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Abdominal Pain and Bowel Obstruction. Mike Goodwin CRASH Course October, 2010. Abdominal Pain - Approach. History Physical Labs Imaging Provisional Dx. History. PQRST AAA etx But don’t forget PSx Bowel/ Gyne / Urol ROS. Physical Exam. Complete

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abdominal pain and bowel obstruction

Abdominal Pain and Bowel Obstruction

Mike Goodwin

CRASH Course

October, 2010

abdominal pain approach
Abdominal Pain - Approach

History

Physical

Labs

Imaging

Provisional Dx

history
History
  • PQRST AAA etx
  • But don’t forget
    • PSx
    • Bowel/Gyne/Urol ROS
physical exam
Physical Exam
  • Complete
  • General appearance/vitals/H+N/Chest
  • Abdo:
    • Rigidity
    • Rebound
    • Guarding
    • IPPA
    • DRE / Pelvic / Groin / Flank-CVA
slide8
Labs
  • Everyone:
    • CBC, lytes BUN Cr
    • LFT, Bili, Amylase/Lipase, lactate
    • Urinalysis
    • Urine Preg
imaging
Imaging
  • AXR
    • 3-views
    • Free air
    • Distended bowel/air-fluid
    • Calcifications (panc or kidney/ureter)
  • US
    • If GS disease suspected
    • Lower abdo pain in female
imaging10
Imaging
  • CT Abdo
    • Test of choice for most patients
    • Protocols to minimize contrast nephropathy
bowel obstruction overview
Bowel Obstruction: Overview
  • History
  • Etiology
  • Pathophysiology
  • Clinical presentation
  • Imaging
  • Management
  • Special considerations
causes of small bowel obstruction in adults
Causes of Small Bowel Obstruction in Adults
  • Lesions Extrinsic to the Intestinal Wall
  • Lesions Intrinsic to the Intestinal Wall
  • Intraluminal/Obturator Obstruction
lesions extrinsic to the intestinal wall
Lesions Extrinsic to the Intestinal Wall
  • Adhesions (usually postoperative)  
  • Neoplastic
    • Carcinomatosis  
    • Extraintestinal neoplasms  
  • Hernia 
    • External (e.g., inguinal, femoral, umbilical, or ventral hernias) 
    • Internal (e.g., congenital defects such as paraduodenal, foramen of Winslow, and diaphragmatic hernias or postoperative secondary to mesenteric defects
  • Intra-abdominal abscess
lesions intrinsic to the intestinal wall
Congenital  

Malrotation  

Duplications/cysts  

Inflammatory  

Crohn’s disease  

Infections  

Tuberculosis 

Actinomycosis  

Diverticulitis

Neoplastic  

Primary neoplasms  

Metastatic neoplasms

Traumatic 

Hematoma  

Ischemic stricture

Miscellaneous  

Intussusception  

Endometriosis 

Radiation enteropathy/stricture

Lesions Intrinsic to the Intestinal Wall
intraluminal obturator obstruction
Intraluminal/Obturator Obstruction
  • Gallstone
  • Enterolith
  • Bezoar
pathophysiology
Pathophysiology
  • Early: Increased motility & contractility
  • Bowel dilation, fluid/lytes accumulate in lumen and bowel wall
  • Third spacing, intravascular volume depletion
slide18

Bowel obstruction

Increased intraluminal pressure

Decreased mucosal blood flow

Progressive Ischemia

Perforation & Peritonitis

clinical diagnosis
Clinical Diagnosis
  • History
    • Colicky abdominal pain
    • Nausea / vomiting
    • Abdominal distension
    • Failure to pass flatus / feces
physical examination
Physical Examination
  • Vitals: Tachycardia, hypotension
  • Abdomen:
    • Distension
    • Surgical scars
    • Bowel sounds, increased or decreased
    • Localized tenderness / rebound / guarding suggests strangulation
    • Hernia exam (ventral, groin, etc)
  • Rectal exam:
    • Rectal masses
    • Blood – suggesting ischemia, malignancy
radiology
Radiology
  • Plain Abdo X-Rays
    • Confirm Diagnosis
    • Localize obstruction to small bowel or colon
    • Evidence of complete or incomplete
plain x ray features
Plain X-ray Features
  • Dilated Small Bowel (>3 cm)
  • Multiple air-fluid levels
  • Colonic gas pattern
    • Normal / Dilated (Ileus or partial obstruction)
    • Absence of gas c/w complete obstruction
  • *Thickened bowel wall
  • *Pneumatosis intestinalis

