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Differentiating Large Bowel Obstruction from Small Bowel Obstruction

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Presentation on theme: "Differentiating Large Bowel Obstruction from Small Bowel Obstruction"— Presentation transcript:

1 Differentiating Large Bowel Obstruction from Small Bowel Obstruction
Specialists Without Borders Seminar in Surgery Rwanda, September 2010 Differentiating Large Bowel Obstruction from Small Bowel Obstruction David Birks FRACS September 2010

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3 Differentiating large bowel obstruction from small bowel obstruction
Objectives Physiology & anatomy of small/large bowel Causes of bowel obstruction Symptoms & signs Investigations (plain xray) Complications Management – conservative & operative

4 Functions of intestine
Small intestine – absorption of fluid, food, vitamins Large intestine – absorption of water & Na - converts ml into 200ml semisolid faeces

5 Fluid replacement - GI loss
Type Na K Cl HCO3 Gastric 100 10 Bile 140 5 80 40 Pancreas Small Bowel 90 30

6 Fluid replacement - GI loss
Type Volume (litres) Gastric 2.0 Bile 1.0 Pancreas Small bowel 3.5 Total 7.5

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12 Causes of small bowel obstruction
adhesions (previous operation) external hernia small bowel volvulus (primary) neoplasms miscellaneous

13 Causes of large bowel obstruction
carcinoma of colon volvulus (sigmoid) diverticular disease miscellaneous

14 Symptoms of bowel obstruction
abdominal pain vomiting distension constipation (no flatus)

15 High small bowel obstruction
frequent, profuse vomiting central abdo pain minimal distension

16 Lower small bowel obstruction
colic pain moderate vomiting ( may be faeculent) moderate distension

17 Large bowel obstruction
abdominal distension constipation lower abdo pain ( may be minimal) minimal vomiting

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19 Physical Examination abdo scars external hernia
signs strangulation (tenderness, fever, mass)

20 Incarcerated groin hernia

21 Investigations Plain Xray – supine - erect - chest
Hb, WCC, Urea & Electrolytes

22 Further investigations
CT abdomen contrast study (via NG )

23 Plain x ray SBO dilated loops with gas centrally placed
transverse lines (circular folds)

24 Plain x ray LBO dilated bowel with gas (caecum) peripheral
haustra (not lines across bowel) may have cut-off point

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26 SBO

27 SBO SBO

28 LBO at sigmoid competent ileocaecal valve
Supine LBO

29 LBO

30 Carcinoma of Sigmoid – LBO – Decompressed into SB
Prone Incompetent ileocaecal valve Carcinoma of Sigmoid – LBO – Decompressed into SB

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32 Sigmoid volvulus

33 Sigmoid volvulus

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35 Could be paralytic ileus

36 Diagnosis of paralytic ileus

37 Lymphoma small bowel -CT scan of the abdomen shows a loop of small bowel in the mid-abdomen with a markedly thickened wall; lower image shows a large, intraluminal collection of barium representing aneurysmal dilatation of the involved loop

38 Complications of bowel obstruction
fluid & electrolyte loss - small bowel aspiration – small bowel respiratory restriction– large bowel strangulation – small bowel caecal perforation – large bowel (competent Ileo-caecal valve)

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40 Management of bowel obstruction
nil orally IV fluid & electrolyte replacement NasoGastric drainage (small bowel)

41 Operation for bowel obstruction
external hernia (SBO) – emergency signs of strangulation – emergency SBO not settling – within hr LBO due to carcinoma - soon

42 Non-operative treatment of bowel obstruction
sigmoid volvulus – decompress via sigmoidoscope post-operative SBO intussusception in infants (2/12 – 2 yr) previous operations for SBO radiation abdominal carcinomatosis

43 Operation - SBO midline incision look for ileo-caecal valve
treat cause external hernia – incision over hernia - if gangrene convert to midline

44 Operation - LBO midline and resect bowel pathology +/- anastomosis
+/- stoma if left sided obstruction – transverse colostomy through right upper trans incision

45 Small bowel chronic enlargement due to pseudo-obstruction

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47 Summary of bowel obstruction
Physiology & anatomy of small/large bowel Causes of bowel obstruction Symptoms & signs Investigations (plain xray) Complications Management – conservative & operative

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