bowel obstruction lee
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Bowel Obstruction
Bowel Obstruction
Tad Kim, M.D.
Connie Lee, M.D.
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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
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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
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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!
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Bowel Obstruction
A*olio + and Ma!tu))iello . N Engl J Med 200;30:2770
nge%ted #agnet%
B l Ob t ti
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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) $!e%ented "it& t&!ee"ee% o' "eane%% and 'e*e!
B l Ob t ti
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Bowel Obstruction
9!au( et al. N Engl J Med 2003;3/:251-252
4adiog!a$&i) Finding% in od Pa)e!%
Bowel Obstruction
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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
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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 $ain and a 3-da &i%to!o' *o#iting
Bowel Obstruction
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Bowel Obstruction
,u!e! M and &inta$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
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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
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