1. Highlights of patient’s history
• 53 year old man with longstanding diabetes
mellitus
• One-week illness, characterized by:
– Nausea, for 6 days
– More nausea, vomiting, bloating, and crampy
lower abdominal pain for 1 day
– No BM for 2 days pta and for hospital days 1-5
2. Highlights of his physical exam
• Temp 98.5, Resp 24 (depth?), BP 157/82,
Pulse 103; tilt test ?
• Oropharynx: slightly dry
• Abdomen: slightly distended; mildly tender
in the “lower abdomen” (RLQ?, LLQ?,
suprapubic region?); “quiet” bowel sounds
– Quiet. adj. making very little sound
4. Physician accuracy: bowel sounds
[Gade et al. Scand J Gastro 33:773, 1998]
• Bowel sounds recorded from 4 normals, 6
pts. with obstruction [SBO(4), LBO(2)], and
2 pts. with peritonitis (perforated viscus)
• Recorded sounds from these 12 people were
amplified and transmitted through a dummy
and listened to with a stethoscope by 100
physicians of different specialty and
experience {normal vs. abnormal}
5. Physician accuracy: bowel sounds
Gade et al. Scand J Gastro 33:773, 1998
• NORMALS (n=400 ratings)
– 25% were called abnormal [75% specificity]
• OBSTRUCTION (n=600 ratings)
– 64% abnormal (69% for surgeons, 50% for GIs)
• PERITIONITIS (n=200 ratings)
– 43% abnormal (50% for surgeons, 25% for GIs)
Conclusion: Our patient’s bowel sounds are certainly
compatible with SBO, LBO, and peritonitis with ileus.
6. Highlights of laboratory tests
• WBC 15.9, with 94% neutrophils
• Glucose 430’s
• Anion gap 14; bicarbonate 22
• Urine + for glucose and ketones; no UTI
• Lactate normal
• LFTs, serum lipase/amylase normal
• EKG, cardiac enzymes normal
7. Summary of clinical presentation
(prior to his X-ray studies):
• Middle-aged diabetic man with nausea and
vomiting, constipation, lower abdominal
pain, tenderness, and distention
• Mild diabetic ketoacidosis
9. GI Symptoms in Diabetics
OUTPATIENTS*
Constipation 60%
Abdominal pain 34%
Nausea, vomiting 29%
Dysphagia 27%
Diarrhea 22%
Fecal incontinence 20%
None of the above 24%
* Feldman and Schiller. Ann Int Med 1983
INPATIENTS, DKA
“Abdominal pain, nausea
and vomiting are common
and may be caused by the
ketoacidosis, but assoc-
iated disorders such as
pyelonephritis, pancrea-
titis, or an acute abdomen
must always be
suspected.”
Williams textbook. Unger and Foster. 1998
10. Hospital course: days 1-5
• No BMs or flatus production
• Abdominal distention did not resolve and
instead increased despite NG suction
• Diabetic ketoacidosis treated successfully
with insulin, fluids and electrolytes
13. Summary of radiological exams
• Plain films: dilated loops of small bowel
and right colon, compatible with LBO or
ileus
• CT: same as above, with probabl”cut off” at
the level of the transverse colon; “probable”
filling defect in SMV; no abscesses or
evidence of diverticulitis/ mass
• Visceral arteriogram: normal vessels; dila-
ted bowel as above
14. Separating pseudo-
obstruction from true obstruction
• Ileus of small bowel = intestinal
pseudoobstruction [can mimic SBO]
• Ileus of colon = Ogilvie’s syndrome [can mimic
LBO] and can affect the right side prodominately
• Ileus involving small and large intestine [can also
mimic LBO]
15. Conditions that may
pseudo-obstruction or ileus
• Electrolyte disturbance, esp. hypokalemia
– DKA can be a cause, but should improve with rx of DKA
• Medications that suppress GI transit, especially anti-
cholinergics and opiates
• Neurological disease (CVA, Parkinson’s, dementia, CP),
bedridden, institutionalized
• Severe intra-abdominal inflammatory and infectious
diseases:
– pancreatitis - bowel ischemia/infarction
– cholecystitis - bowel or GB perf., incl. perf. ulcer
– diverticulitis - appendicitis
– strangulated obstruction - peritonitis
16. Radiology workup of obstruction
vs. ileus in acutely ill inpatients
• Plain films: is there disproportionate bowel
distention with gas or with gas/fluid levels?
• CT with oral ± rectal contrast: is there a cut-
off, transition point or site of blockage?
