Small bowel obstruction: Difference between revisions
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* SBO without hx of sx, no hernia = malignancy until proven otherwise | * SBO without hx of sx, no hernia = malignancy until proven otherwise | ||
* "Never let the sun rise or set on a small bowel obstruction" | * "Never let the sun rise or set on a small bowel obstruction" | ||
==Causes== | ==Causes== | ||
# Postoperative adhesions | # Postoperative adhesions | ||
# Malignancy | # Malignancy | ||
# | # Hernias | ||
# Intraluminal | # Intraluminal strictures | ||
## Crohn's disease | ## Crohn's disease | ||
## Radiation therapy | ## Radiation therapy | ||
## Mesenteric ischemia | ## Mesenteric ischemia | ||
# Trauma (particularly to the duodenum) | # Trauma (particularly to the duodenum) | ||
# Gallstone | # Gallstone ileus | ||
==Clinical Manifestations== | |||
* Nausea/vomiting | * Nausea/vomiting | ||
** Seen more in proximal than distal | ** Seen more in proximal than distal obstruction | ||
* Abdominal distention | * Abdominal distention | ||
** Seen more in distal than proximal | ** Seen more in distal than proximal obstruction | ||
* Abdominal pain | * Abdominal pain | ||
** Typically crampy, periumbilical | ** Typically crampy, periumbilical | ||
** Paroxysms of pain occur | ** Paroxysms of pain occur q5min | ||
* Inability to pass flatus | * Inability to pass flatus | ||
** Pts may pass flatus/stool initially | ** Pts may pass flatus/stool initially | ||
*** Takes 12-24hrs for colon to | *** Takes 12-24hrs for colon to empty | ||
* | * Dehydration | ||
* | * Anorexia | ||
* Metabolic alkalosis | * Metabolic alkalosis | ||
* Strangulation may occur | * Strangulation may occur | ||
** Fever | ** Fever | ||
** | ** Leukocytosis | ||
==Laboratory Diagnosis== | ==Laboratory Diagnosis== | ||
* CBC - evidence of strangulation? | * CBC - evidence of strangulation? | ||
* Chem - degree of dehydration, evidence of ischemia (acidosis) | * Chem - degree of dehydration, evidence of ischemia (acidosis) | ||
* Lactate -Sensitive (90-100%), though not specific, marker of strangulation | * Lactate -Sensitive (90-100%), though not specific, marker of strangulation | ||
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** Upright chest film: r/o free air | ** Upright chest film: r/o free air | ||
** Upright abd film: air-fluid levels | ** Upright abd film: air-fluid levels | ||
** Supine abd film: | ** Supine abd film: width of loops of bowel most visible (estimate of amount of distention) | ||
* Presence of air in colon or rectum makes complete obstruction less likely (esp of symptoms > 24hr) | * Presence of air in colon or rectum makes complete obstruction less likely (esp of symptoms > 24hr) | ||
* If pt cannot be placed in upright position a left lateral decub abd film can substitute | * If pt cannot be placed in upright position a left lateral decub abd film can substitute | ||
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**** 14 French | **** 14 French | ||
**** Intermittent low wall suction | **** Intermittent low wall suction | ||
**** Nasogastric fluid losses can be replaced w/ NS + KCL (30-40 meq) | **** Nasogastric fluid losses can be replaced w/ NS + KCL (30-40 meq) | ||
*** Contrast | *** Contrast | ||
**** Both diagnostic and therapeutic (draws water into the bowel stimulating peristalsis) | **** Both diagnostic and therapeutic (draws water into the bowel stimulating peristalsis) | ||
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*** Repeat CT scan may be helpful to detect early signs of bowel ischemia | *** Repeat CT scan may be helpful to detect early signs of bowel ischemia | ||
**** Repeat plain films are not helpful (only detect perforation) | **** Repeat plain films are not helpful (only detect perforation) | ||
** Operative | ** Operative Management | ||
*** 25% of pts admitted for SBO require surgery | *** 25% of pts admitted for SBO require surgery | ||
*** Indicated for pts with: | *** Indicated for pts with: | ||
| Line 78: | Line 77: | ||
**** Fever, leukocytosis, peritonitis | **** Fever, leukocytosis, peritonitis | ||
==Source | ==Source== | ||
UpToDate | |||
[[Category:GI]] | [[Category:GI]] | ||
Revision as of 14:08, 12 March 2011
Pearls
- SBO without hx of sx, no hernia = malignancy until proven otherwise
- "Never let the sun rise or set on a small bowel obstruction"
Causes
- Postoperative adhesions
- Malignancy
- Hernias
- Intraluminal strictures
- Crohn's disease
- Radiation therapy
- Mesenteric ischemia
- Trauma (particularly to the duodenum)
- Gallstone ileus
Clinical Manifestations
- Nausea/vomiting
- Seen more in proximal than distal obstruction
- Abdominal distention
- Seen more in distal than proximal obstruction
- Abdominal pain
- Typically crampy, periumbilical
- Paroxysms of pain occur q5min
- Inability to pass flatus
- Pts may pass flatus/stool initially
- Takes 12-24hrs for colon to empty
- Pts may pass flatus/stool initially
- Dehydration
- Anorexia
- Metabolic alkalosis
- Strangulation may occur
- Fever
- Leukocytosis
Laboratory Diagnosis
- CBC - evidence of strangulation?
- Chem - degree of dehydration, evidence of ischemia (acidosis)
- Lactate -Sensitive (90-100%), though not specific, marker of strangulation
Imaging
- Acute abdominal series
- Upright chest film: r/o free air
- Upright abd film: air-fluid levels
- Supine abd film: width of loops of bowel most visible (estimate of amount of distention)
- Presence of air in colon or rectum makes complete obstruction less likely (esp of symptoms > 24hr)
- If pt cannot be placed in upright position a left lateral decub abd film can substitute
- CT A/P with PO and IV contrast
- Consider if plain films are non-diagnostic
- Can show closed-loop obstruction, evidence of ischemia
Management
- IV fluid resuscitation with electrolyte repletion
- Assessment of need for operative vs nonoperative management
- Nonoperative Management
- Sometimes successful in patients with partial SBO (must rule-out strangulation first!)
- IV fluid resuscitation with electrolyte repletion
- NG tube
- 14 French
- Intermittent low wall suction
- Nasogastric fluid losses can be replaced w/ NS + KCL (30-40 meq)
- Contrast
- Both diagnostic and therapeutic (draws water into the bowel stimulating peristalsis)
- Associated with decreased hospital stay, more rapid resolution of symptoms
- If increasing pain, distention, or peristent high NGT output, consider operative intervention
- Repeat CT scan may be helpful to detect early signs of bowel ischemia
- Repeat plain films are not helpful (only detect perforation)
- Operative Management
- 25% of pts admitted for SBO require surgery
- Indicated for pts with:
- Complete SBO
- Closed-loop obstruction
- Fever, leukocytosis, peritonitis
- Nonoperative Management
Source
UpToDate