ACUTE MECHANICAL SBO

EPIDEMIOLOGY
• is a common surgical emergency.
• It accounts for 2 to 4 percent of emergency department visits
• approximately 15 percent of hospital admissions
• 20 percent of emergency surgical operations for abdominal pain
• Between 20 and 30 percent of patients with small bowel obstruction undergo operative intervention
• Bowel ischemia as a complication of bowel obstruction is seen in 7 to 42 percent

PATHOPHYSIOLOGY
• Mechanical obstruction is caused by either intrinsic luminal obstruction or extrinsic compression of the small bowel.
• Obstruction leads to progressive dilation of the intestine proximal to the blockage
• Distal to the blockage, the bowel will decompress as luminal contents pass.
• Swallowed air and gas from bacterial fermentation can accumulate, adding to bowel distention.
• As the process continues, the bowel wall becomes edematous, normal absorptive function is lost, and fluid is sequestered into the bowel lumen
• Ischemic necrosis of the bowel is most commonly caused by twisting of the bowel and/or its mesentery around an adhesive band or intestinal attachments.

ETIOLOGY
• EXTRINSIC
◦obstruction to the wall of the small intestine (eg, adhesions, hernia, volvulus) can mechanically compress the bowel and obstruct the luminal flow.
• INTRINSIC
◦Diseases intrinsic to the wall of the small intestine (eg, tumor, stricture, intramural hematoma) can cause small bowel obstruction by encroaching upon the lumen
of the bowel because of edema, infiltration of the bowel wall, or from progressive stricture formation.
• Processes that block an otherwise normal bowel lumen (eg, intussusception, gallstones, foreign body) can also cause mechanical bowel obstruction.

AAST CLASSIFICATION OF SBO

CLINICAL PRESENTATIONS
• Most patients with small bowel obstruction will present acutely with an abrupt onset of colicky abdominal pain, nausea, vomiting, and abdominal distention

RISK FACTORS
• Prior abdominal or pelvic surgery (risk for adhesion formation)
• Abdominal wall or groin hernia
• Intestinal inflammation (eg, Crohn disease)
• History of or increased risk for neoplasm
• Prior abdominopelvic irradiation
• History of foreign body ingestion

SYMPTOMS
• Nausea, vomiting – Proximal small bowel obstruction (duodenum, proximal jejunum) can cause severe nausea and vomiting; as a result, patients typically cease taking in
food or liquids orally.
• Cramping abdominal pain – Abdominal pain associated with small bowel obstruction is frequently described as periumbilical and cramping with paroxysms of pain
occurring every four or five minutes
• Obstipation (ie, inability to pass flatus or stool) – Cessation of passage of stool or flatus indicates a complete obstruction. However, passage of flatus or feces can
continue for 12 to 24 hours after the onset of obstructive symptoms as there is evacuation of luminal contents from the more distal bowel. Hematochezia may be a sign
of tumor, ischemia, inflammatory mucosal injury, or intussusception.

PHYSICAL EXAMINATION
• Systemic signs – A hallmark of small bowel obstruction is dehydration, which manifests as tachycardia, orthostatic hypotension, reduced urine output, and, if severe, dry
mucus membranes.
• Abdominal Inspection - distension was the most frequent physical finding on clinical examination, occurring in 56 to 65 percent of patients. Distention is minimal ; heck
for surgical scars
• Abdominal auscultation – Acute mechanical bowel obstruction is characterized by high-pitched "tinkling" sounds associated with the pain
• Abdominal percussion – Distention of the bowel results in hyperresonance or tympany to percussion throughout the abdomen. Tenderness to light percussion suggests
peritonitis.
• Abdominal palpation may identify any abdominal wall or groin hernias, or abnormal masses
• Digital rectal examination should be performed to identify fecal impaction or rectal mass as the source of obstruction. Gross or occult blood may be related to intestinal
tumor, ischemia, inflammatory mucosal injury, or intussusception.

DIAGNOSIS
• suspected (or obvious) based upon risk factors, symptoms, and physical examination findings consistent with obstruction, abdominal imaging is usually required to
confirm the diagnosis
• Abdominal imaging :
◦to confirm the diagnosis
◦identify the location of obstruction
◦judge whether the obstruction is partial or complete
◦identify complications related to obstruction (ischemia, necrosis, perforation)
◦determine the potential etiology
• all of which will help determine the urgency and nature of further treatment (surgery versus initial nonoperative management)
IMAGING
PLAIN RADIOGRAPHY
• Upright chest film and upright and supine abdominal films.
• If the patient cannot be placed into an upright position, a lateral decubitus abdominal film may show free air and/or air-fluid levels.

