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Disorders of Small and Large Bowel Jay Green October 26, 2006.

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Presentation on theme: "Disorders of Small and Large Bowel Jay Green October 26, 2006."— Presentation transcript:

1 Disorders of Small and Large Bowel Jay Green October 26, 2006

2 Case 1  54 y.o. F, abdominal pain  Started 2 days ago, shortly after Big Mac  Hurts all over, comes and goes, crampy  +D yesterday, bloated, +N today, ø V  PMH: DMII, HTN, TAH/BSO (’04)  Ideas?

3 DDx - Approach  Think anatomy Intraperitonaeal, retroperitoneal, other  Think VITAMIN D, VINDICATED, whatever…  Vascular  Ischemic gut, MI, AAA  Infection  Gastro, PUD, psoas abscess  Neoplastic  Intussusception  Inflammatory  Diverticulitis, Cholecystitis, Pancreatitis, Appendicitis  Traumatic  Obstruction  Pregnancy

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5 Small Bowel Obstruction  Top 3 causes?  Hernia  Adhesions  CA  Most likely to cause strangulation?  Hernia – often closed loop  Others to think about?  Gallstone ileus, volvulus, intussusception, abscess, hematoma, foreign body

6  More than half of SBO recurr  True  False  Bathing in tomato juice removes the smell of a skunk  True  False

7 SBO – Quick facts  20% of acute abdo admissions  Mortality <5% (30% with strangulation, 60% in 1900)  >50% recur

8 H&P  Recurrent abdo pain, crampy, <>  Worry if pain becomes constant severe  Vomiting, distension, constipation  Prev surgery  Vitals: normal, tachy, hypoTN, fever  Distention, ∆BS (↑ pitch), tympany  ±scars/hernia, ±tender mass Bohner H, et al: Simple data from history and physical examination help to exclude bowel obstruction and to avoid radiographic studies in patients with acute abdominal pain. Eur J Surg 1998; 164:777  Vomiting, distension, constipation  Prev surgery ∆BS ∆BS

9 Review of the basics  Types?  Mechanical & functional  Simple & closed loop (±strangulation)  Common causes of ileus?  Trauma, infection, sx, meds, metabolic, renal colic

10  Physicians reliably can distinguish bowel strangulation from simple obstruction  True  False  Cracking knuckles leads to arthritis  True  False

11 Simple vs Strangulated - How good are we?  Confident diagnosis of “non-strangulating obstruction” wrong 31% of the time.  No parameter is sensitive, specific, or predictive for strangulation  Not very good! Sarr et al. Preoperative recognition of intestinal strangulation obstruction: Prospective evaluation of diagnostic capability. Am J Surg 145: , 1983.

12 Pathophysiology  Mechanical SBO → prox dilation → ↑ local peristalsis → ↑ secretory activity → ↓ reabsorption fluid/lytes → capillary/lymphatic obstruction → edema → perforation or strangulation

13 Investigations  Labs:  ↑WBC, ±↑CPK, ±↑lactate  Imaging:  3 views (60% +SBO, 25% suggestive)  Five places to look for air?  How many A/F levels?  Dilated?

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18 CT Scan?  Not required for diagnosis  Can help define site/cause  Other imaging?  Small bowel series, U/S

19 What about U/S? SNSPEtiology Plain films 77%50%7% U/S83%100%23% CT93%100%87%

20  ½ of complete SBO resolve spontaneously  True  False  Eating 3 poppy seed bagels may result in positive urine drug screen for opiates  True  False

21 Management  Fluid resuscitation  Decompression  NG tube  ?Antibiotics  Observation vs. surgery  “never let the sun rise or set on an SBO”  75% of partial/30-50% complete resolve

22 Take home points  You are not good at dx strangulation  AXR - >2 A/F levels, >2.5cm, air x 5  ½ of SBO resolve spontaneously

23 Case 2  28M central/RLQ crampy abdominal pain, N  Last BM this am, no fever/chills/V  Best guess?  28F same hx?  25% signs initially suggestive of appe = gyne  84F type II DM same hx?  4M same hx?