• Water-soluble contrast enema (e.g.,
diatrizoate meglumine [HyapaqueR,
GastrografinR])*
* barium sulfate enema is relatively contraindicated
21. Differential Diagnosis,
in order of likelihood
• Intestinal Obstruction
– MORE LIKELY, BASED ON HIS
DRAMATIC XRAY STUDIES and that THIS
IS A CPC “INTESTINAL OBSTRUCTION”
• Ileus
– LESS LIKELY, SINCE NO EVIDENCE FOR
AN UNDERLYING PRECIPITATOR
22. Intestinal Obstruction (SBO/LBO)
• Common cause for admission to hospital (20% of
acute admissions to surgical services are for SBO)
• SBO and LBO can be either partial or complete
• Strangulation (ischemic infarction of the bowel) is
the most dreaded and lethal consequence
• SBO and LBO have many causes, making a
specific diagnosis of the cause challenging
• Ideal therapy is dictated by knowledge of the
cause, although this is often not known at the time
of surgery
23. Clinical features of
Intestinal Obstruction
• Crampy abdominal pain in waves (intestinal colic)
• Nausea
• Bilious or feculent vomiting
• Abdominal distention
• Constipation with decreased flatus production
• High pitched (musical, tinkling) hyperactive
bowel sounds
• Symptoms and signs of intravascular volume
depletion due to external losses, reduced oral
intake, and 3rd space losses into the bowel wall
and/or abdominal cavity
24. Common causes of SBO/LBO
• Adhesions are most common cause of SBO, but are rare cause of LBO.
• Hernia is a common cause of SBO, but rearely LBO.
• Neoplasm is most common cause of LBO, and accounts for 10% of SBO.
• Volvulus and diverticulitis are common causes of LBO, but rarely SBO.
(LBO)
(SBO)
25. Miscellaneous causes of SBO/LBO
Atresia/stenosis/ bands
IBD (Crohn’s)
Radiation injury
Ischemic stricture
Endometriosis
Anastomotic stricture
Intussusception
Gallstones
Foreign body/bezoar
Meconium
Meckel’s diverticulum
Intra-abdominal abscess
[Children, young adults] S
[History of fever, diarrhea] S
[History of cancer/XRT] S,L
[Vascular disease] L,S
[Premenopausal female] S,L
[Prior anastomosis] S,L
[Children > adults] S>>L
[Biliary colic;pneumobilia] S
[Ingestion history] S
[Neonate, cystic fibrosis] S,L
[Male, young, recurrences] S
[Fever, chills, ? mass] S>L
26. Historical/demographic factors
which aid in assessing the
etiology of SBO and LBO
• Age and gender of the patient
• History of abdominal or pelvic surgery
• History of intra-abdominal disease
• History of recent abdominal surgery/trauma
• History of abdominal radiotherapy
• History of overt rectal bleeding/ weight loss
• History compatible with undiagnosed IBD
27. If obstruction, SBO or LBO?
• Pain before nausea/vomiting is typical in SBO
• History of prior surgery or abdominal trauma
would favor SBO over LBO
• Bilious vomiting favors SBO; feculent vomiting
favors LBO
• No mass on digital exam excludes distal rectal
cause of LBO, but not high rectal/colon obst’n
• Right colon distention on radiographs favors LBO,
especially as there is a distinct cut-off
• Periumbilical pain (SMA distribution ) favors
SBO, while suprapubic pain favors LBO
35. Miscellaneous causes of SBO/LBO
Atresia/stenosis/ bands
IBD (Crohn’s)
Radiation injury
Ischemic stricture
Endometriosis
Anastomotic stricture
Intussusception
Gallstones
Foreign body/bezoar
Meconium
Meckel’s diverticulum
Intra-abdominal abscess
[Children, young adults] S
[History of fever, diarrhea] S
[History of cancer/XRT] S,L
[Vascular disease] L,S
[Premenopausal female] S,L
[Prior anastomosis] S,L
[Children > adults] S>>L
[Biliary colic;pneumobilia] S
[Ingestion history] S
[Neonate, cystic fibrosis] S,L
[Male, young, recurrences] S
[Fever, chills, ? mass] S>L
36. Final diagnosis
• Most likely: large bowel obstruction due to
adenocarcinoma of the colon
– “He has not seen a PCP in over 4 years and has
never had a colonoscopy.”
• Less likely:
– Diverticular stricture (pro:mom;con:age/history)
– Another 1º colonic malignancy (e.g., lymphoma)
– Sigmoid or (less likely) or cecal volvulus
37. What was the
diagnostic procedure?
• PREFERRED: Flexible sigmoidoscopy or
colonoscopy following enema preparation
• ACCEPTABLE ALTERNATIVES:
Diatrizoate meglumine (not barium) enema
or CT with rectal contrast
• LESS ATTRACTIVE APPROACH
(at this point -may do later for therapy):
Laparoscopy or exploratory laparotomy
38. Therapy of Intestinal Obstruction
MEDICAL
– NPO
– fluid and electrolyte
support
– NG decompression
– analgesia p.r.n.
– meds. for underlying
disease, if indicated
e.g., steroids for Crohn’s
disease
– 48-72 hour trial with
frequent bedside exams
SURGICAL
– laparoscopy
– laparotomy
OPTIONS INCLUDE:
• adhesiolysis
• resection/ anastomosis
• stricturoplasty
• removal of intraluminal
obturation (FB, stone)
• bypass
• untwist volvlus/ “pexy”
• “open and close”