• Findings on plain radiography consistent with small bowel obstruction include the following:
◦Dilated loops of bowel with air-fluid levels
‣ The presence of air-fluid levels of differential height in the same loop of bowel and the presence of a mean air-fluid level width ≥25 mm on upright plain
film has been reported to strongly correlate with a complete or high-grade obstruction
◦Proximal bowel dilation with distal bowel collapse
‣ Small bowel obstruction can be diagnosed if the more proximal small bowel is dilated more than 2.5 cm (outer wall to outer wall) and the more distal
small bowel is not dilated
◦Gasless abdomen
‣ gasless abdomen may be due to complete filling of loops of bowel with sequestered fluid
‣ "string of beads (or pearls)" sign may be seen in predominantly fluid-filled small bowel loops on upright or lateral films

ABDOMINAL CT
• performed with intravenous contrast if not contraindicated, though it is possible to diagnose small bowel obstruction without contrast enhancement
• more useful than plain radiographs for identifying the specific site (ie, transition point) and severity of obstruction (partial versus complete)
• have high sensitivity (83 percent) and specificity (92 percent) for identifying bowel ischemia
• Findings :
◦findings of dilated proximal bowel with distal collapsed bowel and air-fluid levels
◦Additional findings :
‣ Bowel wall thickening >3 mm (nonspecific)
‣ Submucosal edema/hemorrhage
‣ Mesenteric edema
‣ Ascites
◦CT can identify nonadhesive causes of a small obstruction, which may require surgical correction:
‣ Incarcerated abdominal wall or groin hernia
‣ Mass lesion
‣ "Target sign" – Alternating hypo/hyperdense layers, indicative of intussusception
‣ "Whirl sign" – Rotation of small bowel mesentery, suggesting an internal hernia or volvulus
‣ "Venous cut-off sign" – Venous flow to a loop of small bowel that is "cut off" suggests thrombosis

DIFFERENTIAL DIAGNOSIS
• Functional bowel obstruction
• Adynamic (Paralytic) ileus
• Pseudoobstruction
• Large bowel obstruction

CAUSES OF BOWEL OBSTRUCTION

SPECIFIC ETIOLOGIES
• Once a diagnosis of small bowel obstruction has been established, it is important to try to determine the specific etiology responsible for the obstruction
• ADHESIVE BOWEL DISEASE
◦most common etiology for small bowel obstruction
◦specific preoperative diagnosis of adhesions as a cause of bowel obstruction is difficult to confirm
◦Signs: "fat-bridging sign," which is a cord-like structure containing mesenteric fat that can bridge across the peritoneum twisting of the mesentery (whirl signs);
and tethering of the omentum.
◦Adhesions are a frequent cause of closed-loop obstruction
◦Early postoperative small bowel obstruction — Small bowel obstruction that occurs within four to six weeks of an abdominal surgery
• TUMOR
◦predominantly metastatic malignant tumors, are the second most common cause of small bowel obstruction, accounting for approximately 20 percent of
cases.
◦PRIMARY TUMOR
‣ Primary tumors of the small or large bowel may be responsible for symptoms and signs of small bowel obstruction.
• COMPLICATED HERNIA
◦Hernias are the third leading cause of intestinal obstruction, accounting for approximately 10 percent of all cases, and incarcerated hernias are the leading
cause of complications (ischemia, necrosis, perforation) related to bowel obstruction
◦External hernias occur at sites of muscular or ligamentous weakness in the abdominal wall.
◦Internal hernias cause 0.6 to 6.0 percent of small bowel obstructions and occur through acquired or congenital defects in the mesentery
• INTRA-ABDOMINAL INFLAMMATION OR INFECTION
◦Inflammation of the intestine (eg, Crohn disease flare-up, appendicitis, colonic diverticulitis, Meckel's diverticulitis) with or without abscess formation can lead to
an acute mechanical small bowel obstruction
• TRAUMATIC INTRAMURAL HEMATOMA
◦history of blunt abdominal trauma (recent or remote), in the absence of other risk factors for bowel obstruction, should suggest a diagnosis of traumatic
intramural hematoma as the etiology of acute mechanical bowel obstruction
◦duodenum is the most frequently involved segment of the bowel because it is fixed in the retroperitoneum and easily compressed between the abdominal wall
and the vertebral column.
◦A common cause is injury from a seatbelt.
• INTESTINAL STRICTURE
• Intestinal stricture as an etiology of bowel obstruction can be due to a number of disorders:
◦Crohn disease - MOST COMMON
◦Mesenteric ischemia
◦Radiation enteritis
◦Drugs (NSAIDs and enteric coated KCl)
• GALLSTONES / FOREIGN BODY
◦Rarely, acute mechanical small bowel obstruction can be caused by intraluminal material.
◦The site of obstruction is usually at the ileocecal valve, where the lumen of the bowel is smallest.
◦GASTROINTESTINAL BEZOARS
‣ composed of ingested material that is not digested within the gastrointestinal tract, can obstruct the bowel lumen and may be related to a high-fiber diet
(phytobezoar), improperly chewed food, hair ingestion (trichobezoar), and medications (pharmacobezoar)
• INTUSSUSCEPTION
◦Intestinal intussusception is rare in adults, accounting for 1 to 5 percent of mechanical bowel obstructions.
◦In adults, intussusception is typically due to pathologic lead point within the bowel, which is malignant in up to 77 percent
◦Lead point is pulled forward by normal peristalsis, telescoping or prolapsing the affected segment of bowel (intussusceptum) into another segment of bowel
(intussuscipiens)

