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Small bowel obstruction


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Small bowel obstruction

  2. 2. Epidemiology  Most frequent surgical disorder of the small intestine  Etiologies according to their relationship to intestinal wall:  1. Intraluminal (e.g., foreign bodies, gallstones, or meconium)  2. Intramural (e.g., tumors, Crohn's disease–associated inflammatory strictures)  3. Extrinsic (e.g., adhesions, hernias, or carcinomatosis)
  3. 3. Continue  75% of cases is caused by intra-abdominal adhesions related to prior abdominal surgery  Less prevalent etiologies include:  hernias  malignant bowel obstruction  (extrinsic compression or invasion from neoplasms arising in organs other than the intestine)  and Crohn's disease
  4. 4. Continue  Congenital abnormalities  Usually become evident during childhood  intestinal malrotation and midgut volvulus should not be forgotten in adult patients  especially in those without history of prior abdominal surgery
  5. 5. Pathophysiology  In the onset, gas and fluid accumulate within the intestinal lumen proximal to the site of obstruction  Intestinal activity increases Colicky pain & Diahrrea  Where does the gas & fluid come from?  Bowel distends and intraluminal and intramural pressures rise  Impair of intestinal microvascular perfusion Ischemia Necrosis  strangulated bowel obstruction
  6. 6. Continues  partial small bowel obstruction  only a portion of the intestinal lumen is occluded  pathophysiologic events occur more slowly & strangulation is less likely  closed loop obstruction  accumulating gas and fluid cannot escape  Leading to a rapid rise in luminal pressure, and a rapid progression to strangulation
  7. 7. Clinical Presentation  colicky abdominal pain, nausea, vomiting, and obstipation  Vomiting is more seen with proximal obstructions than distal  In established obstructions you see vomitus more feculent  Continued passage beyond 6 to 12 hours after onset of symptoms is characteristic of partial obstruction  Abdominal Distention is another sign, esp. if the obstruction is in distal ileum, absent if in proximal small intestine  Bowel sounds
  8. 8. Continue  Laboratory findings intravascular volume depletion consist of:  hemoconcentration and electrolyte abnormalities  Mild leukocytosis is common  Features of strangulated obstruction include:  Odd abdominal pain, suggestive of intestinal ischemia  tachycardia, localized abdominal tenderness, fever, marked leukocytosis, and acidosis  Any of these findings must alert you to the possibility of strangulation Surgery
  9. 9. example  Chronic partial small bowel obstruction  several months' history of chronic abdominal pain, and intermittent vomiting  dilated segment shows evidence of fecalization
  10. 10. Diagnosis  Focus on the following goals: (a) distinguish mechanical obstruction from ileus (b) determine the etiology of the obstruction (c) discriminate partial from complete obstruction (d) discriminate simple from strangulating obstruction
  11. 11. Continue  Important elements to obtain on history:  prior abdominal operations (suggesting the presence of adhesions)  abdominal disorders (e.g., intra-abdominal cancer or inflammatory bowel disease)  hernias (esp. in inguinal & femoral regions)  Blood in Stool (Strangulation)
  12. 12. Radiographic Examination  Abdominal series in X-ray: (1) Abdomen Supine, (2) Abdomen Upright, (3) Chest Upright.  most specific triad for small bowel obstruction:  dilated small bowel loops (>3 cm in diameter)  air-fluid levels  a paucity of air in the colon  Specificity of plain Radiography is low (ileus and colonic obstruction)  False-negative (proximal of small intestine OR filled with fluid but no gas)
  13. 13. CT-Scan  a discrete transition zone with:  dilation of bowel proximally, decompression of bowel distally,  intraluminal contrast that does not pass beyond the transition zone,  and a colon containing little gas or fluid  Closed-loop obstruction  U-shaped or C-shaped dilated bowel loop  mesenteric vessels converging toward a torsion point  Strangulation (thickening of the bowel wall, pneumatosis intestinalis)
  14. 14. Therapy  marked depletion of intravascular volume decreased oral intake, vomiting, and sequestration of fluid in bowel lumen and wall  IV fluid and bladder catheter(urine output)  Broad-spectrum antibiotics  NG tube (decreases nausea, distention, and the risk of vomiting & aspiration)
  15. 15. The END