A 54-year-old woman with a history of hysterectomy for cervical cancer presents with abdominal pain and vomiting. Physical exam shows a distended abdomen without tenderness. Tests show signs of small bowel obstruction. A 72-year-old man reports gradually worsening constipation over two months. Exam reveals a large colon. Tests are needed to diagnose large bowel obstruction or dysfunction. A 54-year-old man with a history of Crohn's disease and bowel resection has recurrent abdominal pain and weight loss, consistent with a flare of his Crohn's disease requiring evaluation and management. A 22-year-old student reports bloody diarrhea for three months, suggesting inflammatory bowel disease like ulcerative colitis requiring diagnostic testing and treatment

1. Vomiting, Diarrhea
& Constipation
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2. Case 1
• A 54-year-old woman presents with a
two day history of crampy abdominal
pain followed by episodes of bilious
emesis.
• Important Items in the History?
• Previously hysterectomy for treatment
of cervical cancer.
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3. Small Bowel Obstruction
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4. Small Bowel Obstruction
Signs & Symptoms
• Intermittent, Crampy Abdominal Pain
• Nausea / Emesis
• Distension
• Obstipation
• Peristaltic Rushes on Auscultation
• Focal Tenderness
• Diffuse Peritonitis Brought to you by

5. Case 1
• What findings should be looked for on
physical exam?
• Distended
• No peritoneal signs
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6. Case 1
• What laboratory tests should be
ordered?
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7. Small Bowel Obstruction
Laboratory Evaluation
• May see hypochloremic, hypokalemic
metabolic alkalosis if having frequent
emesis (proximal obstruction).
• May see evidence of contraction
alkalosis
– Increased H/H, BUN.
• WBC usually normal early.
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8. Case 1
• What laboratory tests should be
ordered?
• What diagnostic tests should be
ordered?
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9. Small Bowel Obstruction
Radiologic Evaluation
• Xrays: ? AFLs, ? Free Air, ? Distal Gas
• UGI / SBFT: Identify mechanical obstruction
• Enteroclysis: Independent of gastric
emptying
• CT Scan: ? Free Air, ? Pneumatosis, ?
Tumor
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14. Small Bowel Obstruction
Etiologies
• Adhesions
• Malignancy
• External or Internal Hernia
• Volvulus
• Crohn’s Disease
• Intra-abdominal Abscess
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15. Small Bowel Obstruction
Etiologies (Cont.)
• Radiation Stricture
• Foreign Body
• Gallstone Ileus
• Meckel’s Diverticulum
• Intramural Hematoma
• Mesenteric Ischemia
• Intussusception Brought to you by

16. Intestinal Ileus
Etiologies
• Postoperative State
• Sepsis
• Electrolyte Imbalance
• Drugs
• Ureteral and Biliary Colic
• Retroperitoneal Hemorrhage
• Spinal Cord Injury
• Myocardial Infarction
• Pneumonia Brought to you by

17. Case 1
• What is the initial management plan?
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18. Small Bowel Obstruction
Partial vs. Total
• Why Not Just Wait??
– Potential for Closed Loop Obstruction
– Risk of Ischemia / Perforation (4-6
hrs)
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19. Small Bowel Obstruction
Treatment
• Correct intravascular volume deficit
• NGT vs. Miller-Abbott or Cantor Tubes
• Serial Exams
• Operation if no improvement or if
signs of complete (closed loop)
obstruction or incarceration.
• Evaluation of Bowel Viability
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21. Small Bowel Obstruction
Special Cases
• Early Postoperative SBO
– <1% risk in first month
– Must be considered after 7 days of
“ileus” since adhesions become dense
in 2-3 weeks.
• Recurrent SBO (5-15%)
• Malignant Obstruction
• Radiation Fibrosis Brought to you by

22. Case 2
• A 72-year-old man presents with a two
month history of gradually increasing
constipation.
• Key Points in History?
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23. Large Bowel Obstruction
Diagnosis
• Crampy Pain
• Onset may be acute or insidious
• Distension (50-60% have competent ileo-cecal
valve and develop severe distension)
• Xrays: 12-14 cm cecum, perforation risk
• Contrast enema: Obstruction vs Oglive’s
• Consider rigid sigmoidoscopy to r/o and treat
sigmoid volvulus
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24. Case 2
• Physical Exam
• What further tests are indicated
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25. Case 2
• Differential Diagnosis
– Colonic Obstruction
• Malignant
• Benign
– Colonic Dysfunction
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26. Large Bowel Obstruction
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27. Large Bowel Obstruction
Etiologies
• Colon Cancer
• Diverticulitis
• Extrinsic Cancer
• Fecal Impaction
• Intussusception
• Volvulus
• Incarcerated Hernias
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28. Large Bowel Obstruction
Colon Cancer
• 20% of colon cancers present with
obstruction
• Left-sided lesions are more prone to
obstruct (more narrow lumen, more
solid fecal stream)
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33. Large Bowel Obstruction
Treatment
• IVF
• NGT
• Operation
– Emergently if signs of peritonitis /
perforation
– Prep bowel if possible
• Is an ostomy necessary?
– Right vs. Left-sided Lesions
– Traditional vs. Newer Attitudes
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34. Large Bowel Dysfunction
• Inflammation
• Colonic Inertia
• Etc
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36. Oglive’s Syndrome
(Colonic Pseudo-Obstruction)
• May mimic mechanical obstruction
• Associated Conditions
• Treatment:
– Rectal tube / enemas /exams (work in most)
– Colonoscopic decompression (80-90% eff.)
– Surgery (Cecostomy vs. Resection) - cecum
>12 cm or peritoneal signs
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37. Case 3
• A 54-yo Caucasian male with history of ileocolonic
Crohn's disease, s/p ileocolectomy in 1979, who has
not been on any Rx for CD. Presents to the UNC ER
complaining of crampy abdominal pain that began at
8 hrs earlier located in the right lower and left lower
quadrant. He also had nausea and vomiting as well
as decreasing flatus associated. The patient stated
his last BM was on the day of admission. He stated
that the pain feels like his previous obstructions.
Occurring every couple of months, recently
increasing in frequency. No fevers. About 10 lb
weight loss.
• Key Points in History
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38. What Is Crohn’s Disease?
• Crohn’s disease (CD)
is an inflammatory
bowel disorder that
may affect any part of
the gastro-intestinal
(GI) tract
• The inflammation
penetrates the lining of
the GI tract and often
causes ulcers to form
Small
Intestine
Large
Intestine
(Colon)
Appendix
Esophagus
Stomach
Rectum
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40. Case 3
• Key Points in History
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41. Case 3
• Key Points in History
– Crohn’s disease
– Previous surgical history
– No Crohn’s Rx
– Chronic symptoms
– Weight loss
– No fevers
– Crampy pain
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42. Case 3
• Physical Exam
• Diagnostic Studies?
• Differential Dx
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43. Crohn’s Disease
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44. Crohn’s Disease
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45. Crohn’s Disease
• Medical vs Surgical Management
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50. Case 4
• 22yo UNC student presents with 3 mos
of increasing “bloody diarrhea”, going
to the bathroom 15-20x/day. “It rules
my life!”
• Key Points in History
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51. Case 4
• 22yo UNC student presents with 3 mos
of increasing “bloody diarrhea”, going
to the bathroom 15-20x/day. “It rules
my life!”
• Key Points in History
– Diarrhea
– Bleeding
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52. Case 4
• Physical Exam
• Diagnostic Studies?
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55. Ulcerative Colitis
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