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Presenters
21-5-2009 1pm
Mr. J.J
66 Yr
Colicky pain abdomen with distension – 4days
Vomiting– 4days
Last stools - 3days back
Fever – ...
Admitted at local hospital on 18-05-2009
USG abdomen – normal study
Endoscopy – Dilated stomach with stasis
AXR – dilated ...
O/E
Septic , Severely dehydrated, febrile – 100 F
Pulse – 140/min
BP – 100/60 mm of Hg GRBS – 216 mg%
SPO2 – 94% - O2 mask...
CXR
Patchy hyper dense zones – Rt upper, middle zones
AXR
Dilated small bowel loops
ECG – WNL
? Aspiration Pneumonia (Sept...
Rx
-SICU
O2 mask
Fluid resuscitation
Antibiotics – Tazobactum + piperacillin,
Metronidazole
NBM
RT Aspiration + drainage
RFT
RBS 150 mg/dl
Urea 13 mg/dl
Creatinine 0.7 mg/dl
Sodium 135 meq/l
Potassium 4 meq/l
Chloride 104 meq/l
LFT
Total bilir...
17000/cumm
22-05-2009
Right lower abdomen transverse incision
Omental band – compressing the distal ileum –
released - Obstruction re...
12-10-2009
Mrs. R
F/22 yr
C/C, History
Recurrent pain abdomen – 5 days
Associated vomiting – multiple times
partially dige...
LMP 10 days back, regular menstrual cycles
No co-morbid medical illness
LSCS – few months back
O/E
Screaming with pain abd...
Abdomen
soft, tender left lumbar quadrant
RS, CVS, CNS – NAD
23/10/2009
Mr. S
M/30 yr
C/C
Pain abdomen – 1week
colicky, no radiation
relieves with medication
became severe since previ...
No h/o fever, dysuria, loose stools
Last stools – 3days back
Known APD on PPI – 1year
Alcoholic – quarter whisky daily – 5...
O/E
Conscious, oriented
Dehydrated
Febrile – 101 F
PR – 98/min
BP – 130/90
Abdomen
No Hernia
P/R – NAD
CVS, RS, CNS – NAD
AXR erect – outside – multiple air-fluid levels
USG Abdomen - outside – normal study
Blood reports - ok
06-11-2009 2 AM
Mr. B. M.B
M/65 yr
C/C, History
Sudden enlargement of the Preexisting swelling over
umbilical region (4 yr...
Hypertensive on medication
No h/o DM/TB/IHD/Asthma
O/E
Conscious, oriented, pallor, afebrile
Tachypnoeic, dehydrated, icte...
P/A
20cm x 20cm globular
Tense, tender swelling over umbilical region
engorged veins +, right inguinal hernia repair scar ...
High blood sugars – 424 mg/dl
WBC – 13800/cumm
HB – 7.5 g%
Sodium – 135meq/l
Potassium – 3.7 meq/l
Chloride – 107 meq/l
Post-operative
SICU
Ventilator for 24 hrs
LFT elevated – up to 4th postop day, started
improving
Financial constraints
Dis...
Adhesions (usually postoperative)
Hernia
External (e.g., inguinal, femoral, umbilical, or ventral hernias)
Internal (e...
Lesions intrinsic to the intestinal wall
Congenital
Malrotation
Duplication/Cysts
Inflammatory
Crohn’s disease
Infection...
Intraluminal obstruction
 Gall stone
 Enterolith
 Bezoar
 Foreign body
Adhesions
Hernia
Neoplasm
Crohns
Miscellaneous
Adhesions ~60%
Hernia ~10%
Neoplasm ~20%
Crohns ~5%
Miscellaneous <5%
CAUSE...
Inflammatory fibroid polyp causing
INTUSSUSCEPTION
Inflammatory fibroid polyp is a rare, benign, non neoplastic
lesion of ...
Synonyms
Eosinophilic granuloma
Hemangiopericytoma
Polypoid fibroma
Gastric fibroma with eosinophilic infiltration
Eo...
Inflammatory fibroid polyps are found in all age groups but
peak incidence is between the 6th & 7th decade
Macroscopically...
Clinical symptoms is according to the location
Stomach -symptoms are vomiting, epigastralgia and bleeding.
Small bowel-Int...
Internal hernias are defined as herniation of a viscus, usually
the small bowel, through a normal or abnormal aperture wit...
Internal hernias are paraduodenal in 30%-50% of cases,
and two-thirds of these occur on the left side.
Right and left para...
MESOCOLIC (OR PARADUODENAL) HERNIAS
Mesocolic hernias are unusual congenital hernias in which the
small intestine herniate...
Patients most commonly present with symptoms of acute or
chronic small bowel obstruction.
Barium radiographs will demonstr...
Operative management of patients with a left mesocolic hernia
Incision of the peritoneal attachments and adhesions along t...
