Bowel Obstruction

General Surgery Presentation by Archie Zhang CC3

 Etiology

Impaired bowel motility

“Ileus”, no mechanical explanation

common causes: opiates, electrolyte disturbances, intra-abdominal

infections (UTI, pneumonia), post-op paralysis of bowel

Mechanical obstruction

small bowel obstruction: adhesions, incarcerated hernia, in ammatory

bowel disease, cancers

large bowel obstruction: volvulus, diverticulitis, ischemic strictures,

colorectal cancer

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 History

Pain: location, radiation, crampy vs. constant, sharp v dull

Nausea-vomiting

Past medical history: Crohn’s disease or In ammatory

Bowel Disease; Radiation or Cancer

Past surgical history: intra-abdo procedures

Cancer screening: recent colonoscopy, results; family

history of GI cancers

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 History

Review of Systems

weight loss, smoking, history of constipation /

laxative use

Medications

Allergies

Differential Diagnosis for

Distention

Air: bowel obstruction

Fluid: ascites (hepatic, renal, cardiac)

Mass: intra-abdominal masses

 Physical Exam

Hemodynamically stable

Heart rate, blood pressure, temperature, immediate

resuscitation, ICU call

Cardio Resp, cervical lymph nodes

 Physical Exam

Distention (types)

air = will congregate centre when lying

uid = will congregate at sides when lying

Skin / dermatology

look to make sure there’s no erythema or necrotic changes

abdominal mass (epigastric, umbilical, femoral or groin

areas)
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 Physical Exam

Percussion

Tympanic with hyperressonance = air distention

Dull sounds = uid distention (shifting dullness)

Dull sounds = mass distention

Peritoneal signs = rigid feeling of abdomen,

increased pain

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 Palpation

hepatomegaly, splenomegaly

abdominal mass

palpate for hernias

ask to bear down “like having BM”

rectal examination

inspection

occult stool test (guaiac test)

 Laboratory Studies

CBC:

WBC = worrisome for ischemia

Hemoglobin / hematocrit: increased if

hemoconcentration or dehydration; decreased if
anemia

Platelets: pre-op assessment

 Laboratory Studies

Electrolytes

Hypochloremic alkalosis (also hypokalemia) = vomit out HCl acid

BUN to Cr ratio = hemoconcentration or volume depletion

LFT = should be normal

Amylase / lipase = pancreatitis can mimic bowel obstruction, can

mildly increase amylase without increase in lipase

PT / INR = unless patient going for pre-op

 Additional Lab Studies

Urinalysis (UA)

UTI, nephrolithiasis can cause ileus and mimic SBO

Arterial Blood Gas

look for base de cit (dehydration); acidemia =

ischemia?

Lactate = increased for dehydration or ischemia

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 Imaging Studies

Abdominal radiograph: 69% sensitivity, 57% speci city

dilatation of proximal small bowel

differentiated air- uid levels

collapse of distal small and large bowel

Computed tomography: 94-100% sensitivity, 90-95%

speci city
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 Imaging Studies

Radiograph for Ileus

diffuse air with multiple air uid levels

air within colon —> non-obstructive

usually 2nd to post-op paralysis of the bowel

String of beads sign

an upright lm, indication of high grade SBO; small pockets of gas that are
trapped between valvular conniventes, inferior margins have ovoid
appearance from meniscal effects

on supine lm, can look normal as all uid levels are lled
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 Complication of SBO

Ischemia (vascular compromise)

pathophysiology: E. coli and air to blood vessels

portal venous air (peripheral to liver)

pneumatosis (circumferential air), on both visceral

and parietal layers of the bowel

free air 2nd to perforation

 Decision Making

Operative Management (resection with diversion or

anastamosis)

Peritonitis

Incarcerated hernia

Fever, increased WBC

No history of previous abdominal surgery

 Decision Making

Non-operative management

NG tube — decompress abdomen

Resuscitation — IV uid de cit (4-5 L); NS or lactated

ringer (if hyochloremic alkalosis, using NS to repalce
chloride and address acid / base balance)

Foley — measure urine output

Serial Abdo — KUB X-Ray

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 Treatment Strategies

Neoplasms

Primary: resection

Secondary: depends on clinical presentation, laparotomy with limited

resection, bypass, gastronomy, tube jejunostomy, or percutaneous
gastronomy

Gallstone ileus

Duodenal stone inpaction with extracorporeal shock wave lithotripsy;

SB impaction is surgical, either enterolithotomy, or cholecystectomy

without closure of stula

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 Treatment Strategies

Crohn’s Disease

Initial treatment with steroids and parenteral nutrition

(TPN) is successful for rst time presentations

Patient with recurrent obstruction, especially with palpable

mass on adequate medical therapy, are candidates for
earlier surgical intervention, namely resection

Stricturoplasty as bowel-preserving surgery in select

group of patients

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 Treatment Strategies

Early Post-Operative Obstruction

SBO within 30 days post-op; bowel activity may not

return (prolonged ileus) or there is temporary return
of bowel obstruction

Obstruction is due to adhesions (92%), phlegmon

(acute in ammation) or abscess, intussusception
(2.5-4%), or internal hernia
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 Treatment Strategies

Radiation Enteritis

Actinic (lightwave) damage to intestinal mucosa, connective

tissue, and vessels; Normal tissue planes obliterated,
intestines are friable, brosis may be extensive (frozen pelvis);
Local factors in intestine and mesentery

When surgery indicated, manipulation of bowel kept to

minimum; attempts to dissect damaged bowel loop glued by
serositis and brosis will result in bowel injury and spillage;
bypass procedure is safe and effective, except if limited
involvement of freely mobile bowel, where resection is optimal
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 Treatment Strategies

NSAID-induced SBO

Chronic use of NSAIDs associated with pathology

Perforation, ulceration, and stricture formation (the

strictures are multiple and appear diaphragm-like that
narrow down the lumen to pinhole); dif cult to feel,
in ation of bowel with air;

Once identi ed treatment, intestinal resection,

stricturoplasty, balloon dilatation
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 Treatment Strategies

Volvulus

Endoscopic reduction and decompression of sigmoid

volvulus can be performed in absence of peritoneal
signs

Recurrence high after decompression: elective

surgical resection should follow;

For decal or transverse colon volvulus, surgical

resection and anastomosis is preferred

 Post-Operative Care

IV Fluid

NG removed when output <200 cc / shift

oral liquids when patient passes gas

Complications: intra-abdominal abscess, anastamotic

leak, wound infection