This document discusses the evaluation and management of intestinal obstruction. Key points include:
- Intestinal obstruction is most commonly caused by adhesions, malignancy, or herniation and presents with abdominal pain, nausea/vomiting, and inability to pass gas/stool.
- Diagnostic testing includes abdominal x-rays, which show dilated bowel loops in 60% of cases, and CT scan, which is more sensitive and can identify the level and cause of obstruction.
- Management involves fluid resuscitation, bowel rest with nasogastric decompression, and surgery if there is evidence of vascular compromise, perforation, or failure to resolve with conservative measures.
Please find the power point on Gastric Outlet Obstruction. I tried present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you
collected from multiple general surgery references (2016) like bailey's and loves short practice of surgery , Schwartzs Principles of Surgery, 10th Edition , Schwartzs Principles of Surgery, 10th Edition and Matary's GIT surgery .
Gastro esophageal Reflux Disease (GERD) and its managementDr. Ankit Gaur
In this presentation I have tried to explain in brief about gastro esophageal Reflux Disease (GERD), its etiology, risk factors, diagnosis, and its management via pharmacotherapy.
Gastric Perforation From Peptic Ulcer Disease - A Review of the Surgical Trea...Joseph A. Di Como MD
A PowerPoint presentation reviewing gastric perforation for peptic ulcer disease and a review of the surgical treatment options. Intended for medical professionals and students.
GERD (Gastro Esophageal Reflux Disease) is one of the commonest medical conditions found in the community today. GERD patients often suffer from frequent symptoms and require long term medication. However, how much of what we know about GERD is truly fact based on medical evidence? We challenge traditional paradigms to GERD
Autors: Richard M. Gore, MD*, Robert I. Silvers, MD, Kiran H. Thakrar, MD,
Daniel R. Wenzke, MD, Uday K. Mehta, MD, Geraldine M. Newmark, MD,
Jonathan W. Berlin, MD
Please find the power point on Gastric Outlet Obstruction. I tried present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you
collected from multiple general surgery references (2016) like bailey's and loves short practice of surgery , Schwartzs Principles of Surgery, 10th Edition , Schwartzs Principles of Surgery, 10th Edition and Matary's GIT surgery .
Gastro esophageal Reflux Disease (GERD) and its managementDr. Ankit Gaur
In this presentation I have tried to explain in brief about gastro esophageal Reflux Disease (GERD), its etiology, risk factors, diagnosis, and its management via pharmacotherapy.
Gastric Perforation From Peptic Ulcer Disease - A Review of the Surgical Trea...Joseph A. Di Como MD
A PowerPoint presentation reviewing gastric perforation for peptic ulcer disease and a review of the surgical treatment options. Intended for medical professionals and students.
GERD (Gastro Esophageal Reflux Disease) is one of the commonest medical conditions found in the community today. GERD patients often suffer from frequent symptoms and require long term medication. However, how much of what we know about GERD is truly fact based on medical evidence? We challenge traditional paradigms to GERD
Autors: Richard M. Gore, MD*, Robert I. Silvers, MD, Kiran H. Thakrar, MD,
Daniel R. Wenzke, MD, Uday K. Mehta, MD, Geraldine M. Newmark, MD,
Jonathan W. Berlin, MD
Annular pancreas is an uncommon condition in adults.
The ring formation generally originates from the failure of
normal clockwise rotation of ventral pancreas. First
described by Tiedmann in 1818, its incidence is
1:20,000 population. It has bimodal presentation i.e is seen
either in Infants or in 4th & 5th decade of life.
An intestinal obstruction occurs when your small or large intestine is blocked. The blockage can be partial or total, and it prevents passage of fluids and digested food. If intestinal obstruction happens, food, fluids, gastric acids, and gas build up behind the site of the blockage.
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
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2. Intestinal Obstruction
160 American Family Physician www.aafp.org/afp Volume 83, Number 2 ◆ January 15, 2011
perforation. A closed-loop obstruction, in
which a section of bowel is obstructed proxi-
mally and distally, may undergo this pro-
cess rapidly, with few presenting symptoms.
Intestinal volvulus, the prototypical closed-
loop obstruction, causes torsion of arterial
inflow and venous drainage, and is a surgical
emergency.
