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Abdominal Pain and Bowel Obstruction

Abdominal Pain and Bowel Obstruction. Mike Goodwin CRASH Course October, 2010. Abdominal Pain - Approach. History Physical Labs Imaging Provisional Dx. History. PQRST AAA etx But don’t forget PSx Bowel/ Gyne / Urol ROS. Physical Exam. Complete

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Abdominal Pain and Bowel Obstruction

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  1. Abdominal Pain and Bowel Obstruction Mike Goodwin CRASH Course October, 2010

  2. Abdominal Pain - Approach History Physical Labs Imaging Provisional Dx

  3. History • PQRST AAA etx • But don’t forget • PSx • Bowel/Gyne/Urol ROS

  4. Physical Exam • Complete • General appearance/vitals/H+N/Chest • Abdo: • Rigidity • Rebound • Guarding • IPPA • DRE / Pelvic / Groin / Flank-CVA

  5. Labs • Everyone: • CBC, lytes BUN Cr • LFT, Bili, Amylase/Lipase, lactate • Urinalysis • Urine Preg

  6. Imaging • AXR • 3-views • Free air • Distended bowel/air-fluid • Calcifications (panc or kidney/ureter) • US • If GS disease suspected • Lower abdo pain in female

  7. Imaging • CT Abdo • Test of choice for most patients • Protocols to minimize contrast nephropathy

  8. Bowel Obstruction: Overview • History • Etiology • Pathophysiology • Clinical presentation • Imaging • Management • Special considerations

  9. Causes of Small Bowel Obstruction in Adults • Lesions Extrinsic to the Intestinal Wall • Lesions Intrinsic to the Intestinal Wall • Intraluminal/Obturator Obstruction

  10. Lesions Extrinsic to the Intestinal Wall • Adhesions (usually postoperative)   • Neoplastic • Carcinomatosis   • Extraintestinal neoplasms   • Hernia  • External (e.g., inguinal, femoral, umbilical, or ventral hernias)  • Internal (e.g., congenital defects such as paraduodenal, foramen of Winslow, and diaphragmatic hernias or postoperative secondary to mesenteric defects • Intra-abdominal abscess

  11. Congenital   Malrotation   Duplications/cysts   Inflammatory   Crohn’s disease   Infections   Tuberculosis  Actinomycosis   Diverticulitis Neoplastic   Primary neoplasms   Metastatic neoplasms Traumatic  Hematoma   Ischemic stricture Miscellaneous   Intussusception   Endometriosis  Radiation enteropathy/stricture Lesions Intrinsic to the Intestinal Wall

  12. Intraluminal/Obturator Obstruction • Gallstone • Enterolith • Bezoar

  13. Common causes of small bowel obstruction in industrialized countries.

  14. Pathophysiology • Early: Increased motility & contractility • Bowel dilation, fluid/lytes accumulate in lumen and bowel wall • Third spacing, intravascular volume depletion

  15. Bowel obstruction Increased intraluminal pressure Decreased mucosal blood flow Progressive Ischemia Perforation & Peritonitis

  16. Clinical Diagnosis • History • Colicky abdominal pain • Nausea / vomiting • Abdominal distension • Failure to pass flatus / feces

  17. Physical Examination • Vitals: Tachycardia, hypotension • Abdomen: • Distension • Surgical scars • Bowel sounds, increased or decreased • Localized tenderness / rebound / guarding suggests strangulation • Hernia exam (ventral, groin, etc) • Rectal exam: • Rectal masses • Blood – suggesting ischemia, malignancy

  18. Radiology • Plain Abdo X-Rays • Confirm Diagnosis • Localize obstruction to small bowel or colon • Evidence of complete or incomplete

  19. Plain X-ray Features • Dilated Small Bowel (>3 cm) • Multiple air-fluid levels • Colonic gas pattern • Normal / Dilated (Ileus or partial obstruction) • Absence of gas c/w complete obstruction • *Thickened bowel wall • *Pneumatosis intestinalis *Suggests ischemia/strangulation

  20. Plain X-rays • Lappas et al 2001 • Review of 12 AXR findings with SBO • Findings: • Combination of • Air-fluid levels of different heights in the same bowel loop • Mean air-fluid level diameter of 2.5 cm or greater • Most predictive of a high-grade partial or complete SBO

  21. AXR Disadvantages • 20-30% false negative rate • Does not localize site of obstruction • Does not establish etiology of obstruction

  22. CT Scan • 95% sensitive • 96% specific • 95% accurate in determining the presence of complete or high-grade SBO • Shows site and cause of obstruction in 95% of instances • Less accurate for partial SBO (50% some studies)

  23. CT for SBO • CT performed with IV and PO contrast • High-grade SBO seen even with no contrast • Lesser grades of obstruction seen with PO contrast • IV contrast for assessment of bowel wall for signs of edema or ischemia.