Series of small bowel obstruction
Series of small bowel obstruction
Series of small bowel obstruction
Series of small bowel obstruction
Series of small bowel obstruction
Series of small bowel obstruction
Series of small bowel obstruction
Series of small bowel obstruction
Series of small bowel obstruction
Series of small bowel obstruction
Series of small bowel obstruction
Series of small bowel obstruction
Series of small bowel obstruction
Series of small bowel obstruction
Series of small bowel obstruction
Series of small bowel obstruction
Series of small bowel obstruction
Series of small bowel obstruction
Series of small bowel obstruction
Series of small bowel obstruction
Series of small bowel obstruction
Series of small bowel obstruction
Series of small bowel obstruction
Series of small bowel obstruction
Series of small bowel obstruction
Series of small bowel obstruction
Series of small bowel obstruction
Series of small bowel obstruction
Series of small bowel obstruction
Series of small bowel obstruction
Series of small bowel obstruction
Series of small bowel obstruction
Series of small bowel obstruction
Series of small bowel obstruction
Series of small bowel obstruction
Series of small bowel obstruction
Series of small bowel obstruction
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Series of small bowel obstruction

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Transcript of "Series of small bowel obstruction"

  1. 1. Presenters
  2. 2. 21-5-2009 1pm Mr. J.J 66 Yr Colicky pain abdomen with distension – 4days Vomiting– 4days Last stools - 3days back Fever – 1day
  3. 3. Admitted at local hospital on 18-05-2009 USG abdomen – normal study Endoscopy – Dilated stomach with stasis AXR – dilated stomach & small bowel loops. Treated conservatively Since previous day evening breathing difficulty following aspiration while feeding Known Type 2 DM, HTN on oral medication No H/O IHD, Asthma, COPD
  4. 4. O/E Septic , Severely dehydrated, febrile – 100 F Pulse – 140/min BP – 100/60 mm of Hg GRBS – 216 mg% SPO2 – 94% - O2 mask Abdomen distended non tender No mass, no hernias BS++ Chest Rales – more at right CVS, CNS – NAD P/R small amount liquid stool No palpable mass
  5. 5. CXR Patchy hyper dense zones – Rt upper, middle zones AXR Dilated small bowel loops ECG – WNL ? Aspiration Pneumonia (Septicemia) due to ? Small bowel obstruction
  6. 6. Rx -SICU O2 mask Fluid resuscitation Antibiotics – Tazobactum + piperacillin, Metronidazole NBM RT Aspiration + drainage
  7. 7. RFT RBS 150 mg/dl Urea 13 mg/dl Creatinine 0.7 mg/dl Sodium 135 meq/l Potassium 4 meq/l Chloride 104 meq/l LFT Total bilirubin 0.8 mg/dl Direct bilirubin 0.1 mg/dl Total protein 6.2 g/dl Albumin 4.2 g/dl SGOT 25 IU/l SGPT 35 IU/l ALP 110 IU/l Gamma GGT 25 IU/l
  8. 8. 17000/cumm
  9. 9. 22-05-2009 Right lower abdomen transverse incision Omental band – compressing the distal ileum – released - Obstruction relieved Bowel viable No other pathology seen Post op 3 days in SICU 2FFP +2PCV Improved Shifted to ward 26-05-2009 Discharged 30-05-2009
  10. 10. 12-10-2009 Mrs. R F/22 yr C/C, History Recurrent pain abdomen – 5 days Associated vomiting – multiple times partially digested food Admitted in hospital 5days back – 1day Last stools 2 days back No h/o dysuria, fever, loose stools
  11. 11. LMP 10 days back, regular menstrual cycles No co-morbid medical illness LSCS – few months back O/E Screaming with pain abdomen Dehydrated, afebrile PR- 86/min BP – 120/80
  12. 12. Abdomen soft, tender left lumbar quadrant RS, CVS, CNS – NAD
  13. 13. 23/10/2009 Mr. S M/30 yr C/C Pain abdomen – 1week colicky, no radiation relieves with medication became severe since previous day vomiting – 3days 4-5 times/day undigested food Admitted in Govt hospital previous day
  14. 14. No h/o fever, dysuria, loose stools Last stools – 3days back Known APD on PPI – 1year Alcoholic – quarter whisky daily – 5yr Smoker – 2 pack beedis/day – 15yr No h/o abdominal surgeries
  15. 15. O/E Conscious, oriented Dehydrated Febrile – 101 F PR – 98/min BP – 130/90
  16. 16. Abdomen No Hernia
  17. 17. P/R – NAD CVS, RS, CNS – NAD AXR erect – outside – multiple air-fluid levels USG Abdomen - outside – normal study
  18. 18. Blood reports - ok
  19. 19. 06-11-2009 2 AM Mr. B. M.B M/65 yr C/C, History Sudden enlargement of the Preexisting swelling over umbilical region (4 yrs) with pain since 3 days with breathing difficulty. Vomiting since 3days, undigested food Not passed flatus/ stools since 3 days No h/o fever, dysuria Alcoholic – regular- ?years
