Large bowel obstruction is an emergent condition that requires prompt surgical intervention. It can result from infectious, inflammatory, neoplastic, or mechanical causes such as volvulus or incarcerated hernia. Symptoms include abdominal pain, distention, nausea, vomiting, and constipation. Diagnosis involves physical exam, imaging studies like CT scan, and lab tests. Treatment involves resuscitation, nasogastric decompression, and surgical resection of the obstructing lesion with proximal diversion such as colostomy. Complications can include perforation, sepsis, and death if not treated early. Prognosis depends on the underlying cause, with cancer outcomes varying based on the specific carcinoma.
Normally, fistula is defined as an abnormal communication between two epithelized surface.But enterocutaneous fistula is an abnormal communication between the skin with various parts of the gut. The ileum is the most common site of origin of enterocutaneous fistula.
OPEN CHOLECYSTECTOMY- OPERATIVE SURGERY
#surgicaleducator #operativesurgery #opencholecystectomy #usmle #babysurgeon #surgicaltutor
Dear viewers,
• Greetings from “Surgical Educator”
• Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries.
• I have already uploaded videos on open and Laparoscopic Appendicectomy, Thyroidectomy and Modified Radical Mastectomy.
• In this video today, I have discussed Open Cholecystectomy.
• However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery.
• Along with these videos, I recommend you to watch real operative surgery videos as well and I will give a link for each surgery in the end of the video as end-cards, which I think will be very useful.
• This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch the video in the following links:
• surgicaleducator.blogspot.com
• youtube.com/c/surgicaleducator
• Thank you for watching the videos.
Choledocholithiasis is one of the main causes for Obstructive Jaundice.In this ppt presentation, I have discussed the etiology, clinical features, complications, investigations and management of Choledocholithiasis. I have also included a mindmap and 2 algorithms for Choledocholithiasis. I hope you will find it very useful and interesting.
GERD is the commonest GI problem afflicting the mankind. The cause is lax LES which is just opposite to Achalasia cadia. That is why GERD is also known as Chalasia cardia.
Normally, fistula is defined as an abnormal communication between two epithelized surface.But enterocutaneous fistula is an abnormal communication between the skin with various parts of the gut. The ileum is the most common site of origin of enterocutaneous fistula.
OPEN CHOLECYSTECTOMY- OPERATIVE SURGERY
#surgicaleducator #operativesurgery #opencholecystectomy #usmle #babysurgeon #surgicaltutor
Dear viewers,
• Greetings from “Surgical Educator”
• Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries.
• I have already uploaded videos on open and Laparoscopic Appendicectomy, Thyroidectomy and Modified Radical Mastectomy.
• In this video today, I have discussed Open Cholecystectomy.
• However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery.
• Along with these videos, I recommend you to watch real operative surgery videos as well and I will give a link for each surgery in the end of the video as end-cards, which I think will be very useful.
• This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch the video in the following links:
• surgicaleducator.blogspot.com
• youtube.com/c/surgicaleducator
• Thank you for watching the videos.
Choledocholithiasis is one of the main causes for Obstructive Jaundice.In this ppt presentation, I have discussed the etiology, clinical features, complications, investigations and management of Choledocholithiasis. I have also included a mindmap and 2 algorithms for Choledocholithiasis. I hope you will find it very useful and interesting.
GERD is the commonest GI problem afflicting the mankind. The cause is lax LES which is just opposite to Achalasia cadia. That is why GERD is also known as Chalasia cardia.
anatomy of large intestine all info. is from snell clinical anatomy
this lecture composed of :- cecum , appendix , colon , rectum and anal canal
with all relation (location , blood supply , lymphatic drainage and nerve supply)
This presentation explains in detail the definition, pathophysiology, signs & symptoms, management, and prognosis of intestinal obstruction, ileus, and volvulus.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
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!
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
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La boob
1. Large Bowel Obstruction
Dr. Vivek Shrihari
Assistant Professor
Department of Surgery
M.G.M.C.R.I., Puducherry
2.
3. Large Bowel Obstruction
Introduction
• Background:
– An emergent condition
• Requires early identification and prompt surgical intervention
• Colonic obstruction may result from
– Infectious/inflammatory
– Neoplastic
– Mechanical pathology
» Volvulus
» Incarcerated hernia
» Stricture
*Obstipation
• Etiology
– Age dependent
– Serosa can expand to a variable but limited diameter
» Rupture and fecal soilage of the peritoneal cavity can occur
4. Large Bowel Obstruction
Introduction
• Pathophysiology:
– Caused by anatomic abnormality
• Leads to
– Colonic distention
– Abdominal pain
– Anorexia
• Late in the course
– Feculent vomiting
– Persistent vomiting
» May result in
» Dehydration and electrolyte disturbances.
