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Large bowel obstruction power point

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  • 1.  78 year old white female presents from nursing home with increasing abdominal distention, vomiting, cramping abdominal pain, and 3 days of constipation. Pt has a history of chronic constipation. T: 99.0 P 115 R 16 BP 110/75 Gen: Elderly white female with chronic debilitation, actively vomiting in room. HEENT: PERRL, NC/AT, Oropharynx clear, CV: mildly tachycardic, no m/r/g Pulm: CTAB Abd: abdominal distention, decreased bowel sounds, diffuse TTP, hyperressonance to percussion Ext: 2+ pulses, no c/c/e
  • 2. What is Diagnosis? (1) Dilated Colon >6cm (2) Effacement of Haustrae Peripherally located (3) Multiple Air Fluid Levels Large Bowel Obstruction
  • 3.  IV & IVFs  Analgesics & Antiemetics  NG decompression  Antibiotics for Gram (-) Aerobes & Anaerobes (ie. Flagyl, Cipro, Zosyn, Clindamycin)  Surgery Consult  Admission for all LBO  Emergency Laparotomy if:  (1) Peritonitis (2) Peritoneal Free Air (3) Sepsis (4) Cecal Distention >12cm
  • 4.  How to Differentiate Large from Small Bowel Obstruction:  Gas in the Large Bowel is usually situated peripherally.  Gas in the small bowel is usually centrally located.  Large intestine has haustrae, which are blunter, thicker, and do not completely transverse intestine.  Small Intestine has valvulae conniventes that transverse width of intestine, giving it a ribbed appearance.  Feces are only found in Large Intestine.
  • 5.  Rule of 3,6,9:  suspect obstruction if small bowel dilated >3cm; large bowel >6cm, cecum >9cm.  Causes of LBO:  Carcinoma (60%), Diverticulitis (20%), Volvulus (10%)
  • 6.  String of Pearls Sign = obstruction  Small Bowel: air pockets trapped in valvulae of small intestine, smaller, rounder  Large Bowel: air pockets trapped in haustra, larger, and have flat underside Large Bowel Small Bowel
  • 7.  Greenberg, Michael. Greenberg’s Atlas of Emergency Medicine.  Ginzberg, Leon. “X-Ray Diagnosis of Acute Intestinal Instruction Without the Use of Contrast Media” Annals of Surgery  Lifeinthefastlane.com “Abdominal X-Ray Interpretation”  Schwartz, David. Emergency Radiology. 2000. pg 527- 529.  Tintanelli’s Emergency Medicine: A Comprehensive Study Guide. Chapter 79 Intestinal Obstruction