasons to examine genitals in men with abdo pain?

Answer 16

testicular torsion

HERNIA!

Question 17

What are you looking for on DRE for abdo pain presentation?

What finding and what does it suggest?

Answer 17

visible blood - may suggest strangulation

hemoccult positive stool - may suggest malignancy

Question 18

What factor about bowel obstructions impacts whether your patient may be distended or not on history or exam?

Answer 18

Location - abdominal distension is more prevalent in distal obstructions

Question 19

What are 3 signs that would make you more concerned for strangulated bowel?
hint - vitals (2), exam (1)

Answer 19

Fever
Tachycardia
Peritonitic

Question 20

What should you do if the abdo xray is unremarkable but you’re still worried about their abdo pain?

Answer 20

• serial exams or home if they’re reliable
• consider US if you’re worried about radiation
• consider getting CT abdo

Question 21

Three good reasons to get a CT abdo in context of confirmed or likely bowel obstruction (3)

Answer 21

1. identify other cause of the acute abdominal pain such as abscess, hernia, tumor, or inflammation.
2. etiologies of SBO (extrinsic causes such as adhesions and hernia vs intrinsic causes such as neoplasms or Crohn disease).
3. recognize complications of the obstruction that might change urgency or method of management.

Question 22

Initial management of a confirmed SBO with a ++vomity patient

hint - obvious stuff (3), vomit related (1), big question (1)
bonus - managementy (1), good docs would do this (1)

Answer 22

Symptoms - pain, nausea
Resuscitation - fluids, electrolyte replacement
Surgical or not, and urgency of this (ie consult)

Bonus
GI decompression - NG tube
Cause of the obstruction (?malignancy)

Question 23

Why should you frequently reassess your SBO abdo pain patient?

Answer 23

Things change, make sure that the patient is not developing signs of strangulation - severity of pain, vitals changing, peritoneal signs

Question 24

Worst complication of bowel obstruction?

Answer 24

Strangulation is the most lethal complication of small bowel obstruction, dead bowel must be resected

Question 25

Perforated hollow viscus is a life-threatening cause of abdominal pain and carries a mortality of what percent??

Ballpark is fine

Answer 25

30-50%