Presentation on theme: "Disorders of Small and Large Bowel Jay Green October 26, 2006."— Presentation transcript:
Disorders of Small and Large Bowel Jay Green October 26, 2006
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?
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
More than half of SBO recurr True False Bathing in tomato juice removes the smell of a skunk True False
SBO – Quick facts 20% of acute abdo admissions Mortality <5% (30% with strangulation, 60% in 1900) >50% recur
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
Review of the basics Types? Mechanical & functional Simple & closed loop (±strangulation) Common causes of ileus? Trauma, infection, sx, meds, metabolic, renal colic
Physicians reliably can distinguish bowel strangulation from simple obstruction True False Cracking knuckles leads to arthritis True False
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.
Investigations Labs: ↑WBC, ±↑CPK, ±↑lactate Imaging: 3 views (60% +SBO, 25% suggestive) Five places to look for air? How many A/F levels? Dilated?
CT Scan? Not required for diagnosis Can help define site/cause Other imaging? Small bowel series, U/S
What about U/S? SNSPEtiology Plain films 77%50%7% U/S83%100%23% CT93%100%87%
½ of complete SBO resolve spontaneously True False Eating 3 poppy seed bagels may result in positive urine drug screen for opiates True False
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
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
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?
History Three most common symptoms? abdo pain, anorexia, nausea Rule out based on pain location? no, can even have LUQ pain
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
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
CMT is uncommon in women with acute appendicitis True False The air expelled in a sneeze can travel up to 100mph True False
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
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:
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
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
?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!
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
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
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
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)
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
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?