5. Large Bowel Obstruction
Introduction
•Pathophysiology:
–Rotating or twisting of the cecum or
sigmoid
•Causes abrupt onset of symptoms
–Sigmoid volvulus
•Usually occurs in older individuals
–History of straining at stool
–Cecal volvulus
•Features a congenital defect in the
peritoneum
•Inadequate fixation of the cecum
•It generally occurs in much younger
individuals
•Venous drainage and arterial inflow are
compromised by a closed loop obstruction
–As the colon twists on its mesentery
6. Large Bowel Obstruction
Age
•Age:
–Most common in elderly individuals
•Incidence of neoplasms and other causative diseases is
higher in this population.
–In neonates
•Colonic obstruction may be caused by
–An imperforate anus
–or other anatomic abnormalities
–May be secondary to meconium ileus
–In pediatrics
•Hirschsprung disease resembles colonic obstruction
7. Large Bowel Obstruction
Clinical Manifestations
• History
– Initially focus on
• Failure to pass stools or gas
• Distinguish complete bowel obstruction from partial obstruction and
from ileus
– Associated with passage of some gas or stools
– Further historical questioning
• May be directed at the patient's current and past history
– Attempt to determine the most likely cause.
• Obtain history of bowel movements, flatus, obstipation and
symptoms
– Major complaints
» Abdominal distention
» Nausea
» Vomiting
» Crampy abdominal pain.
8. Large Bowel Obstruction
Clinical Manifestations
• Complete obstruction
– Characterized by
• Failure to pass either stools or flatus
• Presence of an empty rectal vault upon rectal examination
• Partial obstruction
– Patient appears obstipated but continues to pass some gas or stools
• Less urgent condition.
• Ileus
– Distinguishing colonic ileus from organic obstruction is important
• Ileus may be ruled out by
– Abdominal pain as a dominant feature of the clinical presentation
– Peritoneal signs
– Fever and leukocytosis.
» Constipation also may be accompanied by some degree of fever or
leukocytosis
9. Large Bowel Obstruction
Clinical Manifestations
• Obtaining a thorough history of previous bowel function,
abdominal pain, and general systemic issues is
important.
– Neoplastic obstruction
• History of
– Chronic weight loss
– Passage of melanotic bloody stools
– Diverticulitis, diverticular stricture
• History of
– Recurrent left lower quadrant abdominal pain over several years
– A history of aortic surgery suggests the possibility of an ischemic
stricture.
10. Large Bowel Obstruction
Clinical Manifestations
•Development history
–Right-sided
•Can grow quite large before obstruction
–Large capacity of the right colon
–Soft stool consistency.
–Sigmoid colon and rectal tumors
•Cause colonic obstruction more rapidly
–Colon is narrower and the stool is harder in that area.
•Large-bowel obstruction prior to perforation
–Obstruction that dilates the colon
•Visceral abdominal cramps
–Vague
–Pain receptors sense
»Distention or vigorous contraction.
–Peritonitis may ensue.
–Obstipation
•Patients may state that pants or belts are not fitting properly.
–Intervention is necessary to prevent perforation
11. Large Bowel Obstruction
Clinical Manifestations
•Obstruction secondary to intussusception
–Crampy abdominal pain
•Colicky
•Relieved by assuming fetal position.
–Weight loss and fatigue are common.
•Fistulization
–Sigmoid colon to the bladder
–Pneumaturia
–Mucinuria
–Fecaluria
12. Large Bowel Obstruction
Clinical Manifestations: Physical
–Complete physical examination is
necessary
–Key elements should focus on
•Abdomen
•Groin
•Rectum
–Abdominal examination
•Standard
–Inspection
–Auscultation
–Percussion
–Palpation
•Bowel sounds
–Diminished or
–Absent bowel sounds.
»Late stages
•Quality of abdomen
–Distended
–May be tender.
•Voluntary guarding or peritoneal signs
–Must think about intraabdominal process
such as an abscess
13. Large Bowel Obstruction
Clinical Manifestations: Physical
–Examination of inguinal and
femoral regions
•Should be an integral part
of the examination.
•Incarcerated hernias
–Frequently missed cause
of bowel obstruction.
•Left-sided inguinal hernia
–Colonic obstruction often
is caused by
»Sigmoid colon
incarcerated in the
hernia.
