Bowel Obstruction Lee

7/21/2019 Bowel Obstruction Lee

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Bowel Obstruction

Bowel Obstruction

Tad Kim, M.D.

Connie Lee, M.D.



Bowel Obstruction

Definitions

• Ileus = obstruction 22 d!sfunctional

motilit! of bowel

• Mec"anical obstruction = #$% &B, '$%

lar(e bowel

• &im)le obstruction

• Closed loo) obstruction

• &tran(ulation



Bowel Obstruction

&BO* +tiolo(!• d"esion -' #/01/% of &BO in )ts w)rior abdominal sur(er!3

• 4ernia -2 o5erall 0 -' cause of &BO in )ts wo )rior abdominalsur(er!

• Tumor

• bscess

• 4ematoma

• nnular )ancreas

• &M s!ndrome

• Con(enital lesions

• 6allstone ileus

• Intussusce)tion

• 7orei(n bod! be8oars, worms, etc3

• Meconium ileus

• Malrotation



Bowel Obstruction

Colonic Obstruction* +tiolo(!

• Cancer -' 9/%3

• :ol5ulus si(moid ; cecum3

• d"esions

• 4ernia

• <C

• Di5erticulitis

• Con(enital lesions

• 7ecal im)action

• d!namic ileus

• 4irsc"s)run(s

• Meconium ileus

• 7orei(n bod!



Bowel Obstruction

(e DD>

• (e matters?

@ Aeonate* meconium ileus, 4irsc"s)run(s,

malrotation, atresia

@ C"ild* intussusce)tion, 4irsc"s)run(s @ dult* "ernia, IBD, C, di5erticular disease

@ +lderl!* C, di5erticular disease, O(il5ies



Bowel Obstruction

4istor! DD>

• ro>imal obstruction* earl! bilious 5omitin(, flatusBM

• Distal obstruction* obsti)ation, distension, 5omitin( feculent material

22 bacterial o5er(rowt" of &B contents3

• ain wobstruction* be(ins as cram)in( )ain, c"an(es to continuous

se5ere )ain wstran(ulation )eritonitis• M4>* remember to as about cardiac "istor! arr"!t"mias, )rior

MI, fib 0 t"in about intestinal isc"emia3, IBD, (allstones, cancer

• &4>* remember to as about ostom! out)ut

• Meds* narcotics ileus3, anti)s!c"otics ileus3, diuretics "!)oK aw

ileus3

• EO&* recent wei("t loss C, &M s!ndrome3



Bowel Obstruction

+

• &tart wit" BCs

• Loo for sur(ical scars

• Bowel sounds

• Distention* distal obstruction ;; )ro>imal• Locali8ed tenderness* t"in )eritonitis

• Loo for "erniasmasses

•Do a rectal e>am



Bowel Obstruction

Labs

• FBC nml in uncom)licated &BO3

• CBC anemia wC3

• BM "!)oK3• lalosis aw )ro>imal obstruction3

• cidosis aw bowel infarction3

• m!lase ma! be ele5ated in &BO3



Bowel Obstruction

&tudies

• <)ri("t CGE* loo for free air

• 7lat and u)ri("tleft lateral decubitus* loo for

dilated bowel loo)s, air0fluid le5els• Aote* if cecal diameter ;'2cm, t"ere is a ris

of )erforation. t '20'Hcm, t"e wall tension ;)erfusion )ressure, increasin( ris of necrosis

• Barium enema• <6I series w&B follow0t"rou("

• CT scan



Bowel Obstruction

&BO* Mana(ement

• AO, A6T, 7ole!, I:7

• +lectrol!te re)lacement

• Man! )artial obstructions will resol5e

• Dont let t"e sun set on a com)lete3 &BOJ

• Com)lete bowel obstruction wconcern for

stran(ulation)erforation reuires immediate

o)erati5e inter5ention resuscitate first3



Bowel Obstruction

Dedouit F and Otal P. N Engl J Med 2008;358:1381

A 72-ea!-old "o#an $!e%ented "it& a 2-da &i%to! o' a(do#inal $ain a%%o)iated "it& nau%eaand *o#iting



Bowel Obstruction

+iu , and +in . N Engl J Med 2007;35:1152

A /8-ea!-old &ealt& "o#an $!e%ented "it& ano!eia o' 2 da% du!ation and a(do#inal $ain int&e !ig&t lo"e! uad!ant



Bowel Obstruction

Jang M and +ee ,. N Engl J Med 2008;358:e1

A 0-ea!-old "o#an $!e%ented to t&e out$atient )lini) "it& *ague a(do#inal di%)o#'o!t t&at&ad de*elo$ed o*e! t&e $!e*iou% %e*e!al "ee%

B l Ob i



Bowel Obstruction

Mi!ala 4 and Neilan 4. N Engl J Med 200;30:e32

A 8-ea!-old #an "it& al)o&oli) )i!!&o%i%6 $o!tal &$e!ten%ion6 a%)ite%6 and an u#(ili)al &e!nia$!e%ented to t&e e#e!gen) de$a!t#ent a'te! an e$i%ode o' )oug&ing t&at "a% 'ollo"ed ( a

!u%& o' 'luid and 'at '!o# t&e u#(ili)u%

B l Ob t ti



Bowel Obstruction

A*olio + and Ma!tu))iello . N Engl J Med 200;30:2770

nge%ted #agnet%

B l Ob t ti



Bowel Obstruction

4o%#a!in D and 9an . N Engl J Med 200;355:01

A 8-ea!-old #an "it& )&!oni) d%u!ia and in)!ea%ed u!ina! '!euen) $!e%ented "it& t&!ee"ee% o' "eane%% and 'e*e!

B l Ob t ti



Bowel Obstruction

9!au( et al. N Engl J Med 2003;3/:251-252

4adiog!a$&i) Finding% in od Pa)e!%

Bowel Obstruction



Bowel Obstruction

!a&a# J and 4ot&"ell . N Engl J Med 200/;351:111

An 83-ea!-old "o#an "a% &o%$itali<ed "it& nau%ea6 *o#iting6 and o(%ti$ation

Bowel Obstruction



Bowel Obstruction

&an D. N Engl J Med 200;355:171/

A $!e*iou%l &ealt& 102-ea!-old "o#an "a% ad#itted "it& a(do#inal $ain and a 3-da &i%to!o' *o#iting

Bowel Obstruction



Bowel Obstruction

,u!e! M and &inta$atla . N Engl J Med 2007;35:15

A /-ea!-old "o#an "it& ul)e!ati*e )oliti% $!e%ented "it& a(do#inal $ain

Bowel Obstruction



Bowel Obstruction

Tae 4ome oints• lwa!s start wit" BC, resuscitation

@ Includes 2 lar(e bore I:, 7ole!, A6T, monitor

• DDG is sim)le* @ O: Ad"esions, ul(es, ancer, ro"ns

@ +O: ANE4, :ol5ulus, Di5erticulitis

• Labs to assess de"!dration leuoc!tosis

• Ima(in( to assess obstruction etiolo(!

• If "!)oTAs"oc, to>icJ, or si(ns of stran(ulation

or isc"emia, resusc OE stat• Ot"erwise, for &BO, A6T treat etiolo(!

• LBO is different* reall! must rule out cancer,colonosco)! )la!s a lar(er role t"an w &BO

Bowel Obstruction Lee

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