*Suggests ischemia/strangulation

plain x rays
Plain X-rays
  • Lappas et al 2001
  • Review of 12 AXR findings with SBO
  • Findings:
  • Combination of
    • Air-fluid levels of different heights in the same bowel loop
    • Mean air-fluid level diameter of 2.5 cm or greater
  • Most predictive of a high-grade partial or complete SBO
axr disadvantages
AXR Disadvantages
  • 20-30% false negative rate
  • Does not localize site of obstruction
  • Does not establish etiology of obstruction
ct scan
CT Scan
  • 95% sensitive
  • 96% specific
  • 95% accurate in determining the presence of complete or high-grade SBO
  • Shows site and cause of obstruction in 95% of instances
  • Less accurate for partial SBO (50% some studies)
ct for sbo
CT for SBO
  • CT performed with IV and PO contrast
  • High-grade SBO seen even with no contrast
  • Lesser grades of obstruction seen with PO contrast
  • IV contrast for assessment of bowel wall for signs of edema or ischemia.
when to order ct
When to Order CT?
  • Clinical presentation or abdominal films nondiagnostic
  • Hx of abdominal malignancy
  • Immediate postsurgical patients
  • Patients who have no history of abdominal surgery
barium contrast studies
Barium / Contrast Studies
  • History of recurring obstruction
  • Low-grade mechanical obstruction
  • Defines the obstructed segment and degree of obstruction
gastrograffin swallow in adhesive sbo cochrane review 2004
Gastrograffin Swallow in Adhesive SBO, Cochrane Review, 2004
  • Diagnostic
    • Gastrofraffin seen in the cecum on AXR within 24 hours predicts resolution
    • Sensitivity of 0.96, specificity of 0.96
  • Therapeutic
    • Hospital length of stay 2-3 days shorter in non-operative patients
    • Studies prospective, non-blinded
simple versus strangulating obstruction
Simple Versus Strangulating Obstruction
  • Classic signs:
    • Fever
    • WBC inc
    • Constant Abdo pain
  • But no parameters reliably detect strang.
  • CT findings detect late ischemic changes
treatment nonoperative
Treatment – Nonoperative
  • Fluid resuscitation
    • IV resuscitation with isotonic saline
    • Electrolyte replacement
    • Monitor urine output
  • Tube decompression
    • Empties stomach
    • Reduces aspiration risk
    • No benefit to long intestinal tubes
  • In partial obstruction: 60-85% success rate
treatment operative
Treatment - Operative
  • Complete obstruction
    • Generally mandates operation
    • Some have argued for nonoperative approach in selected patients
    • 12-24hr delay of surgery is safe
    • >24hr delay is unsafe
operative technique
Operative Technique
  • Dependent on underlying problem
  • Adhesive band: Lysis of adhesions
  • Incarcerated hernia: manual reduction and closure of defect
  • *Presence of hernia with SBO mandates OR
  • Malignant tumors: Difficult challenge
    • Diverting stoma
    • Resection / anastamosis
    • Enteroenterostomy
intestinal viability at surgery
Intestinal Viability at Surgery
  • Release obstructed segment
  • Place in warm sponge x 15-20 minutes
  • If normal colour and peristalsis: return to abd
  • Doppler probe adds little to clinical judgment (Bulkley, 1981)
  • Fluorescein may be useful in difficult cases
  • “Second look” in 24 hrs if questionable viability or if clinically deteriorates post-op
laparoscopy in acute sbo
Laparoscopy in Acute SBO?
  • Criteria:
    • Mild distension
    • Proximal obstruction
    • Partial obstruction
    • Anticipated single-band obstruction
    • No matted adhesions / carcinomatosis
special considerations recurrent adhesions
Special Considerations: Recurrent Adhesions
  • Multiple agents have been tried, none successful
  • Hyaluronate-based membrane shown to reduce severity of adhesion formation (Becker, 1996; Vrigland, 2002)
  • No studies yet to show reduction in obstruction
special considerations recurrent adhesions45
Special Considerations: Recurrent Adhesions
  • So far, best evidence to prevent adhesions is good surgical technique:
  • Gentle handling of bowel
  • Avoid unnecessary dissection
  • Exclusion of foreign material from peritoneum
  • Adequate irrigation / removal of debris
  • Place omentum around site of surgery
special considerations acute post op obstruction
Special Considerations: Acute Post-op Obstruction
  • Obstructive symptoms after an initial return of bowel function and resumption of oral intake
  • Technical complication versus adhesions
  • CT scan useful to evaluate for complications:
    • Anastamotic leak
    • Narrow anastomosis
    • Internal hernia
    • Obstruction at stoma
  • Early reoperation may be indicated
acute adhesive postoperative obstruction
Acute Adhesive Postoperative Obstruction
  • Difficult to distinguish from ileus
  • Incidence 0.7%
  • Highest incidence on small intestine (3% – 10%)
  • Present as early as POD 4
  • Usually partial SBO
  • CT preferred modality
acute postoperative obstruction adhesive
Acute Postoperative Obstruction (Adhesive)
  • 80% spontaneous resolution of symptoms
  • 4% of patients required more than 2 weeks of treatment
  • SBO after laparoscopy: suspect herniaat trocar site
surgery for malignant bowel obstruction in advanced gynaecological and gastrointestinal cancer
Surgery for Malignant Bowel Obstruction in Advanced Gynaecological and Gastrointestinal Cancer
  • Cochrane Review:2004
  • Role of surgery controversial
  • No firm conclusions from many retrospective case series
  • Control of symptoms varies from 42% to over 80
  • Rates of re-obstruction, from 10-50%, though time to re-obstruction was often not included
  • Continues to be a challenging problem
steroids in advanced gyne gi cancer with sbo
Steroids in Advanced Gyne/GI Cancer With SBO
  • Cochrane Review of prospective data (89 patients)
  • Trend, not statistically significant, for resolution of bowel obstruction using corticosteroids
  • No statistically significant difference in mortality
  • NNT 6
  • Morbidity associated with steroids appears low
summary
Summary

