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Flashcards in Bowel obstruction Deck (17):
1

Common cause of small bowel obstruction in adults

Adhesion due to prev. surgery
Hernia (inguinal, incisional, parastomal)
Crohn's disease
Intestinal malignancy
Appendicitis

2

Common cause of small bowel obstruction in children

Appendicitis
Intussusception
Intestinal atresia
Volvulus.

3

Common symptoms of bowel obstruction

Abdominal pain (crampy, intermittent)
Bloating
Abdominal mass (possible)
Inability to pass flatus or stool
Vomiting

4

Findings on abdominal x-rays for SBO

Partial SBO: gas throughout the abdomen and into the rectum.

Complete SBO: no distal gas, and staggered air-fluid levels.

Complicated SBO: free air under the diaphragm suggestive of perforation; thumb-printing of the bowel suggestive of ischaemia.

5

Differentials of small bowel obstruction

Ileus
Infectious gastroenteritis
Large bowel obstruction
Intestinal pseudo-obstruction
Appendicitis
Pancreatitis

6

Non operative treatment for bowel obstruction

Fluid resuscitation
Bowel decompression (nasogastric tube)
Analgesia
Prophylactic Antibiotic if considering surgery

7

Surgical management for complete SBO or complicated partial SBO

Exploratory Laparotomy
Endoscopic balloon dilation (Crohn's disease)

8

Common causes of large bowel obstruction

Colorectal cancer (90%)
Colonic volvulus - sigmoid or caecal (5%)
Benign strictures (3%) - (i.e., diverticular, inflammatory, ischaemic, radiation-induced, or anastomotic)
Rest are:
Hernia
Foreign body
Benign neoplasm
Gynaecological neoplasm
Pelvic abscess or endometriosis

9

Pathophysiology of LBO

The colon proximal to the cause of mechanical obstruction dilates and, with increased colonic pressure, mesenteric blood flow is reduced producing mucosal oedema with transudation of fluid and electrolytes into the colonic lumen. This can produce dehydration and electrolyte imbalances. With progression, the arterial blood supply becomes jeopardised with mucosal ulceration, full thickness wall necrosis, and eventual perforation. This provides conditions for bacterial translocation, which can produce septic complications. The caecum is the usual site of rupture, as it has the largest diameter, resulting in faecal soilage of the peritoneal cavity and sepsis.

10

Symptoms of LBO

Colicky abdo pain- Increasing constant pain and pain on movement, coughing, or deep breathing may imply perforation or impending perforation.

Abdominal distention
Tympanic abdomen
Change in bowel habits
Palpable rectal/abdominal mass

11

Normal diameter of bowels

Small bowel 3cm
Colon 6cm
Caecum 9cm
3/6/9 rule

12

Surgical management of LBO

Sigmoid Volvulus
Flexible or rigid sigmoidoscopy with insertion of rectal tube (in situ 24hrs)
Where peritonitis or mucosal gangrene has been identified, emergency mid-line laparotomy is required.

Caecal volvulus
Laparotomy. Resection with or without ileostomy is required for non-viable colon

Colorectal malignancy
High risk- Ileostomy or diverting proximal colostomy
Low risk- primary anastomosis in the right colon rather than ileostomy

Diverticular disease
A persistent obstruction merits surgical intervention with either a non-eponymous Hartmann's procedure or a resection and primary anastomosis, with or without a proximal diverting stoma

13

Post op advice for laparotomy patients

Rest-Usually takes 6 weeks to start getting back to regular routine and months to be fully fit.
Avoid excessive, pushing, pulling or lifting
Avoid heavy lifting or activities for 12 weeks
Eat balanced diet avoid fatty foods, cakes, excessive alcohol

14

Immediate Post op complications

Immediate
Primary hemorrhage (starts during procedure)
Reactive hemorrhage ( post op due to increase in BP)
Basal Atelectasis
Shock: Blood loss, MI, PE or Septicaemia
Low urine output

15

Early post op complications

Pain
Acute confusion not due to dehydration or septicemia
Nausea & vomiting: analgesia or anesthetic related, paralytic ileus
Post Op fever
Secondary hemorrhage-infection
Pneumonia
DVT
UTI
Acute urinary retention
Post op wound infection
Pressure sores

16

Late Post op complications

Bowel obstruction due to fibrous adhesion
Incisional hernia
Persistent sinus
Keloid formation
Recurrence of condition causing injury

17

Post Op fever stages

DAY 0-2:

Mild <38 (common): tissue damage and necrosis at op site or formation of haematoma

Persistent >38: Actelectasis-result in infection. Infection in general or drug reaction or blood transfusion

DAY 3-5:
Bronchopneumonia.
Sepsis.
Wound infection.
Drip site infection or phlebitis.
Abscess formation - eg, subphrenic or pelvic, depending on the surgery involved.
DVT.

More than 5 days:
Wound infection.
Distant sites of infection - eg, UTI, chest infection.
DVT, pulmonary embolus.

Specific to surgery: example bowel surgery and leaky anastomosis