Bowel obstruction

Question 1

how can you classify bowel obstruction

Answer 1

mechanical bowel obstruction

paralytic ileus

Question 2

mechanical bowel obstruction classification

Answer 2

intraluminal
intramural
extramural

Question 3

sites of bowel obstruction

Answer 3

SBO

LBO

Question 4

degrees of bowel obstruction

Answer 4

partial
complete
closed loop - at 2 points, segment in middle is building up pressure

Question 5

progression of BO

Answer 5

simple

strangulated

Question 6

Causes of SBO

Answer 6

1. adhesions
2. hernias
   gallstone ileus
   Meckel’s diverticulum
   strictures - Crohn’s
   Malignancy
   Paed:
   congenital atresia
   intussusception

Question 7

Causes of LBO

Answer 7

1. tumours
2. volvulus
   adhesions
   strictures
   faecal impaction
   Paed:
   Hirschprung disease
   meconium ileus
   rectal atresia

Question 8

bacterial translocation in bowel obstruction

Answer 8

bacteria from bowel goes into bloodstream and peritoneum

Question 9

4 cardinal symptoms of bowel obstruction

Answer 9

abdominal pain - colicky
vomiting
constipation
abdominal distension

Question 10

aspects of history you should ask in bowel obstruction for the following:
adhesions
obstructed hernia 
CRC 
bowel ischaemia 
perforation

Answer 10

adhesions - previous surgery, recurrent episodes (structural band)
obstructed hernia - irreducible lump
CRC - elderly, CIBH, weight loss, FH, polyps
bowel ischaemia - change in pain character, becomes sharp
perforation - dramatic change in pain, worse with movement, very unwell

Question 11

clinical findings in bowel obstruction

Answer 11

dehydration 
abdominal distension - 3rd space losses
abdominal inspection 
abdominal tenderness 
septic - perforation 
tympanic percussion 
high pitched tinkling sounds or absent later on 
collapsed empty rectum on DRE

Question 12

explain tinkling bowel sounds

Answer 12

fluid in bowel moves from one point to another, trickling

Question 13

always examine for a hernia, true or false

Answer 13

true, bowel obstruction might be from strangulated hernia

Question 14

complications of bowel obstruction

Answer 14

perforation

infection

Question 15

lab tests for BO

Answer 15

loss of acid and electrolytes, alkalosis in vomiting
high lactate, urea and creatinine
lactic acidosis in bowel strangulation
raised WCC - bacterial translocation

Question 16

radiological investigations for BO

Answer 16

plain supine AXR

CT abdo pelvis

Question 17

AXR features for SBO

Answer 17

step laddering
valvulae coniventes
centrally in the abdomen

Question 18

AXR features for LBO

Answer 18

haustrations

peripherally located

Question 19

what does a coffee bean shape on AXR indicate

Answer 19

volvulus

very high risk of perforation

Question 20

what does gas in the bowel wall mean

Answer 20

sign of ischaemic bowel

Question 21

management of bowel obstruction

Answer 21

ABCDE - urgent resuscitation
‘DRIP’ - IV fluids, electrolyte correction
‘SUCK’ - NG tube for gastric decompression
Bowel rest
IV analgesia and antiemetics

Question 22

why would you not operate on a patient with bowel obstruction

Answer 22

not: likely adhesions, no signs of ischaemia/necrosis/perforation
need active monitoring for 3-5 days

Question 23

would you give prokinetics in BO?

Answer 23

No, Prokinetics are CONTRAINDICATED

Question 24

when would you operate on bowel obstruction

Answer 24

ischaemia
necrosis 
perforation 
tumour 
hernia 
closed loop obstruction 
when it can't be managed conservatively

Question 25

adhesional BO is managed operatively/conservatively

Answer 25

conservatively

Question 26

what must you ensure before operating

Answer 26

optimise the patient a couple of hours prior to theatre rehydrate, correct electrolytes, acidosis Don't just rush to surgery

Question 27

what do you do in theatre if you are unsure that the bowel is dead

Answer 27

wrap bowel in warm towels and wait declares itself either resect or leave it in

Question 28

how does an ileostomy look on the skin

Answer 28

spouts out of skin | like a smaller rose

Question 29

how does a colostomy look on the skin

Answer 29

smaller spout

Question 30

most common cause of paralytic ileus

Answer 30

1. post operative others: hypokalaemia peritonitis and inflammation parturition pelvic fractures neuropathy

Question 31

would you do an abdominal CT to rule out mechanical obstruction, true or false

Answer 31

true

Question 32

what is mechanical bowel obstruction

Answer 32

interruption to the normal passage of bowel contents due to a structural abnormality

Question 33

what is a paralytic ileus

Answer 33

temporary impairment of peristalsis in the absence of mechanical obstruction

Question 34

what is a general rule for differentiating between small and large bowel obstruction from the history

Answer 34

small: early, large volume, bilious vomiting late constipation large: late onset, bilious then faeculent vomiting early constipation abdominal distension