24 Case 2  Vitals – 37.3, 85, 126/85, 18  RLQ tenderness, +guarding  Investigations?

25 Appendicitis – Quick facts  7% lifetime incidence  cases/yr in the USA  First appendectomy – 1735

26 What the heck is this?

27 The Appendix  "Its major importance would appear to be financial support of the surgical profession." - Alfred Sherwood Romer Leonardo da Vinci (1492)

28 Pathophysiology  Obstruction  ↑ pressure  distension  ischemia + bacteria/PMN invasion  swells, irritates  necrosis and rupture

29 History  Three most common symptoms?  abdo pain, anorexia, nausea  Rule out based on pain location?  no, can even have LUQ pain

30 Physical exam  Vitals – 37.3, 85, 126/85, 18  Do normal vitals r/o appendicitis?  What if T = 38.1?  Low grade fever in 15% (40% if ruptured)  Eponyms  McBurney’s, Rovsing’s, Obturator, Psoas, Dunphy

31 H&P  Three important signs/symptoms?  RLQ pain, rigidity, migration of pain  Four to help rule out appendicitis?  Pain > 48h, similar pain, lack of migration, lack of ↑ pain with movement/cough

32  CMT is uncommon in women with acute appendicitis  True  False  The air expelled in a sneeze can travel up to 100mph  True  False

33 Classic Appendicitis  Peri-umbilical pain  RLQ migration  N, anorexia, V  No history of similar pain in past  Pain < 48hrs at presentation  Pain ↑ with movement/cough  Low grade fever  Rigidity & guarding  Local RLQ tenderness

34 Serial exams  Review of 30 years of publications  “active observation” = reassess pt q2-3h  Pain resolved in 1/3 of patients  No change in perforation rate  Negative appendectomy rate 6%  vs 20-30% (?lower with CT or U/S) Jones PF. Suspected acute appendicitis: Trends in management over 30 years. Br J Surg 2001; 88:

35 What labs?  Commonly ordered  CBC, β-hcg, U/A  ±LFT’s/lipase, ±CRP  Findings  ↑ WBC, U/A – pyuria, microscopic hematuria  Necessary?  β-hcg!

36 U/S vs CT  CT  SN 94%, SP 95%, LR+ 13.3, LR  + usually visualize appendix, not operator dependent, ID other pathology  - radiation  Contrast?  Rectal – best but not practical  Oral – delay, ?tolerated, esp. helpful in thin/kids  IV – not recommended

37 U/S vs CT  U/S  SN 86%, SP 81%, LR+ 5.8, LR  + pregnant, kids, female, thin pts  - obese, strictures, retrocecal, normal  MRI?  Very sensitive but not available

38 ?Change Management?  2 studies of CT in pts w/ suspected appendicitis comparing Tx plan before & after access to results of scans  CT changed disposition in 27 – 59% of pts  Prevented d/c of ~3% pts w/ appendicitis  Prevented negative laparotomy in 3-13%  Alternate Dx in 11-20%  Frank et al. Unenhanced helical CT scanning of the abdomen and pelvis changes disposition of patients presenting to the emergency department with possible acute appendicitis. J Emerg Med 2002; 23: 1-7  Rao et al. Effect of computed tomography of the appendix on treatment of patients and use of hospital resources. N Eng J Med. 1998; 338: Thanks Moritz!

39 To image or not?  Imaging based on risk-stratification  Don’t image:  Low risk – minimal physical findings, hungry, alternative dx, hx similar pain, sympt > 3 days  First few hours of pain  Image  Intermediate risk – lack classic appendicitis finding  ?Image  High risk – classic presentation  Will go to OR anyway

40 Wake the surgeon?  Time from onset of symptoms to rupture?  hours  Average time to seek medical care  17 hours  Complication rate  3% vs 12% with rupture  Mortality  <0.1% vs 3-4% with rupture

41 Take home points  Normal vitals do not rule out appendicitis  Think about U/S over CT in skinny/kids  Image pts with equivocal presentation  Single most important lab test  β-hcg

42 Mesenteric adenitis?  Most common associated condition  5-10% admissions for appendicitis  ?More common than appendicitis  Mostly children  Non-specific infl. of mesenteric LN  Can follow viral illness  Yersinia species (Y. enterocolitica)

43 Mesenteric adenitis?  O/E:  ±Mild fever  Diffuse tenderness, RLQ, no peritonitis  20% other lymphadenopathy  Ix:  ±↑WBC  U/S or CT may be helpful  Tx:  none, self-limited

44 Case 3  65M  Suprapubic and LLQ pain x days, similar bouts of pain in past  Anorexia, nausea  O/E: Vitals normal, LLQ tender, no peritoneal signs, ?distended  #1 in DDx?  Initial investigations?

