May,3, 2008

filetype:ppt

Normal small bowel follow _through demonstrates the normal anatomy of the small bowel.
2002 by the Rector & Visitors of the University of Virginia

Interruption in the passage of intestinal contents. Small bowel obstruction much more common than colon: 70:30

This is an example of SBO at surgery. The bowel is dilated proximal to the point of obstruction and collapsed distal to the point of obstruction.

Closed Loops , mostly seen in large bowel due to ileocecal valve. More prone to arterial occlusion, because of greater intra luminal pressure.

Increased contractily below and above obstruction Hyper contractility hypo contractility bowel distension--increased intraluminal pressure-impediment in venous return--arterial insufficiency Massive third space losses

oliguria, hypotension, hemoconcentration

Electrolyte depletion

Colicky abdominal pain

Occurs in 4-5 min intervals and occurs less frequently with distal obstruction

Nausea and vomiting

The higher the level of obstruction, earlier and more profuse.

Distention
More marked, the more distant the obstruction.

Obstipation (Failure to pass flatus and feces)

Inspection
Distention Previous surgical scars Peristaltic waves

Palpation
Mass anywhere in abdomen. Irreducible mass at hernial orifice. Tenderness and guarding. (suggestive of strangulation)

Percussion
Tympanic note due to gas filled loops. Exception in slowly developing low SBO !

Auscultation
frequency (in obstruction) if absent : 1. Advanced 2. Peritonitis
Did you know that

If there is an air-fluid interface , peristalsis and segmental movements produce bowel sounds
Interesting , ha?

Signs of dehydration, including:

tachycardia, dry mucus membranes, possibly hypotension, oliguria.

Possible fever with strangulation

A picture is worth a thousand words!

Better understanding of patient s disease process and underlying illness

Is there an obstruction? If so, is it in small or large bowel? What is the level of obstruction? Can a specific cause be determined?

Upright chest x-ray

look for free air

Plain abdomen X-ray (erect/supine)

look for air fluid levels see extent of dilatation (~ 50% can be seen definitively /~ 30% suggestive of SBO)

Contrast X-rays
Barium sulphate is never given by mouth in acute obstruction! Use Gastrografin

Small bowel follow through

gold standard for determining if it is partial v. complete obstruction

CT

Step-ladder dilated bowel loops on supine view Step-ladder air-fluid levels on erect/decubitus views Stretch sign on supine view String-of-pearls sign on erect/decubitus views

Always abnormal in small bowel, but not specific; often normal in colon The height of the fluid levels, same or different, is NOT helpful in distinguishing ileus from obstruction

The upper limits of normal for the diameter of the small bowel lumen is 3 cm. When the luminal diameter is larger than this, it is DILATED If small bowel and colon dilated equally, probably not small bowel obstruction: nonspecific ILEUS If small bowel significantly more dilated than colon, suggests SBO

Post laparatomy

small bowel- 24h, stomach- 48h, colon- 3-5d

Inflammation e.g. appendicitis, pancreatitis Electrolyte derangement ( hyponatremia,

hypokalemia, hypomagnesemia, )

Retroperitoneal hemorrhage Systemic sepsis Drugs e.g. opiates, Ca-channel blockers, psychotropics

ADYNAMIC ILEUS

MECHANICAL OBSTRUCTION

Gas diffusely through intestine, incl. colon May have large diffuse A/F levels Quiet abdomen No obvious transition point on contrast study Peritoneal exudate if peritonitis

Large small intestinal loops, less in colon Definite laddered A/F levels Tinkling , quiet= late Obvious transition point on contrast study No peritoneal exudates

Site Etiology Partial vs. complete Simple vs. strangulated Fluid & electrolyte status Operative vs. non-operative management

History

prior operations, ( in bowel habits, pattern of vomiting scars, masses/ hernias, amount of distension gas in colon?, volvulus?, transition point, mass

Ph/Ex

Radiological studies

(Almost) always operate on LBO, often treat SBO non-operatively

Outside the wall Inside the wall Inside the lumen

Adhesions (usually postoperative) Hernia

External (e.g., inguinal, femoral, umbilical, or ventral

hernias)

Internal (e.g., congenital defects, foramen of Winslow,

diaphragmatic hernias or postoperative secondary to mesenteric defects)

Neoplastic

Carcinomatosis, extraintestinal neoplasm

Intra-abdominal abscess/ diverticulitis Volvulus (sigmoid, cecal)

Partial small bowel obstruction with an adhesive band at the transition point (white arrow) between dilated proximal bowel and decompressed distal bowel. The black arrows point to the site of constriction caused by the band.