  24. CTFindings in Patients with Small Intestinal Obstruction

  25. CTFindings in Patients with Small Intestinal Obstruction

  26. CTFindings in Patients with SBO

  27. When to Order CT? • Clinical presentation or abdominal films nondiagnostic • Hx of abdominal malignancy • Immediate postsurgical patients • Patients who have no history of abdominal surgery

  28. Barium / Contrast Studies • History of recurring obstruction • Low-grade mechanical obstruction • Defines the obstructed segment and degree of obstruction

  29. Gastrograffin Swallow in Adhesive SBO, Cochrane Review, 2004 • Diagnostic • Gastrofraffin seen in the cecum on AXR within 24 hours predicts resolution • Sensitivity of 0.96, specificity of 0.96 • Therapeutic • Hospital length of stay 2-3 days shorter in non-operative patients • Studies prospective, non-blinded

  30. Simple Versus Strangulating Obstruction • Classic signs: • Fever • WBC inc • Constant Abdo pain • But no parameters reliably detect strang. • CT findings detect late ischemic changes

  31. Treatment – Nonoperative • Fluid resuscitation • IV resuscitation with isotonic saline • Electrolyte replacement • Monitor urine output • Tube decompression • Empties stomach • Reduces aspiration risk • No benefit to long intestinal tubes • In partial obstruction: 60-85% success rate

  32. Treatment - Operative • Complete obstruction • Generally mandates operation • Some have argued for nonoperative approach in selected patients • 12-24hr delay of surgery is safe • >24hr delay is unsafe

  33. Operative Technique • Dependent on underlying problem • Adhesive band: Lysis of adhesions • Incarcerated hernia: manual reduction and closure of defect • *Presence of hernia with SBO mandates OR • Malignant tumors: Difficult challenge • Diverting stoma • Resection / anastamosis • Enteroenterostomy

  34. Intestinal Viability at Surgery • Release obstructed segment • Place in warm sponge x 15-20 minutes • If normal colour and peristalsis: return to abd • Doppler probe adds little to clinical judgment (Bulkley, 1981) • Fluorescein may be useful in difficult cases • “Second look” in 24 hrs if questionable viability or if clinically deteriorates post-op

  35. Laparoscopy in Acute SBO? • Criteria: • Mild distension • Proximal obstruction • Partial obstruction • Anticipated single-band obstruction • No matted adhesions / carcinomatosis

  36. Special Considerations: Recurrent Adhesions • Multiple agents have been tried, none successful • Hyaluronate-based membrane shown to reduce severity of adhesion formation (Becker, 1996; Vrigland, 2002) • No studies yet to show reduction in obstruction

  37. Special Considerations: Recurrent Adhesions • So far, best evidence to prevent adhesions is good surgical technique: • Gentle handling of bowel • Avoid unnecessary dissection • Exclusion of foreign material from peritoneum • Adequate irrigation / removal of debris • Place omentum around site of surgery

  38. Special Considerations: Acute Post-op Obstruction • Obstructive symptoms after an initial return of bowel function and resumption of oral intake • Technical complication versus adhesions • CT scan useful to evaluate for complications: • Anastamotic leak • Narrow anastomosis • Internal hernia • Obstruction at stoma • Early reoperation may be indicated

  39. Acute Adhesive Postoperative Obstruction • Difficult to distinguish from ileus • Incidence 0.7% • Highest incidence on small intestine (3% – 10%) • Present as early as POD 4 • Usually partial SBO • CT preferred modality

  40. Acute Postoperative Obstruction (Adhesive) • 80% spontaneous resolution of symptoms • 4% of patients required more than 2 weeks of treatment • SBO after laparoscopy: suspect herniaat trocar site

  41. Surgery for Malignant Bowel Obstruction in Advanced Gynaecological and Gastrointestinal Cancer • Cochrane Review:2004 • Role of surgery controversial • No firm conclusions from many retrospective case series • Control of symptoms varies from 42% to over 80 • Rates of re-obstruction, from 10-50%, though time to re-obstruction was often not included • Continues to be a challenging problem

  42. Steroids in Advanced Gyne/GI Cancer With SBO • Cochrane Review of prospective data (89 patients) • Trend, not statistically significant, for resolution of bowel obstruction using corticosteroids • No statistically significant difference in mortality • NNT 6 • Morbidity associated with steroids appears low

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