Causes and Risk Factors
The most common causes of intestinal
obstruction include adhesions, neoplasms,
and herniation (Table 1). Adhesions resulting
from prior abdominal surgery are the pre-
dominant cause of small bowel obstruction,
accounting for approximately 60 percent
of cases.5
Lower abdominal surgeries, includ-
ing appendectomies, colorectal surgery,
gynecologic procedures, and hernia repairs,
confer a greater risk of adhesive small
bowel obstruction. Less common causes of
obstruction include intestinal intussuscep-
tion, volvulus, intra-abdominal abscesses,
gallstones, and foreign bodies.
Management of Small Bowel Obstruction
Figure 1. Algorithm for evaluation and treatment of patients with suspected small bowel
obstruction.
Patient presents with signs and
symptoms of small bowel obstruction
Clinically stable?
No Yes
Radiography or
computed tomography
Vascular compromise
or perforation?
Complete
obstruction
Partial
obstruction
No oral intake,
nasogastric intubation,
intravenous rehydration
Exploratory
laparotomy
No oral intake,
nasogastric intubation,
intravenous rehydration
Yes No
Resolution within 24 to 48 hours? Resolution within 24 to 48 hours?
Yes NoNo Yes
Advance diet
Upper gastrointestinal/
small bowel follow-
through/enteroclysis?
Resolution?
No
Yes
Exploratory
laparotomy
Exploratory
laparotomy
Exploratory
laparotomy
3. Intestinal Obstruction
January 15, 2011 ◆ Volume 83, Number 2 www.aafp.org/afp American Family Physician 161
History and Physical Examination
Patients should be asked about their history
of abdominal neoplasia, hernia or hernia
repair, and inflammatory bowel disease,
because these conditions increase the risk
of obstruction. The hallmarks of intesti-
nal obstruction include colicky abdominal
pain, nausea and vomiting, abdominal dis-
tension, and a cessation of flatus and bowel
movements. It is important to differentiate
between true mechanical obstruction and
other causes of these symptoms (Table 2).
Distal obstructions allow for a greater intes-
tinal reservoir, with pain and distension
more marked than emesis, whereas patients
with proximal obstructions may have mini-
mal abdominal distension but marked
emesis. The presence of hypotension and
tachycardia is an indication of severe dehy-
dration. Abdominal palpation may reveal a
distended, tympanitic abdomen; however,
this finding may not be present in patients
with early or proximal obstruction. Aus-
cultation in patients with early obstruction
reveals high-pitched bowel sounds, whereas
those with late obstruction may present with
minimal bowel sounds as the intestinal tract
becomes hypotonic.
Diagnostic Testing and Imaging
LABORATORY TESTS
Laboratory evaluation of patients with sus-
pected obstruction should include a com-
plete blood count and metabolic panel.
Hypokalemic, hypochloremic metabolic
alkalosis may be noted in patients with
severe emesis. Elevated blood urea nitrogen
levels are consistent with dehydration, and
hemoglobin and hematocrit levels may be
increased. The white blood cell count may
be elevated if intestinal bacteria translocate
into the bloodstream, causing the systemic
inflammatory response syndrome or sepsis.
The development of metabolic acidosis, espe-
cially in a patient with an increasing serum
lactate level, may signal bowel ischemia.