45 Diverticular disease facts  10% > 45yrs, 80% > 80yrs  ?Dietary deficiency in fibre  85% L-sided (opposite in Japan)

46 Definitions Diverticulosis Asymptomatic (70%) Diverticular bleeding (10%) Diverticulitis (20%) Uncomplicated (75%) Complicated (25%)

47 Definitions Diverticulosis Asymptomatic (70%) Diverticular bleeding (10%) Diverticulitis (20%) Uncomplicated (75%) Complicated (25%)

48 Anatomy/Pathogenesis  Vasa recta penetrate colonic wall  Forms weak points  Small (low fibre) stool  ↑ pressure  herniation of mucosa at vasa recta

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50 Diverticulosis

51 Clinical features  Usually nil  Can present like IBS  Abdo pain/cramping  Bloating  Constipation/diarrhea

52 Management  If necessary  Analgesia  Anti-spasmodics  Modify natural history of disease  High-fibre diet  ±stool softeners

53 Case 3b  65M  Hematochezia  No pain  O/E: Vitals normal, abdo benign, FOB+  Top 3 in DDx?

54 Definitions Diverticulosis Asymptomatic (70%) Diverticular bleeding (10%) Diverticulitis (20%) Uncomplicated (75%) Complicated (25%)

55 Diverticular bleeding  40% of all LGIB  5% severe bleed  Typically painless hematochezia

56 Management  Resuscitation  Localization of bleeding site  r/o UGIB, colonoscopy  ± angiography or radionuclide scan  Treatment  Surgery

57 Definitions Diverticulosis Asymptomatic (70%) Diverticular bleeding (10%) Diverticulitis (20%) Uncomplicated (75%) Complicated (25%)

58 Diverticulitis Diverticulum obstructed  inflammation  microperforation  pericolic inflammation  pain

59 Diagnosis – H&P, Labs  History  LLQ pain, several days, prev. pain  O/E  Fever, LLQ tenderness, ±distension, ±mass  Labs  ↑WBC

60 Diagnosis - Imaging  Options  Plain films  Barium enema  Water-soluble contrast enema  Colonoscopy  CT scan

61  Barium enema is an appropriate investigation in acute diverticulitis  True  False  Spicy food can cause ulcers  True  False

62 Plain films  Not useful in diagnosis of diverticulitis  Utility lies in ruling out obstruction/ perforation

63 Barium enema  Useful to diagnose asymptomatic diverticulosis  CONTRAINDICATED in acute diverticulitis  Potential for barium peritonitis

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66 Water-soluble contrast enema  Less detail than barium  Can see contrast collect in abscess cavity, peritoneum, along fistulae  Less info than CT about disease extent

67 Colonoscopy  Not for acute setting

68 CT scan  Investigation of choice  SN 69-95%, SP %  Evaluate extent of disease  Exclude other pathology  If known uncomplicated diverticulitis – not necessary

69 Management  Uncomplicated  Outpatient  Analgesia  Oral Abx  Septra/Flagyl, Cipro/Flagyl, Clavulin  Fibre  F/U

70 Management  Complicated  Inpatient  Analgesia  IV Abx  Surgery vs. medical management

71 Surgery or not?  First episode  Usually medical management  3-30% recurr  Subsequent episodes, immunocompromised  More likely to require surgery or precutaneous abscess drainage

72 Take home points  Diverticulosis  asympt vs. IBS-like  bleeding  bleeding  inflammation  inflammation  Imaging of choice in diverticulitis is CT  Most uncomplicated pts can go home

73 Questions?

74 References  Ferri: Ferri's Clinical Advisor: Instant Diagnosis and Treatment, 8th ed., 2006 Mosby  Leyner, Goldberg. Why Do Men Have Nipples? 2005 Three Rivers Press  Mandell, Bennett, & Dolin: Principles and Practice of Infectious Diseases, 6th ed., 2005 Churchill Livingstone  Marx, Hockberger & Walls. Rosen’s Emergency Medicine, 6 th ed., 2006 Mosby  UpToDate


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