14. Large Bowel Obstruction
Clinical Manifestations: Physical
–Digital rectal examination
•Verify the patency of the anus in a neonate.
•Focus on identifying
–Rectal pathology
»May be causing the obstruction
–Determining the contents of the rectal vault.
•Hard stools
–Suggests impaction.
•Soft stools
–Suggest obstipation.
•Empty vault
–Suggests obstruction
»Proximal to the level that the examining finger can reach
•Fecal occult blood testing
–Positive result may suggest the possibility of a more proximal neoplasm
15. Large Bowel Obstruction
Clinical Manifestations: Causes
•Obstructions caused by:
–Tumors
•Gradual onset
•Normally result from tumor ingrowth into the colonic lumen
–Diverticulitis
•Muscular hypertrophy of the colonic wall
•Repetitive episodes of inflammation
•Lumen becomes narrow as the colonic wall becomes fibrotic
and thickened
–Intussusception
•Commonly involves a tumor
–Volvulus
–Incarcerated hernia
–Ogilvie syndrome
•Symptoms and definition
–May occur in elderly individuals who abuse cathartics or have
diabetes
–Loss of peristalsis.
–No obstruction is evident
–Colon becomes significantly and dangerously dilated.
•Once a contrast evaluation demonstrates nonobstructive
colonic dilation
–Management should be pharmacologic
–Stimulation of colonic contractions
–Intravenous neostigmine has been therapeutic in these situations
17. Large Bowel Obstruction
Workup
•Lab Studies:
–Obtain blood for a
•CBC
•Electrolyte levels
•PT
•Type and crossmatch.
•Imaging Studies:
–Upright chest radiograph
•Will demonstrate free air of perforated
–Flat and upright abdominal radiographs
•May be diagnostic of sigmoid or cecal volvulus
–Kidney bean appearance on the radiograph
–CT
•Gastrograffin
–An enema with water-soluble contrast
•CT with intravenous and rectal contrast.
•Procedures:
–Nasogastric tube
•If the patient has been vomiting
–Intravenous fluid resuscitation (intravascular depletion)
•Isotonic saline or Ringer lactate solution
18. Large Bowel Obstruction
Workup
•Lab Studies:
–Chemistry
•Evaluating the dehydration
•Electrolyte imbalance
–May occur as a consequence of large bowel obstruction
–Ruling out ileus as a diagnosis.
•Abnormal anion gap
–Should prompt an arterial blood gas and/or a serum lactate level
–Routine urine specific gravity should be evaluated.
–A decreased hematocrit
•With evidence of chronic iron-deficiency anemia
–Suggests chronic lower gastrointestinal bleeding
»Colon cancer?
–Leukocytosis
•Mild leukocytosis may be seen with obstruction or constipation
•Severe leukocytosis should prompt reconsideration of the diagnosis
•Ileus, secondary to an intra-abdominal or extra-abdominal infection or another process, is
a possibility.
19. Large Bowel Obstruction
Workup
Imaging Studies:
–Upright chest radiograph
•Will demonstrate free air
of perforated
–Flat and upright
abdominal radiographs
•May be diagnostic of
sigmoid or cecal volvulus
–Kidney bean
appearance on the
radiograph
•Demonstrates dilation of
the small and/or large
bowel and air fluid levels
Sigmoid volvulus
20. Large Bowel Obstruction
Workup
•X-ray findings
–Tracing colonic air around the colon, into the left gutter, and down into the rectum or demonstrating an abrupt cut-off in
colonic air suggests the anatomic location of the obstruction
–A dilated colon without air in the rectum is more consistent with obstruction
–Air in the rectum is consistent with
•Obstipation
•Ileus
•Partial obstruction.
•Rectal examinations may cause misleading results
–The characteristic bird's beak of volvulus may be seen.
•Radiopaque contrast
–Imaging of the colon may be performed under the following circumstances.
•Perform it if the diagnosis of large bowel obstruction is suspected but not proven.
•If differentiation between obstipation and obstruction is required, imaging with contrast is indicated.
•If localization is required for surgical intervention, imaging with contrast is indicated.
•Gastrograffin (water soluble)
–Advantages over barium (first line)
•It usually does not cause chemical peritonitis if the patient has colonic perforation.
•It has an osmotic laxative effect that may actually wash out an obstipated colon.
•Barium enema
–If large bowel perforation is ruled out using a Gastrograffin study and
–More detailed anatomic definition is required (particularly of the right colon)
•CT scanning
–Generally is not used initially in patients with large bowel obstruction unless a diagnosis has been made
•CT scan, particularly with rectal contrast, may demonstrate a mass or evidence of metastatic disease.
