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Small bowel obstruction
- 2. Small Bowel Obstruction SCHWARTZ'S PRINCIPLES OF SURGERY; 9TH EDITION
- 3. Epidemiology Most frequent surgical disorder of the small intestine Etiologies according to their relationship to intestinal wall: 1. Intraluminal (e.g., foreign bodies, gallstones, or meconium) 2. Intramural (e.g., tumors, Crohn's disease–associated inflammatory strictures) 3. Extrinsic (e.g., adhesions, hernias, or carcinomatosis)
- 4. Continue 75% of cases is caused by intra-abdominal adhesions related to prior abdominal surgery Less prevalent etiologies include: hernias malignant bowel obstruction (extrinsic compression or invasion from neoplasms arising in organs other than the intestine) and Crohn's disease
- 5. Continue Congenital abnormalities Usually become evident during childhood intestinal malrotation and midgut volvulus should not be forgotten in adult patients especially in those without history of prior abdominal surgery
- 8. Pathophysiology In the onset, gas and fluid accumulate within the intestinal lumen proximal to the site of obstruction Intestinal activity increases Colicky pain & Diahrrea Where does the gas & fluid come from? Bowel distends and intraluminal and intramural pressures rise Impair of intestinal microvascular perfusion Ischemia Necrosis strangulated bowel obstruction
- 9. Continues partial small bowel obstruction only a portion of the intestinal lumen is occluded pathophysiologic events occur more slowly & strangulation is less likely closed loop obstruction accumulating gas and fluid cannot escape Leading to a rapid rise in luminal pressure, and a rapid progression to strangulation
- 11. Clinical Presentation colicky abdominal pain, nausea, vomiting, and obstipation Vomiting is more seen with proximal obstructions than distal In established obstructions you see vomitus more feculent Continued passage beyond 6 to 12 hours after onset of symptoms is characteristic of partial obstruction Abdominal Distention is another sign, esp. if the obstruction is in distal ileum, absent if in proximal small intestine Bowel sounds
- 12. Continue Laboratory findings intravascular volume depletion consist of: hemoconcentration and electrolyte abnormalities Mild leukocytosis is common Features of strangulated obstruction include: Odd abdominal pain, suggestive of intestinal ischemia tachycardia, localized abdominal tenderness, fever, marked leukocytosis, and acidosis Any of these findings must alert you to the possibility of strangulation Surgery
- 13. example Chronic partial small bowel obstruction several months' history of chronic abdominal pain, and intermittent vomiting dilated segment shows evidence of fecalization
- 15. Diagnosis Focus on the following goals: (a) distinguish mechanical obstruction from ileus (b) determine the etiology of the obstruction (c) discriminate partial from complete obstruction (d) discriminate simple from strangulating obstruction
- 17. Continue Important elements to obtain on history: prior abdominal operations (suggesting the presence of adhesions) abdominal disorders (e.g., intra-abdominal cancer or inflammatory bowel disease) hernias (esp. in inguinal & femoral regions) Blood in Stool (Strangulation)
- 18. Radiographic Examination Abdominal series in X-ray: (1) Abdomen Supine, (2) Abdomen Upright, (3) Chest Upright. most specific triad for small bowel obstruction: dilated small bowel loops (>3 cm in diameter) air-fluid levels a paucity of air in the colon Specificity of plain Radiography is low (ileus and colonic obstruction) False-negative (proximal of small intestine OR filled with fluid but no gas)
- 22. CT-Scan a discrete transition zone with: dilation of bowel proximally, decompression of bowel distally, intraluminal contrast that does not pass beyond the transition zone, and a colon containing little gas or fluid Closed-loop obstruction U-shaped or C-shaped dilated bowel loop mesenteric vessels converging toward a torsion point Strangulation (thickening of the bowel wall, pneumatosis intestinalis)
- 28. Therapy marked depletion of intravascular volume decreased oral intake, vomiting, and sequestration of fluid in bowel lumen and wall IV fluid and bladder catheter(urine output) Broad-spectrum antibiotics NG tube (decreases nausea, distention, and the risk of vomiting & aspiration)
- 30. The END
Notes de l'éditeur