  20. 20. Hypertensive on medication No h/o DM/TB/IHD/Asthma O/E Conscious, oriented, pallor, afebrile Tachypnoeic, dehydrated, icteric Pulse – 120/min B.P – 150/90 mm of Hg R.R – 38/min SPO2 – 98% - room air
  21. 21. P/A 20cm x 20cm globular Tense, tender swelling over umbilical region engorged veins +, right inguinal hernia repair scar +, BS absent Inguinal , external genitalia – NAD RS Clear Bil. NVBS CVS, CNS - NAD
  22. 22. High blood sugars – 424 mg/dl WBC – 13800/cumm HB – 7.5 g% Sodium – 135meq/l Potassium – 3.7 meq/l Chloride – 107 meq/l
  23. 23. Post-operative SICU Ventilator for 24 hrs LFT elevated – up to 4th postop day, started improving Financial constraints Discharged at request Doing well at local hospital
  24. 24. Adhesions (usually postoperative) Hernia External (e.g., inguinal, femoral, umbilical, or ventral hernias) Internal (e.g., congenital defects viz paraduodenal,diaphragmatic hernias or postoperative secondary to mesenteric defects) Neoplastic Carcinomatosis Extraintestinal neoplasms Intra-abdominal abscess CAUSES OF SMALL BOWEL OBSTRUCTION Lesions Extrinsic to the Intestinal Wall
  25. 25. Lesions intrinsic to the intestinal wall Congenital Malrotation Duplication/Cysts Inflammatory Crohn’s disease Infections Tuberculosis Actinomycosis Diverticulitis Neoplastic Primary neoplasms Metastatic neoplasms Traumatic Hematoma Ischemic Stricture Miscellaneous Intussusception Endometriosos Radiation enteropathy/Stricture
  26. 26. Intraluminal obstruction  Gall stone  Enterolith  Bezoar  Foreign body
  27. 27. Adhesions Hernia Neoplasm Crohns Miscellaneous Adhesions ~60% Hernia ~10% Neoplasm ~20% Crohns ~5% Miscellaneous <5% CAUSES OF SMALL BOWEL OBSTRUCTION
  28. 28. Inflammatory fibroid polyp causing INTUSSUSCEPTION Inflammatory fibroid polyp is a rare, benign, non neoplastic lesion of the GIT Originates from submucosa and grows as a polypoid mass Most common in stomach rarely in colon and small bowel lesion was first described by Vanek in 1949
  29. 29. Synonyms Eosinophilic granuloma Hemangiopericytoma Polypoid fibroma Gastric fibroma with eosinophilic infiltration Eosinophilic gastroenteritis Polyp with eosinophilic granuloma Inflammatorypseudotumor
  30. 30. Inflammatory fibroid polyps are found in all age groups but peak incidence is between the 6th & 7th decade Macroscopically - sessile or a pedunculated polypoid lesion . Usually non-encapsulated and shows an ulceration in the overlying mucosa Microscopically-Shows cellular proliferation possibly originating from the submucosa.
  31. 31. Clinical symptoms is according to the location Stomach -symptoms are vomiting, epigastralgia and bleeding. Small bowel-Intussusception and obstruction Colonic -colicky pain, weight loss, diarrhea, bleeding and anemia The treatment is surgical resection of the lesion.
  32. 32. Internal hernias are defined as herniation of a viscus, usually the small bowel, through a normal or abnormal aperture within the peritoneal cavity. These hernias may be either congenital or acquired. Its incidence has been reported to be 1-2%. This herniation may be persistent or intermittent. Internal hernia is a rare cause of small bowel obstruction with a reported incidence of 0.2-0.9%.
  33. 33. Internal hernias are paraduodenal in 30%-50% of cases, and two-thirds of these occur on the left side. Right and left paraduodenal hernias are separate entities, differing in embryologic origin. The left mesocolic hernia is a result of anomalous rotation of the midgut into the developing mesentery of the descending colon. The sac lies to the left of the duodenum, and the inferior mesenteric vessels constitute the anterior free margin
  34. 34. MESOCOLIC (OR PARADUODENAL) HERNIAS Mesocolic hernias are unusual congenital hernias in which the small intestine herniates behind the mesocolon. Result from abnormal rotation of the midgut and have been categorized as either right or left
  35. 35. Patients most commonly present with symptoms of acute or chronic small bowel obstruction. Barium radiographs will demonstrate displacement of the small intestine to the left or the right side of the abdomen. CT with IV contrast may demonstrate displacement of the mesenteric vessels and evidence of intestinal obstruction, if present.
  36. 36. Operative management of patients with a left mesocolic hernia Incision of the peritoneal attachments and adhesions along the right side of the inferior mesenteric vein Reduction of the herniated small intestine from beneath the inferior mesenteric vein. The neck of the hernia may be closed by suturing the peritoneum adjacent to the vein to the retroperitoneum

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