•Generally, the findings do not alter management because these patients will be explored and operatively decompressed,
regardless of the CT scan findings.
23. Large Bowel Obstruction
Workup
•Procedures:
•Endoscopic reduction of volvulus
–Indicated for sigmoid volvulus when
•Peritoneal signs are absent
•Evidence of mucosal ischemia is not present upon endoscopy
–Rigid sigmoidoscopy
•May be used if a flexible instrument is not available
–Reduction of a volvulus does not imply cure
•Sigmoid usually revolvulizes
–Patients admitted, subjected to mechanical bowel preparation,
and managed surgically by sigmoid resection
•Barium enema for reduction of intussusception
–Children
•Often successful
–Adults
–Success is far less likely, and patients still require surgery to
deal with their pathology.
•Cleansing enemas
–Used if obstipation is suspected rather than true large bowel
obstruction
–Also perform them to prepare the distal colon for endoscopic
evaluation.
24. Large Bowel Obstruction
Treatment
•Emergency Department Care
–Initial therapy
•Directed at patient comfort
•Volume resuscitation
•Ultimate goal to decompress the large intestine.
•Medical Care:
–Resuscitation
•Correction of fluid and electrolyte imbalance
•Nasogastric decompression
–Treat temporarily
»Obstruction and prevent vomiting and aspiration
–Directed primarily at supporting the patient and
treating any comorbid illnesses
25. Large Bowel Obstruction
Treatment
•Surgical Care:
–Surgical care is directed at relieving the obstruction
–Obstructed lesion is resected.(most cases)
•Because the colon has not been cleansed, anastomosis often is risky.
•After resection, most surgeons perform a proximal colostomy if the obstruction is on the left side or ileostomy if it is on the right
side.
–Diverting proximal colostomy or ileostomy
•Substantial comorbidity and surgical risk or in the presence of an unresectable tumor
–Diverting transverse loop colostomy
•Least invasive procedure for a very ill patient with a left colonic obstruction
•Permits relief of the obstruction and further resuscitation without compromising chances for a subsequent resection
–Sigmoid colostomy without resection
•Employed in patients with a rectal obstruction that cannot be managed without a combined abdominoperineal approach.
–Cecostomy should not be performed because the diversion is inadequate.
•Youth
–Some surgeons would consider primary anastomosis, rather than ileostomy, in the right colon, assuming no
intraoperative hypotension, blood loss, or other complications are present.
•If nonsurgical therapy employed
–i.e. decompressing a volvulus
–Deferring surgery temporarily and supporting the patient while the large bowel is cleansed so that primary
anastomosis may be performed more safely is preferable
26. Large Bowel Obstruction
Treatment
•Consultations
–Obtain early consultation from a general surgeon
–Surgical intervention frequently is indicated
•Diet
–Complete obstruction – NPO
–Partial obstruction – Clear liquids
•Specific cases
–Sigmoid volvulus
•First choice is sigmoidoscopy with volvulus reduction.
•Second choice is sigmoid colectomy.
–Cecal volvulus
•First choice is hemicolectomy.
•Second choice is colonoscopy.
–Sigmoid obstruction secondary to diverticulitis or carcinoma
•Procedure of choice is a sigmoid resection and Hartman procedure or a sigmoid resection.
•Alternative is primary anastomosis.
–Obstruction of splenic flexure
•First choice is extended hemicolectomy.
•Second choice is proximal colostomy with delayed resection.
27. Large Bowel Obstruction
Treatment
•In/Out Patient Meds:
Pain medicines generally should be avoided
preoperatively
–If the pain is sufficiently severe to merit use of
significant analgesics
•Peritonitis, rather than large bowel obstruction, should be
considered as the first diagnosis.
–Oral laxatives are contraindicated in patients with
complete large bowel obstruction.
•Chemotherapy?
•Temporary or permanent colostomy?
28. Large Bowel Obstruction
Follow up
•Complications:
–Perforation
–Sepsis
–Intra-abdominal abscess
–Death
•Prognosis:
–If treated early, outcome is generally good.
–If secondary to carcinoma
•Outcome is dependent on the carcinoma prognosis
29. References
• www.emedicine.com
– Large bowel obstruction, 2004
– Colonic Obstruction, 2004
• Baker, R., Fischer, J., LBO, Mastery of Surgery, fourth edition, pp 1405-1407
• Haubrich, W., Schaffner, F., 1995, Gastroenterology, LBO, pp 1189