RADIOGRAPHY
The initial evaluation of patients with
clinical signs and symptoms of intestinal
obstruction should include plain upright
abdominal radiography. Radiography can
quickly determine if intestinal perforation
has occurred; free air can be seen above the
liver in upright films or left lateral decubi-
tus films. Radiography accurately diagno-
ses intestinal obstruction in approximately
60 percent of cases,6
and its positive predic-
tive value approaches 80 percent in patients
with high-grade intestinal obstruction.7
However, plain abdominal films can appear
normal in early obstruction and in high
jejunal or duodenal obstruction. Therefore,
when clinical suspicion for obstruction is
high or persists despite negative initial radi-
ography, non-contrast computed tomogra-
phy (CT) should be ordered.8
In patients with small bowel obstruc-
tion, supine views show dilation of multiple
loops of small bowel, with a paucity of air in
the large bowel (Figure 2). Those with large
bowel obstruction may have dilation of the
Table 1. Causes of Intestinal
Obstruction
Adhesive disease (60 percent)
Neoplasm (20 percent)
Herniation (10 percent)
Inflammatory bowel disease (5 percent)
Intussusception (< 5 percent)
Volvulus (< 5 percent)
Other (< 5 percent)
Table 2. Differential Diagnosis of Abdominal Pain,
Distension, Nausea, and Cessation of Flatus and
Bowel Movements
Alternate diagnosis Clues
Ascites Acute liver failure, history of hepatitis or
alcoholism
Medications (e.g., tricyclic
antidepressants, narcotics)
Review of medications; diagnosis of
exclusion
Mesenteric ischemia History of peripheral vascular disease,
hypercoagulable state, or postprandial
abdominal angina; recent use of
vasopressors
Perforated viscus/intra-
abdominal sepsis
Fever, leukocytosis, acute abdomen, free
air on imaging
Postoperative paralytic ileus Recent abdominal surgery with no
postoperative flatus or bowel movement
Pseudo-obstruction
(Ogilvie syndrome)
Acutely dilated large intestine, history of
intestinal dysmotility, diabetes mellitus,
scleroderma
4. Intestinal Obstruction
162 American Family Physician www.aafp.org/afp Volume 83, Number 2 ◆ January 15, 2011
colon, with decompressed small bowel in the
setting of a competent ileocecal valve. Upright
or lateral decubitus films may show laddering
air fluid levels (Figure 3). These findings, in
conjunction with a lack of air and stool in the
distal colon and rectum, are highly suggestive
of mechanical intestinal obstruction.
COMPUTED TOMOGRAPHY
CT is appropriate for further evaluation of
patients with suspected intestinal obstruc-
tion in whom clinical examination and radi-
ography do not yield a definitive diagnosis.
CT is sensitive for detection of high-grade
obstruction (up to 90 percent in some series),9
and has the additional benefit of defining
the cause and level of obstruction in most
patients.10-12
In addition, CT can identify
emergent causes of intestinal obstruction,
such as volvulus or intestinal strangulation.
CT findings in patients with intestinal
obstruction include dilated loops of bowel
proximal to the site of obstruction, with dis-
tally decompressed bowel. The presence of a
discrete transition point helps guide opera-
tive planning (Figure 4). Absence of contrast
material in the rectum is also an impor-
tant sign of complete obstruction. For this
Figure 3. Lateral decubitus view of the abdomen, showing air-fluid
levels consistent with intestinal obstruction (arrows).
Figure 2. Supine view of the abdomen in a patient with intestinal
obstruction. Dilated loops of small bowel are visible (arrows).
Figure 4. Axial computed tomography scan
showing dilated, contrast-filled loops of
bowel on the patient’s left (yellow arrows),
with decompressed distal small bowel on
the patient’s right (red arrows). The cause of
obstruction, an incarcerated umbilical hernia,
can also be seen (green arrow), with proxi-
mally dilated bowel entering the hernia and
decompressed bowel exiting the hernia.
The rights holder did not grant the American Academy of Family
Physicians the right to sublicense this material to a third party. For
the missing item, see the original print version of this publication.
The rights holder did not grant the American Academy of Family
Physicians the right to sublicense this material to a third party. For
the missing item, see the original print version of this publication.
The rights holder did not grant the Ameri-
can Academy of Family Physicians the
right to sublicense this material to a third
party. For the missing item, see the origi-
nal print version of this publication.
5. Intestinal Obstruction
January 15, 2011 ◆ Volume 83, Number 2 www.aafp.org/afp American Family Physician 163
reason, rectal administration of contrast
material should be avoided. A C-loop of dis-
tended bowel with radial mesenteric vessels
with medial conversion is highly suspicious
for intestinal volvulus. Thickened intesti-
nal walls and poor flow of contrast material
into a section of bowel suggests ischemia,
whereas pneumatosis intestinalis, free intra-
peritoneal air, and mesenteric fat stranding
suggest necrosis and perforation.
