Presentation on theme: "Vomiting, Diarrhea & Constipation"— Presentation transcript:
1Vomiting, Diarrhea & Constipation Mark J. Koruda, MDProfessor of Surgery
2AssumptionsStudents understand the anatomy, embryology and physiology of the gastrointestinal tract.
3Case 1A 54-year-old woman presents with a two day history of crampy abdominal pain followed by episodes of bilious emesis.Important Items in the History?Previously hysterectomy for treatment of cervical cancer.
8Small Bowel Obstruction Laboratory Evaluation May see hypochloremic, hypokalemic metabolic alkalosis if having frequent emesis (proximal obstruction).May see evidence of contraction alkalosisIncreased H/H, BUN.WBC usually normal early.
9Case 1 What laboratory tests should be ordered? What diagnostic tests should be ordered?
19Small Bowel Obstruction Partial vs. Total Why Not Just Wait??Potential for Closed Loop ObstructionRisk of Ischemia / Perforation (4-6 hrs)
20Small Bowel Obstruction Treatment Correct intravascular volume deficitNGT vs. Miller-Abbott or Cantor TubesSerial ExamsOperation if no improvement or if signs of complete (closed loop) obstruction or incarceration.Evaluation of Bowel Viability
22Small Bowel Obstruction Special Cases Early Postoperative SBO<1% risk in first monthMust be considered after 7 days of “ileus” since adhesions become dense in 2-3 weeks.Recurrent SBO (5-15%)Malignant ObstructionRadiation Fibrosis
23Case 2A 72-year-old man presents with a two month history of gradually increasing constipation.Key Points in History?
24Large Bowel Obstruction Diagnosis Crampy PainOnset may be acute or insidiousDistension (50-60% have competent ileo-cecal valve and develop severe distension)Xrays: cm cecum, perforation riskContrast enema: Obstruction vs Oglive’sConsider rigid sigmoidoscopy to r/o and treat sigmoid volvulus
25Case 2Physical ExamWhat further tests are indicated
34Large Bowel Obstruction Treatment IVFNGTOperationEmergently if signs of peritonitis / perforationPrep bowel if possibleIs an ostomy necessary?Right vs. Left-sided LesionsTraditional vs. Newer Attitudesright colon - can reanastamosetransverse colon - extended right hemileft colon3 stage (ostomy, resection, takedown)2 stage (resect with protecting ostomy, takedown)1 stage (resect, anastamose with or without colonic lavage)leak rate 5%1 stage (resect whole colon and do an ileoproctostomy to avoid fecal loading)
37Oglive’s Syndrome (Colonic Pseudo-Obstruction) May mimic mechanical obstructionAssociated ConditionsTreatment:Rectal tube / enemas /exams (work in most)Colonoscopic decompression (80-90% eff.)Surgery (Cecostomy vs. Resection) - cecum >12 cm or peritoneal signsAssociated Conditions:AmyloidosisBlunt traumaCardiopulmonary BypassC-sectionChemotherapyDermatofibrosisDiabetesElectrolyte abnormalitiesHypothyroidismMedications (anticholinergics, ganglionic blockers, narcotics, phenothiazines, tricyclic antidepressants)Ortho or Neurologic ProceduresRenal FailureRenalTransplantationSclerodermaDementia / StrokeSLE
38Case 3A 54-yo Caucasian male with history of ileocolonic Crohn's disease, s/p ileocolectomy in 1979, who has not been on any Rx for CD. Presents to the UNC ER complaining of crampy abdominal pain that began at 8 hrs earlier located in the right lower and left lower quadrant. He also had nausea and vomiting as well as decreasing flatus associated. The patient stated his last BM was on the day of admission. He stated that the pain feels like his previous obstructions. Occurring every couple of months, recently increasing in frequency. No fevers. About 10 lb weight loss.Key Points in History
39What Is Crohn’s Disease? Crohn’s disease (CD) is an inflammatory bowel disorder that may affect any part of the gastro-intestinal (GI) tractThe inflammation penetrates the lining of the GI tract and often causes ulcers to formEsophagusSmallIntestineStomachLargeIntestine(Colon)RectumAppendix