Bowel Obstruction

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Bowel Obstruction

• Tad Kim, M.D.
• UF Surgery
• tad.kim_at_surgery.ufl.edu
• (c) 682-3793 (p) 413-3222

2
Overview

• Case
• ABC Resuscitation
• History
• Physical
• Labs Imaging
• Differential Diagnosis
• Management
• Indications for emergent surgery

3
Case

• 50yo male p/w abd pain, distension, bilious
  emesis
• Think bowel obstruction
• What else could kill the patient?
• Ischemic bowel, perforated viscus (ulcer)
• Acute appendicitis, diverticulitis, pancreatitis
• Acute cholecystitis or cholangitis
• Could be an atypical presentation of MI
• Other possible causes, i.e. medical?
• Acute hepatitis, gastroenteritis, food poisoning

4
ABC Resuscitation

• Vomited 5x past 4 hrs, oliguric, dry mucous
  membranes, looks ill, distended
• VS Pulse 110, BP 100/60
• Clinically hypovolemic, needs fluid boluses
• ABC, 2 large bore IVs, Foley, monitor
• Isotonic fluid bolus 1-2 Liters, repeat until
  clinically appropriate response
• Bowel obstrux patients need resuscitation

5
History

• Colicky, intermittent mid-abd pain (SBO)
• Obstipation no BM or flatus
• Prior surgeries, esp pelvic (adhesions)
• History of CA, unexplained weight loss
• History of hernias
• History of Crohns or Crohns flare-ups
• Any similar prior episodes of abd pain
• ROS for other causes of acute abdomen

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Physical Exam

• Vitals hopefully more stable if ABCs done
• Is patient toxic appearing? (get to OR)
• Feculent emesis bad (dead bowel)
• Signs of dehydration
• Mucous membranes, skin turgor, oliguria
• Examine abdomen for peritoneal signs
• Check for hernias (groins or ventral)
• Rectal for impaction, mass, fluctuance

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Labs Imaging

• Flat Upright KUB
• Free air
• Air-fluid levels
• Dilatation/obstruction
• CT scan
• Partial vs complete
• transition point of obstruction
• Find cancers/hernias
• Signs of diverticulitis
• Free air or free fluid
• Ischemia/necrosis

• CBC w diff
• Left shift more telling than elevated WBC
• BMP
• Correct electrolytes
• BUN/Crgt20 (hypovol)
• Amylase
• Ischemic/perf bowel
• UA
• spec grav gt 1.030 means dehydrated

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Differential Diagnosis of SBO

• 1 Adhesions (60)
• 2 Cancer (20)
• 3 Hernias or Bulges (10)
• Crohns disease strictures (5)
• Gallstone ileus (rare)
• Erosion of gallstone from gallbladder to small
  bowel (cholecystoenteric fistula) obstruction
• Other abscess, radiation stricture, foreign
  body, tuberculosis
• Just remember the top 4

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Management

• NPO, NGT, Foley (No Abx unless perf)
• Resuscitation IVF at 1.5x maintenance
• Most partial obstructions will resolve
• Complete obstructions need OR urgently
• Signs strangulation/ischemia ? OR stat
• Leukocytosis, left shift, fever, tachycardia
• Unrelenting or constant, noncramping pain
• Origin of Never let the sun set on a SBO

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Management of SBO

• In general, failure of non-operative management
  is an indication for surgery
• Adhesions ? NGT vs OR for adhesiolysis
• Hernias ? reduce hernia versus OR if incarcerated
  or strangulated (stat)
• Crohns ? Treat Crohns flare-up vs OR to resect
  the strictured segment
• Cancer ? NGT vs ex-lap/resection vs ex-lap
  bypass the obstructing cancer

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DDx Management of LBO

• Cancer (colon or rectum)
• Dx by colonoscopy biopsy
• Some data for stenting before surgical resection
• Volvulus (torsion of a segment of GI tract)
• Sigmoid volvulus (emesis less common)
• Tx Sigmoidoscopic reduction if no gangrene
• Surgery recommended w pexy or resection
• Cecal volvulus (Like SBO p/w N/V distension,
  obstipation). Tx Surgery (scope wont work)
• Diverticulitis (at some point, need to r/o
  cancer)
• Tx w surg if complicated or medical tx fails

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Take Home Points

• Always start with ABC, resuscitation
• Includes 2 large bore IV, Foley, NGT, monitor
• DDX is simple
• SBO Adhesions, Bulges, Cancer, Crohns
• LBO CANCER, Volvulus, Diverticulitis
• Labs to assess dehydration leukocytosis
• Imaging to assess obstruction etiology
• If hypoTN/shock, toxic, or signs of
  strangulation or ischemia, resusc OR stat
• Otherwise, for SBO, NGT treat etiology
• LBO is different really must rule out cancer,
  colonoscopy plays a larger role than w SBO