Although CT is highly sensitive and spe-
cific for high-grade obstruction, its value
diminishes in patients with partial obstruc-
tion. In these patients, oral contrast mate-
rial may be seen traversing the length of the
intestine to the rectum, with no discrete area
of transition. Fluoroscopy may be of greater
value in confirming the diagnosis.
The American College of Radiology rec-
ommends non-contrast CT as the initial
imaging modality of choice.13
However,
because most causes of small bowel obstruc-
tion will have systemic manifestations or fail
to resolve—necessitating operative interven-
tion—the additional diagnostic value of CT
compared with radiography is limited. Radi-
ation exposure is also significant. Therefore,
in most patients, CT should be ordered when
the diagnosis is in doubt, when there is no
surgical history or hernias to explain the eti-
ology, or when there is a high index of suspi-
cion for complete or high-grade obstruction.
CONTRAST FLUOROSCOPY
Contrast studies, such as a small bowel
follow-through, can be helpful in the diag-
nosis of a partial intestinal obstruction in
patients with high clinical suspicion and in
clinically stable patients in whom initial con-
servative management was not effective.14
The use of water-soluble contrast material is
not only diagnostic, but may also be thera-
peutic in patients with partial small-bowel
obstruction. A randomized controlled trial
of 124 patients showed a 74 percent reduc-
tion in the need for surgical intervention in
patients receiving gastrografin fluoroscopy
within 24 hours of initial presentation.15
Contrast fluoroscopy may also be useful in
determining the need for surgery; the pres-
ence of contrast material in the rectum
within 24 hours of administration has a
97 percent sensitivity for spontaneous resolu-
tion of intestinal obstruction.16,17
There are several variations of contrast
fluoroscopy. In the small-bowel follow-
through study, the patient drinks contrast
material, then serial abdominal radiographs
are taken to visualize the passage of contrast
through the intestinal tract. Enteroclysis
involves naso- or oro-duodenal intubation,
followed by the instillation of contrast mate-
rial directly into the small bowel. Although
this study has superior sensitivity compared
with small-bowel follow-through,18
it is more
labor-intensive and is rarely performed.
Rectal fluoroscopy can be helpful in deter-
mining the site of a suspected large bowel
obstruction.
ULTRASONOGRAPHY
In patients with high-grade obstruction,
ultrasound evaluation of the abdomen has
high sensitivity for intestinal obstruction,
approaching 85 percent.19
However, because
of the wide availability of CT, it has largely
replaced ultrasonography as the first-line
investigation in stable patients with suspected
intestinal obstruction. Ultrasonography
remains a valuable investigation for unstable
patients with an ambiguous diagnosis and in
patients for whom radiation exposure is con-
traindicated, such as pregnant women.
MAGNETIC RESONANCE IMAGING
Magnetic resonance imaging (MRI) may be
more sensitive than CT in the evaluation of
intestinal obstruction.20
MRI enteroclysis,
which involves intubation of the duodenum
and infusion of contrast material directly
into the small bowel, can more reliably
determine the location and cause of obstruc-
tion.21
However, because of the ease and cost-
effectiveness of abdominal CT, MRI remains
an investigational or adjunctive imaging
modality for intestinal obstruction.
Treatment
Management of intestinal obstruction is
directed at correcting physiologic derange-
ments caused by the obstruction, bowel rest,
and removing the source of obstruction. The
6. Intestinal Obstruction
164 American Family Physician www.aafp.org/afp Volume 83, Number 2 ◆ January 15, 2011
former is addressed by intravenous fluid
resuscitation with isotonic fluid. The use of
a bladder catheter to closely monitor urine
output is the minimum requirement for
gauging the adequacy of resuscitation; other
invasive measures, such as arterial canaliza-
tion or central venous pressure monitoring,
can be used as the clinical situation war-
rants. Antibiotics are used to treat intestinal
overgrowth of bacteria and translocation
across the bowel wall.22
The presence of fever
and leukocytosis should prompt inclusion of
antibiotics in the initial treatment regimen.
Antibiotics should have coverage against
gram-negative organisms and anaerobes,
and the choice of a specific agent should be
determined by local susceptibility and avail-
ability. Aggressive replacement of electro-
lytes is recommended after adequate renal
function is confirmed.