Guidelines for Operative and Nonoperative Therapy

emergent operation
Emergent Operation
  • Incarcerated, strangulated hernia
  • Peritonitis
  • Pneumatosis
  • Pneumoperitoneum
  • Suspected / proven strangulation
  • Closed-loop obstruction
  • Complete bowel obstruction
urgent operation
Urgent Operation
  • Progressive bowel obstruction after conservative measures started
  • Failure to improve with conservative therapy in 24-48 hours
  • Early post-op technical complications (not adhesions)
operation usually delayed safely
Operation Usually Delayed Safely
  • Postoperative adhesions
  • Immediate post-op obstruction (adhesive)
  • Acute exacerbation of Crohn’s dx, diverticulitis, radiation enteritis
  • Chronic, recurrent partial obstruction
large bowel obstruction
Large Bowel Obstruction
  • Cancer
  • Cancer
  • Cancer (>90%)
  • Other things
    • Sigmoid Volvulus (5%)
    • Diverticular Disease (3%)
large bowel obstruction56
Large Bowel Obstruction
  • Approach
    • Contrast Enema
  • CT Abdo
  • Treat underlying cause
acute pseudo obstruction
Acute Pseudo-Obstruction
  • Common ward consult
  • Predisposing Conditions:
    • Surgery
    • Trauma
    • Infection
    • Cardiac (CHF/MI)
    • Neurological (PD, SCI, MS, AD
    • Metabolic (↓K/Na)
ogilvie s syndrome
Ogilvie’s Syndrome

Meds Assoc w/Ogilvie’s

  • Narcotics
  • Anticholinergic
  • TCA
  • Chlorpromazine
  • Levodop
  • Ca++ blockers
  • Clonidine

 Ogilvie’s Initial Tx:

  • Correct fluid and lyte
  • NPO/NG
  • Rectal tube
  • Limit offending medications
  • >80% success
ogilvie s treatment
Ogilvie’s Treatment

Neostigmine

  • 2 mg IV
  • Atropine at bedside
  • Monitored bed
  • Patient supine, on bedpan 
  • 90% success rate

Colonoscopy

  • If neostigmine fails
  • Decompression

Surgery

  • Last resort; rarely needed
  • If ischemia/perforation