Surgical bowel disorders Flashcards
(38 cards)
Ischemic Bowel Disease
● Ischemic Bowel Disease (also known as Mesenteric Ischemia) occurs when blood supply to the intestine is decreased or cut off.
● It could be an acute problem or a
chronic problem (acute versus chronic
mesenteric ischemia).
● Because of the close association with
atherosclerotic disease, chronic is considered a condition of the elderly
Pathophysiology of Ischemic Bowel Disease
■ Embolism- Arterial blood clot becomes lodged.
■ Thrombosisatherosclerotic disease or
dissection or SMV clot
■ Low Flow- Insufficient blood pressure to
maintain adequate blood flow can occur with CHF, shock, or vasoconstrictive Rx (digoxin)
● Aka nonocclusive mesenteric ischemia
Ischemic Bowel Disease S&S (Chronic vs. Acute)
Chronic: presents similarly to “angina,”
where significant pain starts 10-30 minutes after eating food
Acute: comes on suddenly
Both:
○ Abdominal pain out of proportion to the physical exam findings in an elderly patient is classic.
○ Later in the process, involuntary guarding, rebound tenderness, and bloody stool may be positive.
○ A gangrenous bowel can rupture and result in hemodynamic shock
Ischemic Bowel Disease diagnosis:
○ Plain film X-rays may reveal dilated loops
of bowel and free air
○ CTA of the abdomen can rule out other
causes of severe abdominal pain, but may
also reveal the bowel distention and
intestinal edema of ischemic injury.
○ Mesenteric Angiography (arterial access) can provide very precise anatomic diagnosis
(and treatment) of vascular compromise.
(Gold Standard)
Gold standard testing for Ischemic Bowel Disease
Mesenteric Angiography (arterial access)
Ischemic Bowel Disease Management - ACUTE
○ Acute ischemia requires emergent Tx.
■ IV hydration is an important therapy.
■ Most patients require extensive bowel
resection of the diseased bowel.
■ Open laparotomy is preferred
Ischemic Bowel Disease Management - Chronic
○ Chronic ischemia with viable intestine may
be candidates for Angioplasty with
Revascularization. (consult vascular)
■ Anticoagulation is sometimes needed
Postoperative adhesions are the most common etiology of
Small Bowel Obstruction
Etiology of Small bowel obstruction
● Small bowel obstruction is relatively common and can occur
secondary to multiple processes.
● Postoperative adhesions are the most common etiology.
● The second most common etiology is incarceration and strangulation
of a hernia.
● Tumors, intussusception, and volvulus are less-common causes.
Common hernia locations:
● Umbilical
● Inguinal
● Ventral
● Incisional
Small Bowel Obstruction pathophysiology
■ Obstruction of intestinal motility, which leads to intestinal dilation and potential for perforation
■ Strangulation of intestinal tissue, which can lead to ischemic injury and the potential for necrosis and perforation
Small Bowel Obstruction S&S
○ Nausea and vomiting (60-80%)
○ Obstipation
○ Initial abdominal cramping followed by constant severe pain when necrosis is occurring.
○ Cramping abdominal pain often has a
“crescendo-decrescendo” pattern, classically.
○ Distention, diarrhea, inability to flatulate
○ High-pitched bowel sounds are common early
○ GU exam: check for hernias and rectal bleeding
Diagnosis of a Small Bowel Obstruction
○ Upright Chest/ Abdomen X-ray is the most
common 1st diagnostic study. (75% sens)
● Abdomen/Pelvis CT w/ IV and PO
contrast (if tolerated)
When is emergency surgery needed in a small bowel obstruction
Pneumoperitoneum is seen on CT
Small bowel obstruction Management-Nonsurgical (3Ns)
■ Change to NPO diet-bowel rest
■ IV hydration Normal Saline
■ NG tube for gastric decompression
Management-Surgical of small bowel obstructions - When do we do surgery?
■ Signs of ischemic bowel/sepsis
■ Possibility of perforation
■ No improvement after 3-7 days
○ Monitor labs daily
■ CBC
■ CMP
■ Glucose q6
○ Consider TPN (total parenteral nutrition)
Causes of large bowel obstructions:
○ Tumors
○ Volvulus
○ Adhesions
○ Strictures
○ Foreign objects
Volvulus
● Volvulus is the twisting or malrotation of the intestine, small intestine most common in children.
● This is a similar concept to testicular torsion, where the twisting may produce ischemia.
● Bowel obstruction also may occur.
● In adults, most commonly occurs in the sigmoid area of the bowel, followed by cecal region.
● Ischemic injury and bowel perforation are the two largest and significant concerns.
S&S of a volvulus
-Majority present with acute presentation
○ Tachycardia, fever, and constant severe pain accompany ischemia (with concern for necrosis)
Diagnosis of a volvulus
○ Abdominal X-ray is the initial diagnostic
study of choice.
■ Reveals intestinal distention
■ Often described as “double bubble”
What is this?
Pneumoperitoneum - surgical emergency
Volvulus diagnosis
○ Barium Enema-used if no evidence of
peritonitis and inconclusive x-ray
○ CT usually not needed unless suspect
cecal volvulus or pneumoperitoneum
not apparent on x-ray
○ Labs not conclusive, but can point to
complications:
■ CBC: check WBC
■ CMP: check electrolytes
Management of a Volvulus
○ Regardless, definitive treatment is
surgery either elective or emergent
○ Emergent surgical intervention as an open laparotomy is usually
indicated, with reduction of the rotation and resection.
Indications for emergent volvulus surgery
○ Cecal volvulus as endoscopic
decompression unlikely
○ Unsuccessful endoscopic sigmoid
decompression
○ Evidence of ischemia/peritonitis
