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Food/electrolyte status in small bowel obstruction? Mechanism? Treatment?

Dehydration (from vomiting and poor oral intake)

contraction alkalosis with hypokalemia (Alkalosis from increased hydrogen secretion stomach, and hypokalemia from retention of H at the expense of K I. Kidney)

IV fluids

1

45-year-old woman with three day history of nausea and crampy abdominal pain followed by vomiting and abdominal distention. Last bowel movement over three days ago. Crescendo-decrescendo bowel sounds. No stool in rectum. WBC count of 14,000 – suspected diagnosis? Test? (Expected Interpretation?)

Small bowel obstruction

Abdominal radiograph (upright and lateral) – multiple air fluid levels in small bowel but no air in colon or rectum

2

45-year-old woman with three day history of nausea and crampy abdominal pain followed by vomiting and abdominal distention. Last bowel movement over three days ago. Crescendo-decrescendo bowel sounds. No stool in rectum. Management?

Small bowel obstruction

1. NG tube drainage
2. IV fluids
3. Observe for signs of ischemia or perforation (leukocytosis, fever, acidosis, localized tenderness)

3

45-year-old woman with three day history of nausea and crampy abdominal pain followed by vomiting and abdominal distention. Last bowel movement over three days ago. Crescendo-decrescendo bowel sounds. No stool in rectum. Treatment is begun. Patient improvements over the next several days, pain resolves, and appetite returns. Current management?

1. Remove NG tube
2. Begin feeding and if Patient tolerates food, discharge

4

45-year-old woman a one day history of nausea and crampy abdominal pain followed by vomiting and abdominal distention. Last bowel movement over three days ago. Crescendo-decrescendo bowel sounds. No stool in rectum. Suspected diagnosis?

If one day duration of symptoms, suspect more proximal obstruction (no change in management)

5

45-year-old woman with three day history of nausea and crampy abdominal pain followed by vomiting and abdominal distention. Last bowel movement over three days ago. Crescendo-decrescendo bowel sounds. No stool in rectum. History of prior appendicitis. Presumptive diagnosis?

Small bowel obstruction due to Adhesions secondary to prior appendectomy

6

45-year-old woman with three day history of nausea and crampy abdominal pain followed by vomiting and abdominal distention. Last bowel movement over three days ago. Crescendo-decrescendo bowel sounds. Diagnoses higher on differential if Heme positive stool in rectum?

Obstructing tumor or ischemic bowel

7

45-year-old woman with three day history of nausea and crampy abdominal pain followed by vomiting and abdominal distention. Last bowel movement over three days ago. Crescendo-decrescendo bowel sounds. No stool in rectum. Passing of flatus. Suspected diagnosis? Less likely complications?

Partial small bowel obstruction

Ischemia, perforation

8

45-year-old woman with three day history of nausea and crampy abdominal pain followed by vomiting and abdominal distention. Last bowel movement over three days ago. Crescendo-decrescendo bowel sounds. Small amount of diarrhea. Suspected diagnosis? Differential?

Partial obstruction; fecal impaction, severe constipation

9

45-year-old woman with three day history of nausea and crampy abdominal pain followed by vomiting and abdominal distention. Last bowel movement over three days ago. Crescendo-decrescendo bowel sounds. No stool in rectum. Presence of inguinal hernia – management?

Urgent laparoscopic repair and relief of bowel obstruction

10

Most common tumor that metastasizes to the intestine?

Management of tumor related obstructions?

Melanoma

Do not resolve with nonoperative management – must get surgery

11

45-year-old woman with three day history of nausea and crampy abdominal pain followed by vomiting and abdominal distention. Last bowel movement over three days ago. Crescendo-decrescendo bowel sounds. No stool in rectum. Previously excised ovarian cancer – suspected diagnosis? Management?

Local recurrence of cancer or peritoneal stunning

Debulking if incurable cancer

12

45-year-old woman with three day history of nausea and crampy abdominal pain followed by vomiting and abdominal distention. Last bowel movement over three days ago. Crescendo-decrescendo bowel sounds. No stool in rectum. Signs that warrant surgical intervention? Why?

Peritonitis! Leukocytosis, fever, acidosis, localized tenderness

indicates series complication (closed loop obstruction, perforation, ischemia, abscess)

13

Patient with suspected small bowel obstruction. Sign that can warrant urgent exploration or mesenteric arteriography?

Metabolic acidosis (indicating ischemic or necrotic bowel)

14

30 year old woman with small bowel obstruction and no evidence of complications. Test history of appendicitis. Past history of appendicitis. Place NG tube, and correct fluid/electrolyte abnormalities. Partial improvement with some flatus and one small bowel movement. Upon removing NG tube, becomes nauseated and distended. Next step? Most likely finding? Management?

Exploratory laparotomy

Adhesive band scar tissue from the appendicitis

Lysis of adhesions

15

46-year-old woman who presents with signs and symptoms of small bowel obstruction. Radiograph shows closed loop obstruction – physiology? Locations? management?

Adhesive band occludes inlet and outlet of loop of bowel – accumulates secretions and air. Can become ischemic or can perforate.

Exploration.
1. Determine whether bowel is viable (if not, resect and re-anastomose)
2. If unsure, second look operation 24 hours later

16

46-year-old woman who presents with signs and symptoms of small bowel obstruction. Has crampy abdominal pain and free air in peritoneal cavity. Suspected diagnosis?

Surgical exploration Due to likely perforation

17

46-year-old woman who presents with signs and symptoms of small bowel obstruction. Evidence of herniation. Management options?

Urgent exploration after resuscitation

1. If stable patient, exploration through hernial incision is growing
2. If ill, midline abdominal incision

18

60-year-old man with small bowel extraction and dense adhesions. During lysis, enter bowel lumen. Management? Post operative problems?

It's small, primary repair. If big, may require resection

Postoperative leak or small bowel fistula

19

49-year-old man recovering from pneumonia. Abdominal distention, nausea, crampy abdominal pain develops – differential? How to confirm diagnosis?

1. Small bowel obstruction
2. Air swallowing
3. Constipation
4. Paralytic ileus

Upper G.I. series with barium swallow