- Stricture: an abnormal narrowing of a bodily passage (as from inflammation, cancer, or the formation of scar tissue) <esophageal stricture>; also : the narrowed part Carcinomatosis: a condition in which multiple carcinomas develop simultaneously usually after dissemination from a primary source Simultaneous: happening or done at the same time as sth else Meconium : a dark greenish mass of desquamated cells, mucus, and bile that accumulates in the bowel of a fetus and is typically discharged shortly after birth
- Asthenic : of, relating to, or exhibiting asthenia : debilitated Asthenia : lack or loss of strength : debility
- Hematemesis ˌhē-mə-ˈtem-ə-səs: the vomiting of blood Intestinal Malrotation: Many authors define intestinal malrotation as intestinal nonrotation or incomplete rotation around the superior mesenteric artery (SMA). Interruption of typical intestinal rotation and fixation during fetal development can occur at a wide range of locations; this leads to various acute and chronic presentations of disease. The most common type found in pediatric patients is incomplete rotation predisposing to midgut volvulus, which can result in short-bowel syndrome or even death. Presentations: Acute & Chronic midgut volvulus-Acute & Chronic duodenal obstruction-Internal herniation Midgut Volvulus: Intestinal volvulus is defined as a complete twisting of a loop of intestine around its mesenteric attachment site. It is related to but not precisely synonymous with malrotation. Presentations: In the first month of life, the most typical presentation includes feeding intolerance with bilious (ie, yellow or green) vomiting and sudden onset of abdominal pain.
- Internal hernias are protrusions of the viscera through the peritoneum or mesentery but remaining within the abdominal cavity. Most common presentation is an acute intestinal obstruction of small bowel loops that develops through normal or abnormal apertures. Intussusception is caused by part of the intestine being pulled inward into itself. This can block the passage of food through the intestine. If the blood supply is cut off, the segment of intestine pulled inside can die. Decreased blood flow, Irritation & Swellings are clinical presentations. The intestine can die, and the patient can have significant bleeding. If a hole occurs, infection, shock, and dehydration can take place very rapidly. Diverticulits happens when pouches (diverticula ) form in the wall of the colon . If these pouches get inflamed or infected, it is called diverticulitis. Diverticulitis can be very painful.
- Meticulous : paying careful attention to every detail SYN fatidious, thorough
- Paucity : a small amount of sth; less than enough of sth
- Discrete : independent of other things of the same type SYN separate
- Small bowel obstruction. A computed tomographic scan of a patient presenting with signs and symptoms of bowel obstruction. Image shows grossly dilated loops of small bowel, with decompressed terminal ileum (I) and ascending colon (C), suggesting a complete distal small bowel obstruction. At laparotomy, adhesive bands from a previous surgery were identified and divided.
- Intestinal pneumatosis. This computed tomographic scan shows intestinal pneumatosis (arrow). The cause of this radiologic finding was intestinal ischemia. Patient was taken emergently to the operating room and underwent resection of an infarcted segment of small bowel.
- The CT-presentation of a closed loop obstruction in the small bowel depends on two things: length of the bowel segment that forms the closed loop orientation of the loop in relation to the imaging plane If we have a short closed loop oriented within the plane of imaging, we will see a U- or C-shaped loop of bowel.
- Another important appearance of a closed loop obstruction is that of a radial array of dilated small bowel loops with the mesenteric vessels converging to a central point. This is almost always due to a small bowel volvulus.
- If the closed loop is longer and is oriented perpendicular to the plane of section, we will see a clump of bowel loops as shown in the case on the left. Sometimes this is difficult to appreciate on just the axial images and coronal or sagittal reconstructions can be helpful. In this case there is also mesenteric edema and localised ascites in combination with dilated loops with wall thickening indicating strangulation and risk of infarction.
- Integral : being an essential part of sth