Patient with chronic constipation & abdominal distension

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Patient with chronic constipation & abdominal distension

  1. 1. MUSADAQ ASRAR Shifa College of Medicine 2013-051
  2. 2.  A 95 yr old woman is sent to the ER from nursing home with complaints of abdominal pain and distension. It is unclear, but staff at nursing home thinks it has been about 4 days since she had a bowel movement.
  3. 3.  The woman has an expressive aphasia and rt. hemiparesis from a previous stroke.  Her vitals; pulse 90, B.P 120/80, afebrile.  Her abdomen is markedly distended with hyperactive bowel sounds and tympanitic throughout.  There is no abdominal tenderness.  Rectal exam reveals large quantities of soft, brown stool.  KUB and upright images reveal marked dilated colon consistent with obstruction.
  4. 4. Classification. Can be divided into paralytic and mechanical.  Mechanical is further classified according to, 1. Speed of onset: acute, chronic, acute on chronic 2. Site: high or low. 3. Nature: simple or strangulated 4. Aetiology.
  5. 5.  In acute obstruction, the onset is rapid and the symptoms are severe.  In chronic obstruction, symptoms are insidious and slowly progressive e.g most case of carcinoma of large bowel.  A chronic obstruction may develop acute symptoms as obstruction becomes complete. e.g narrow lumen occluded by inspissated bowel contents.
  6. 6.  Small intestine  Large intestine  Simple: when bowel is occluded without damage to its blood supply.  Closed loop obstruction  Strangulated: blood supply of involved segment is cut off. e.g strangulated hernia, volvulus, intussusception.  Gangrene is inevitable if left untreated.
  7. 7.  Causes in the lumen; fecal impaction, gallstone ‘ileus’, food bolus, parasites, intussusception.  Causes in the wall; congenital atresia, Crohn’s, tumors, diverticulitis.  Causes outside the wall; strangulated hernia, volvulus and obstruction due to adhesions or bands.
  8. 8.  Neonatal; congenital atresia, stenosis, imperforate anus, volvulus neonatorum, hirschsprung’s and meconium ileus.  Infants; intussusception, hirschsprung’s, strangulated hernia, and meckel’s diverticulum.  Young & middle age; strangulated hernia, adhesion, bands and Crohn’s disease.  Elderly; strangulated hernia, carcinoma of bowel, colonic diverticulitis, impacted faeces.
  9. 9.  Simple occlusion causes Intestine distal to obstruction to empties rapidly and collapsed. The bowel above the obstruction becomes dilated with gas and secretions, increased peristalsis to over come obstruction causes which intestinal colic.  Impaired blood supply due to distention may cause mucosal ulceration and perforation.
  10. 10.  Integrity of mucosal barrier lost due to ischemia.  Secondary peritonitis occurs due to transudation of organisms in gut.  Strangulation is followed by gangrene of the ischemic bowel with perforation.
  11. 11.  Fluid and electrolyte depletion occur due to copious vomiting and loss into the bowel lumen.  Protein loss into the gut and toxemia due to migration of toxins and intestinal bacteria into the peritoneal cavity.
  12. 12.  Colicky abdominal pain.  Distension.  Absolute constipation.  Vomiting.
  13. 13.  Small bowel; pariumbilical  Distal colonic; suprapubic in location  Postoperative obstruction; colic may be disguised by general discomfort.
  14. 14.  Usually seen in chronic large bowel obstruction.  Volvulus of the sigmoid colon.  In high intestinal obstruction distension will not be marked.
  15. 15.  Failure to pass flatus or faeces.  It is an early feature in large bowel obstruction.  Late feature in small bowel obstruction.  Pt. may pass 1 or 2 stools after onset of obstruction as bowel completely empties below obstruction.
  16. 16.  Usually occurs in high obstruction, but late in low bowel obstruction, or may be absent.  In late stages vomiting becomes faeculent but not faecal.  True vomiting of faeces occurs only in gestrocolic fistula.
  17. 17.  Dehydration  Elevated pulse  Temperature usually raised in strangulation.  Distention and visible peristalsis  Any hernia or presence of any abdominal scar suggests adhesions or bands as a cause.  Mass in intussuseption or carcinoma  Digital rectal examination.
