Vomiting, Diarrhea & Constipation

1. Vomiting, Diarrhea & Constipation Mark J. Koruda, MD Professor of Surgery

2. Case 1 • A 54-year-old woman presents with a two day history of crampy abdominal pain followed by episodes of bilious emesis. • Important Items in the History? • Previously hysterectomy for treatment of cervical cancer.

3. Small Bowel Obstruction

4. Small Bowel ObstructionSigns & Symptoms • Intermittent, Crampy Abdominal Pain • Nausea / Emesis • Distension • Obstipation • Peristaltic Rushes on Auscultation • Focal Tenderness • Diffuse Peritonitis

5. Case 1 • What findings should be looked for on physical exam? • Distended • No peritoneal signs

6. Case 1 • What laboratory tests should be ordered?

7. Small Bowel ObstructionLaboratory Evaluation • May see hypochloremic, hypokalemic metabolic alkalosis if having frequent emesis (proximal obstruction). • May see evidence of contraction alkalosis • Increased H/H, BUN. • WBC usually normal early.

8. Case 1 • What laboratory tests should be ordered? • What diagnostic tests should be ordered?

9. Small Bowel ObstructionRadiologic Evaluation • Xrays: ? AFLs, ? Free Air, ? Distal Gas • UGI / SBFT: Identify mechanical obstruction • Enteroclysis: Independent of gastric emptying • CT Scan: ? Free Air, ? Pneumatosis, ? Tumor

14. Small Bowel ObstructionEtiologies • Adhesions • Malignancy • External or Internal Hernia • Volvulus • Crohn’s Disease • Intra-abdominal Abscess

15. Small Bowel ObstructionEtiologies (Cont.) • Radiation Stricture • Foreign Body • Gallstone Ileus • Meckel’s Diverticulum • Intramural Hematoma • Mesenteric Ischemia • Intussusception

16. Intestinal IleusEtiologies • Postoperative State • Sepsis • Electrolyte Imbalance • Drugs • Ureteral and Biliary Colic • Retroperitoneal Hemorrhage • Spinal Cord Injury • Myocardial Infarction • Pneumonia

17. Case 1 • What is the initial management plan?

18. Small Bowel ObstructionPartial vs. Total • Why Not Just Wait?? • Potential for Closed Loop Obstruction • Risk of Ischemia / Perforation (4-6 hrs)

19. Small Bowel ObstructionTreatment • Correct intravascular volume deficit • NGT vs. Miller-Abbott or Cantor Tubes • Serial Exams • Operation if no improvement or if signs of complete (closed loop) obstruction or incarceration. • Evaluation of Bowel Viability

21. Small Bowel ObstructionSpecial Cases • Early Postoperative SBO • <1% risk in first month • Must be considered after 7 days of “ileus” since adhesions become dense in 2-3 weeks. • Recurrent SBO (5-15%) • Malignant Obstruction • Radiation Fibrosis

22. Case 2 • A 72-year-old man presents with a two month history of gradually increasing constipation. • Key Points in History?

23. Large Bowel ObstructionDiagnosis • Crampy Pain • Onset may be acute or insidious • Distension (50-60% have competent ileo-cecal valve and develop severe distension) • Xrays: 12-14 cm cecum, perforation risk • Contrast enema: Obstruction vs Oglive’s • Consider rigid sigmoidoscopy to r/o and treat sigmoid volvulus

24. Case 2 • Physical Exam • What further tests are indicated

25. Case 2 • Differential Diagnosis • Colonic Obstruction • Malignant • Benign • Colonic Dysfunction

26. Large Bowel Obstruction

27. Large Bowel ObstructionEtiologies • Colon Cancer • Diverticulitis • Extrinsic Cancer • Fecal Impaction • Intussusception • Volvulus • Incarcerated Hernias

28. Large Bowel ObstructionColon Cancer • 20% of colon cancers present with obstruction • Left-sided lesions are more prone to obstruct (more narrow lumen, more solid fecal stream)

33. Large Bowel ObstructionTreatment • IVF • NGT • Operation • Emergently if signs of peritonitis / perforation • Prep bowel if possible • Is an ostomy necessary? • Right vs. Left-sided Lesions • Traditional vs. Newer Attitudes

34. Large Bowel Dysfunction • Inflammation • Colonic Inertia • Etc

36. Oglive’s Syndrome(Colonic Pseudo-Obstruction) • May mimic mechanical obstruction • Associated Conditions • Treatment: • Rectal tube / enemas /exams (work in most) • Colonoscopic decompression (80-90% eff.) • Surgery (Cecostomy vs. Resection) - cecum >12 cm or peritoneal signs

37. Case 3 • A 54-yo Caucasian male with history of ileocolonic Crohn's disease, s/p ileocolectomy in 1979, who has not been on any Rx for CD. Presents to the UNC ER complaining of crampy abdominal pain that began at 8 hrs earlier located in the right lower and left lower quadrant. He also had nausea and vomiting as well as decreasing flatus associated. The patient stated his last BM was on the day of admission. He stated that the pain feels like his previous obstructions. Occurring every couple of months, recently increasing in frequency. No fevers. About 10 lb weight loss. • Key Points in History

38. What Is Crohn’s Disease? • Crohn’s disease (CD) is an inflammatory bowel disorder that may affect any part of the gastro-intestinal (GI) tract • The inflammation penetrates the lining of the GI tract and often causes ulcers to form Esophagus Small Intestine Stomach Large Intestine (Colon) Rectum Appendix

40. Case 3 • Key Points in History

41. Case 3 • Key Points in History • Crohn’s disease • Previous surgical history • No Crohn’s Rx • Chronic symptoms • Weight loss • No fevers • Crampy pain

42. Case 3 • Physical Exam • Diagnostic Studies? • Differential Dx

43. Crohn’s Disease

44. Crohn’s Disease

45. Crohn’s Disease • Medical vs Surgical Management

50. Case 4 • 22yo UNC student presents with 3 mos of increasing “bloody diarrhea”, going to the bathroom 15-20x/day. “It rules my life!” • Key Points in History