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INTESTINAL OBSTRUCTIONBernard M. Jaffe, MD Professor of Surgery, Emeritus
INTESTINAL OBSTRUCTIONCommon Clinical Problem Carries 3-5% Mortality Rate/Episode Some Patients Have Multiple Bouts Can Involve Small or Large Bowel Requires Both Operative and Non- Operative Care
SYMPTOMS Specifics Depends on Site of ObstructionCrampy Abdominal Pain Abdominal Fullness Nausea, Vomiting Thirst, Weakness, Dehydration
PHYSICAL FINDINGS Abdominal Distention Bowel Sounds Early- HyperactiveRushes High Pitched Late- Hypoactive to Absent Tachycardia, Dry Skin
DIFFERENTIAL- ILEUS Functional ObstructionElectrolyte Abnormalities- ↓Na, ↓K, ↓Mg Meds- Opiates, Anti-Cholinergics, Anti- Psychotics Intra-Abdominal Infection/Inflammation Systemic Sepsis Post-Laparotomy
INITIAL MANAGEMENT Done During Evaluation/ DiagnosisIntravenous Fluid Resuscitation Ringer’s Lactate Electrolytes Close to Those Lost Nasogastric Tube Decompression Foley Catheter Placement
DIAGNOSIS Upright Abdominal X-Ray Air Fluid LevelsObstruction- Step Ladder Pattern Ileus- All at Same Level ? Air in Colon- Incomplete Obstruction ? Thumb Printing- Ischemic Bowel
CT SCAN Not Always NecessaryCan Localize Site- Transition Point (Change from Distended to Flat Bowel) Sometimes Diagnose Cause Distinguish Complete from Incomplete Obstruction Markedly Overused
CAUSES Adhesions (60-70%) Neoplasms (20%)Hernias (10%)- External, Internal Others- Intussusception Volvulus Intra-Abdominal Abcess/Infection Gallstone Ileus Stricture, Extrinsic Compression
GALLSTONE ILEUS Fistula Between Biliary Tract (Gallbladder) and Intestine Stone Passes into Intestine Travels to Narrowest Point –Distal Ileum X-Ray Diagnosis- Air in Biliary Tract Stone Visible in RLQ
CARCINOID Malignancy Ileum > Jejunum 30% are MultipleMetastasizes Nodes, Liver Syndrome- Flushing Diarrhea Bronchoconstriction Right Sided Cardiac Valvular Lesions
OTHER NEOPLASMS Adenocarcinoma Lymphoma Leiomyosarcoma Other Sarcomas
COMPLICATIONS Gangrene- Intraluminal Tension>Venous PressureVenous Flow Stops Venous → Arterial Gangrene Perforation Short Gut Syndrome Following Resection
EMERGENCY OPERATION Closed Loop Obstruction Complete ObstructionImpending Gangrene All Increase Risk of Intestinal Gangrene
IMPENDING GANGRENE Very Difficult to Diagnose- Variable, Non-SpecificAbdominal Tenderness Rebound Tenderness, Guarding Fever, Tachycardia Acidosis Elevated White Blood Cell Count
NON-EMERGENCY OPERATIONSFailure to Respond to Conservative Management Partial Obstruction Multiply Recurrent Bouts of Obstruction
ACUTE POST-OP OBSTRUCTIONDifficult to Diagnose Behaves Like Ileus Enteroclysis is Most Successful Modality Non-Operative Management Post-Op Days 1-7
TREATMENT of ADHESIONSAdhesiolysis at Site of Obstruction ? Lysis of All Adhesions Resect Gangrenous Bowel/Re- Anastamose Run Bowel of Site of Injury Perforation
JEJUNUM Proximal 40% of Intestine Larger Circumference, Thicker WallProminent Plicae Circulares End-Arterial Blood Supply Fewer Vascular Arcades (1-2) Less Lymphatic Material
LAPAROSCOPY Mild Abdominal Distention Proximal ObstructionPartial Obstruction Anticipated Single Band Obstruction
GALLSTONE ILEUS TREATMENTEnterotomy with Removal of Stone Try to Identify Site of Fistula Cholecystectomy with Fistula Closure ONLY IF RUQ Not Too Inflamed or Indurated
OPERATIVE COMPLICATIONSPerforation- Missed Injury Bovie Burn Delay in Opening Up Nutrition- Enteral, Parenteral Wound Failure- Dehiscence, Hernia. Infection- Superficial Wound Intraperitoneal Recurrent Obstruction
Differentiating Large Bowel Obstruction from Small Bowel Obstruction
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DIVERTICULITIS Bernard M. Jaffe, MD Professor of Surgery, Emeritus.
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