Bowel Obstruction Tad Kim, M.D. UF Surgery tad.kim@surgery.ufl.edu (c) 682-3793; (p) 413-3222
Overview • Case • ABC & Resuscitation • History • Physical • Labs & Imaging • Differential Diagnosis • Management • Indications for emergent surgery
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
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 IV’s, Foley, monitor • Isotonic fluid bolus 1-2 Liters, repeat until clinically appropriate response • Bowel obstrux patients need resuscitation
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 Crohn’s or Crohn’s flare-ups • Any similar prior episodes of abd pain • ROS for other causes of acute abdomen
Physical Exam • Vitals: hopefully more stable if ABC’s 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
CBC w diff Left shift more telling than elevated WBC BMP Correct electrolytes BUN/Cr>20 (hypovol) Amylase Ischemic/perf bowel UA spec grav > 1.030 means dehydrated 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 Labs & Imaging
Differential Diagnosis of SBO • #1 Adhesions (60%) • #2 Cancer (20%) • #3 Hernias or Bulges (10%) • Crohn’s 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
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”
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) • Crohn’s → Treat Crohn’s flare-up vs OR to resect the strictured segment • Cancer → NGT vs ex-lap/resection vs ex-lap & bypass the obstructing cancer
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 won’t work) • Diverticulitis (at some point, need to r/o cancer) • Tx w surg if complicated or medical tx fails
Take Home Points • Always start with ABC, resuscitation • Includes 2 large bore IV, Foley, NGT, monitor • DDX is simple: • SBO: Adhesions, Bulges, Cancer, Crohn’s • 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