Stricture
congenital Inflammatory Malignant Ischemic

Intussusceptions
Ileocolic intussusception. The ileum (intussusceptum, blue arrow) is seen entering the ascending colon (intussuscipiens, green arrow).
(Courtesy of Feldman's online Atlas, Current Medicine.)

Gallstone ileus
Air can often be seen in biliary tree. Usually results in low small bowel obstruction.

Food bolus Meconium ileus Foreign body

Adhesions Neoplasms Hernia Crohn etc

Colorectal Carcinoma Volvulus Diverticular Disease Etc

Unlike SBO, adhesions are very unlikely to produce LBO.

Extramural Causes (Extrinsic Compression) Neonates and infants Meconium ileus, milk Congenital atresias, Inguinal hernia, <24 mo curd obstruction, stenoses, and congenial bands, midgut foreign bodies diaphragms; volvulus intussusception; Henoch-Schnlein purpura Children and young adults Foreign bodies, A lumbricoides Crohn disease, Inguinal hernia, tuberculosis, benign congenital and neoplasms, primary postoperative adhesions, and secondary midgut volvulus, malignant neoplasms complications of appendicitis

Age Group

Intraluminal Causes Intramural Causes

Elderly persons

Foreign bodies, Crohn disease, Postoperative adhesions; gallstones, food bolus tuberculosis, primary femoral, inguinal, and secondary umbilical, or incisional neoplasia, potassium hernia; colonic and strictures, radiation ovarian neoplasia; strictures, adhesion to an complications of inflammatory process surgical anastomosis (eg, appendicitis or diverticulitis

PARTIAL

Flatus Adhesions 60-80% resolve non-operatively If no improvement by 48h after initiation of medical therapy, consider OR

COMPLETE

Complete obstipation No residual colonic gas on AXR SBFT may differentiate early complete from high-grade partial Almost all should be operated on within 24h

Associated with an increased morbidity and mortality.

Classic Signs fever, tachycardia, localized abdominal tenderness, leukocytosis

No clinical parameter or lab measurement can accurately detect it. Accelerated with closed-loop obstructions.

CT
useful only in late stages of irreversible ischemia

Superconducting Quantum Interference Device (SQUID)

noninvasive measurement of mesenteric ischemia

Intestinal ischemia is associated with changes in basic electrical rhythm of small intestine.

Hydrate, hydrate, and hydrate some more Electrolyte, acid-base correction Close monitoring

foley, central line

use of long intestinal tubes controversial

NGT decompression Antibiotics controversial TO OPERATE OR NOT TO OPERATE ?!

Massive third space losses as fluid and electrolytes accumulate in bowel wall and lumen Depend on site and duration

proximal- vomiting early, with dehydration, hypochloremia, alkalosis distal- more distension, vomiting late, dehydration profound, fewer electrolyte abnormalitie

Requirements = DEFICIT + MAINTENANCE + ONGOING LOSSES CV line in elderly

Established or suspected strangulation Peritonitis Failure of resolution after a period of nonoperative treatment A cause (carcinoma) requiring surgical removal Closed loop obstruction Complete large bowel obstruction

Nature of problem dictates the plan

Adhesion lysed Tumors rejected Hernia repaired

Criteria for laparoscopic management:

Mild distention, allowing adequate visualization Proximal Obs. Partial Obs.

In laparatomy, a mid line incision must be made Once the area of obstruction/non-viable bowel is found, it should be resected with reanastamosis of proximal and distal bowel

Distinguish viable from non-viable bowel A subjective method often used involves wrapping the bowel with warm moist laps for fifteen minutes; the laps are then removed and the bowel is observed for return of pink color, motility and pulses If borderline :
dye (Perfusion)
Doppler probe(Pulsation) / Fluorescing

Small bowel obstruction if adhesions suspected etiology i.e. CANNOT have a virgin abdomen No signs of strangulation Adynamic ileus

Small Bowel Obstruction CT sensitivity ~ 94% CT findings

Dilated loops of bowel (>3cm) proximal to obstruction w/collapse of bowel distal Wall thickening (>3mm)

Nothing is better than having a good clue!