The decision to perform surgery for intes-
tinal obstruction can be difficult. Perito-
nitis, clinical instability, or unexplained
leukocytosis or acidosis are concerning for
abdominal sepsis, intestinal ischemia, or
perforation; these findings mandate imme-
diate surgical exploration. Patients with an
obstruction that resolves after reduction of
a hernia should be scheduled for elective
hernia repair, whereas immediate surgery
is required in patients with an irreducible
or strangulated hernia. Stable patients with
a history of abdominal malignancy or high
suspicion for malignancy should be thor-
oughly evaluated for optimal surgical plan-
ning. Abdominal malignancy can be treated
with primary resection and reconstruction
or palliative diversion, or placement of vent-
ing and feeding tubes.
Treatment of stable patients with intesti-
nal obstruction and a history of abdominal
surgery presents a challenge. Conservative
management of a high-grade obstruction
should be attempted initially, using intesti-
nal intubation and decompression, aggres-
sive intravenous rehydration, and antibiotics.
The inclusion of oral magnesium hydroxide,
simethicone, and probiotics decreased the
length of hospitalization in a randomized
controlled trial of 144 patients with partial
small bowel obstructions (number needed
to treat = 7).23
Caution should be used when
clinical and radiologic evidence suggest com-
pleteobstruction,becausetheuseofintestinal
stimulation can exacerbate the obstruction
and precipitate intestinal ischemia.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
Clinical recommendation
Evidence
rating References Comments
Abdominal radiography is an effective initial
examination in patients with suspected intestinal
obstruction.
C 6, 7 Radiography has greater sensitivity in
high-grade obstruction than in partial
obstruction.
Computed tomography is warranted when
radiography indicates high-grade intestinal
obstruction or is inconclusive.
C 8-10 Computed tomography can reliably determine
the cause of obstruction, and whether
serious complications are present, in most
patients with high-grade obstructions.
Upper gastrointestinal fluoroscopy with small
bowel follow-through can determine the need
for surgical intervention in patients with partial
obstruction.
C 14, 15 Contrast material that passes into the cecum
within four hours of oral administration is
highly predictive of successful nonoperative
management.
Antibiotics can protect against bacterial
translocation and subsequent bacteremia in
patients with intestinal obstruction.
C 22 Enteric bacteria have been found in cultures
from serosal scrapings and mesenteric lymph
node biopsy in patients requiring surgery.
Clinically stable patients can be treated
conservatively with bowel rest, intubation
and decompression, and intravenous fluid
resuscitation.
A 22-26 Several randomized controlled trials have
shown that surgery can be avoided with
conservative management.
Surgery is warranted in patients with intestinal
obstruction that does not resolve within 48 hours
after conservative therapy is initiated.
B 25 Study found that conservative management
beyond 48 hours does not diminish the need
for surgery, but increases surgical morbidity.
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-
oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.
org/afpsort.xml.
7. Intestinal Obstruction
January 15, 2011 ◆ Volume 83, Number 2 www.aafp.org/afp American Family Physician 165
Conservative management is successful in
40 to 70 percent of clinically stable patients,
with a higher success rate in those with partial
obstruction.24-26
Although conservative man-
agement is associated with shorter initial hos-
pitalization (4.9 versus 12 days), there is also a
higher rate of eventual recurrence (40.5 versus
26.8 percent).27
With conservative manage-
ment, resolution generally occurs within 24
to 48 hours. Beyond this time frame, the risk
of complications, including vascular compro-
mise, increases. If intestinal obstruction is not
resolved with conservative management, sur-
gical evaluation is required.25
Figures 2 through 4 provided by Cirrelda J. Cooper, MD.
The Authors
PATRICK G. JACKSON, MD, is chief of gastrointestinal sur-
gery at Georgetown University Hospital, Washington, DC.
MANISH RAIJI, MD, is a third year surgical resident at
Georgetown University Hospital.
Address correspondence to Patrick G. Jackson, MD, 3800
Reservoir Rd., 4th Floor, PHC, Washington, DC 20007.
Reprints are not available from the authors.
Author disclosure: Nothing to disclose.
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