  18. 18.  Strangulation verses simple must be distinguished because strangulation ensuing peritonitis has a high mortality of up to 15%.  Toxic appearance  Colicky pain  Tenderness & abdominal rigidity  Absent bowel sounds  Raised white cell count
  19. 19.  Abdominal x rays; erect and supine  Barium follow through; in cases of small bowel  barium enema.  Sigmoidoscopy; chronic obstruction  Colonoscopy; chronic obstruction  CT scan
  20. 20. Ladder pattern of dilated loops
  21. 21. haustrations in large bowel obstruction
  22. 22.  IV fluids and nasogastric aspiration. (dip and suck)  Nil orally  2 hourly temperature and pulse  Abdominal examination 8 hourly.
  23. 23.  Strangulating obstruction  Dip and suck regimen failure  Also require for simple obstruction which fails to settle.  Caecum >10 cm in diameter on radiograph.  At the surgery bowel is inspected for viability.  Non viability includes 1. Absence of peristalsis 2. Loss of normal sheen 3. Loss of pulsation in mesentry 4. Color; green or black, purple may recover
  24. 24.  Small bowel; can be resected and primary anastomosis performed with safety because of rich blood supply  Large bowel; resection of obstructing lesion & primary ileocolic anastomosis (lesion proximal to splenic flexure). Left sided lesions; excision of affected segment and exteriorizing the two ends of colon as a temporary colostomy and mucus fistula.  If not reached to surface it is closed ( hartmann’s procedure)
  25. 25.  T.B  Meckel’s diverticulum  Tumours
  26. 26.  Occurs in elderly, constipated patients  4 time common in men  X ray shows distended loop of a bowel the shape of a ‘coffee bean’ arising out of the pelvis on the left side. Barium enema gives bird beak appearance.  Treatment; decompression by sigmoidoscopy.  Rectal flatus tube placed in situ for 48 h. later elective resection.
  27. 27.  If decompression is unsuccessful or there are signs of gangrene or perforation, laparotomy with resection is under taken, the two ends of the colon being brought out as a double barrelled colostomy. Paul- Mikulicz procedure which is later closed.
  28. 28.  Usually associated with congenital malformation. Excessively mobile caecum and ascending colon, defect in rotation, caecum retain its mesentry.  AXR; dilated caecum in left upper quadrant  Treatment; laparotomy, if bowel is viable, untwisting with caecostomy. Right hemicolectomy is necessary if the caecum is infarcted, and to prevent recurrence.  The mortality rate is high
  29. 29.  Mesenteric embolus; AF, vegetation on valves.  Mesenteric arterial thrombosis; atheroma, aortic dissection.  Mesenteric venous thrombosis; portal hypertension, may follow splenectomy. Crohn’s disease, OCPs.
  30. 30.  Vascular occlusion results in infarction of the affected gut, leads to bleeding.  Gangrene and perforation occurs  Classic triad; acute abdominal pain, rectal bleeding, shock in an elderly who has AF.  Treatment; early embolectomy and revascularization before gangrene sets up.
  31. 31.  Lower abdominal colicky pain  Alternating constipation and diarrhoea  Abdominal distension  Sigmoidoscopy to exclude carcinoma  D.D’s; Ca colon, crohn’s, ischemic colitis  Complications; large bowel obstruction, hemorrhage, fistula, perforation and stricture.
  32. 32.  Treatment; resection either by Hartmann’s procedure followed by subsequent restorative surgery or a primary anastomosis protected by a temporary defunctioning loop ileostomy.
  33. 33.  Telescoping of the one segment of bowel into adjacent segment.  Ileo-colic  Ileo-ileal  Ileo-caecal  Colo-colic
  34. 34.  Most common in children 5-10month of age  70-90% idiopathic  Other association; meckel’s diverticulum, polyp in children  Adult intussuseption is associated with peutz- jegher’s syndrome, lipoma or tumor  Redcurrent jelly stool.  Sausage shaped hump in the abdomen and emptiness in RIF.
  35. 35.  USG diagnostic  Barium enema give claw sign  CT-scan  Treatment; resuscitation, hydrostatic reduction, surgery (cope’s method)
  36. 36.  Intestinal atresia  Volvulus neonatorum  Meconium ileus  Necrotizing enterocolitis  Hirschsprung’s disease  Anorectal atresias
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