MANAGEMENT OF SBO :

CROHN’S DISEASE , MECKEL’S

• See book

SMALL BOWEL SYNDROME (SBS)

• Short bowel syndrome (SBS) is a malabsorptive condition most often caused by massive resection of the small intestine.
• Clinical disease is only modestly correlated with the amount of intestine that is resected because of the highly variable length of the human small bowel and the
remarkable ability of the bowel to compensate for bowel resection.
• Therefore, the best definition of SBS is based upon intestinal dysfunction, ie, the presence of significant malabsorption of both macronutrients and micronutrients.
• presence of less than 200 cm of residual small bowel in adult patients — Measured from duodenojejunal flexure with or without colon in adults
• INTESTINAL FAILURE
◦Gastrointestinal function is inadequate to maintain his or her nutrient and hydration status w/o IV or enteral supplementation
◦Functionally, may be classified by duration:
‣ type I (acute)
‣ type II (prolonged acute)
‣ type III (chronic)
• SBS is the most common cause of chronic intestinal failure

• INITIAL DETERMINANTS OF INTESTINAL FUNCTION

◦The main determinants of intestinal dysfunction in the initial phases after bowel resection are:
‣ Length of the intestinal resection (relative to age or body size)
‣ Loss of the ileum and ileocecal valve
‣ Loss of all or part of the colon
‣ Continuity versus incontinuity of the intestines
 ◦Ileum – Resection of the ileum has important implications for patients with SBS because of the ileum's special roles in absorbing vitamin B12 and bile acids and
reducing intestinal motility when stimulated by fat (the "ileal brake") and its ability to undergo adaptive changes.

◦Colon – The colon has an important role in absorption of water and electrolytes and the salvage of energy in the form of short-chain fatty acids. The latter can
provide a significant portion of energy requirements in patients with SBS, at least in adults. The colon also helps to slow intestinal transit and stimulate intestinal
adaptation.

• INTESTINAL ADAPTATION
◦Intestinal adaptation refers to changes that occur after intestinal resection that increase absorptive capacity.
◦Both structural and functional changes occur.
◦Most intestinal adaptation occurs in the ileum, but some functional adaption may also occur in the jejunum or colon.
◦Best established stimulant is the presence of nutrients in the intestinal lumen.
◦Enteral feeding is the cornerstone of treatment for patients with SBS

• ACUTE PHASE MANAGEMENT

◦INTRAVENOUS FLUIDS AND NUTRITIONAL SUPPORT
‣ Primarily involves close monitoring of stool and urine output, and parenteral replacement of fluid and electrolyte losses
◦ACID SUPPRESSION
‣ Administer acid suppressing medications (H2 blockers, PPI) during the first 3-6 months after intestinal resection in order to reduce gastric secretion and
enteral fluid losses (GRADE 1B)
• ADAPTATION PHASE MANAGEMENT
◦Oral diet and medication precaustions
◦Fluid management
◦Patients with persistent intestinal failure:
‣ Use of intestinotrophic factor (Teduglutide)
‣ Autologous GI reconstruction
‣ Small bowel transplantation

SMALL BOWEL NEOPLASM

• MALIGNANT (adenocarcinomas, neuroendocrine tumors, lymphomas, and sarcomas)

• BENIGN (adenomas, leiomyomas, lipomas)
• The most common presenting symptom of a small bowel tumor is abdominal pain
• Other symptoms include weight loss, nausea and vomiting, gastrointestinal bleeding, and intestinal obstruction.
• As compared with those with benign tumors, patients with malignant small bowel neoplasms are more often symptomatic, and the majority of symptomatic small bowel
tumors are malignant.
• Well-differentiated gastrointestinal NETs arising in the small bowel are most commonly found in the ileum, within 60 cm of the ileocecal valve
• Primary gastrointestinal tract lymphoma is the most common extranodal form of lymphoma; the lymphoid-rich ileum is the most common location
• Malignant mesenchymal tumors (sarcomas) represent approximately 10 percent of small bowel neoplasms and are most common in the jejunum and ileum.
• The most common type of intestinal sarcoma is gastrointestinal stromal tumor (GIST).

• Complete resection of duodenal adenocarcinomas is associated with postoperative 5-year survival rates ranging from 50% to 60%.
• Complete resection of adenocarcinomas located in the jejunum or ileum is associated with 5-year survival rates of 20% to 30%.
• The overall 5-year survival rate for patients diagnosed with intestinal lymphoma ranges from 20% to 40%.
• For patients with localized lymphoma amenable to surgical resection, the 5-year survival rate is 60%.

OBSCURE GI BLEEDING
• No source has been identified by routine endoscopic studies (EGD and colonoscopy)
• Small bowel: beyond the reach of these examinations
• Angiodysplasias
◦Account for ~75% of cases in adults
◦Neoplasms in 10%
◦Meckel’s diverticulum
• Most common etiology in children
• Enteroscopy may play a role
• RBC tagged scan
• Angiography