1. Vomiting, Diarrhea & Constipation
Mark J. Koruda, MD
Professor of Surgery

2. Assumptions
Students understand the anatomy, embryology and physiology of the gastrointestinal tract.

3. Case 1
A 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.

4. Small Bowel Obstruction

5. Small Bowel Obstruction Signs & Symptoms
Intermittent, Crampy Abdominal Pain
Nausea / Emesis
Distension
Obstipation
Peristaltic Rushes on Auscultation
Focal Tenderness
Diffuse Peritonitis

6. Case 1 What findings should be looked for on physical exam? Distended
No peritoneal signs

7. Case 1
What laboratory tests should be ordered?

8. Small Bowel Obstruction Laboratory Evaluation
May see hypochloremic, hypokalemic metabolic alkalosis if having frequent emesis (proximal obstruction).
May see evidence of contraction alkalosis
Increased H/H, BUN.
WBC usually normal early.

9. Case 1 What laboratory tests should be ordered?
What diagnostic tests should be ordered?

10. Small Bowel Obstruction Radiologic Evaluation
Xrays: ? AFLs, ? Free Air, ? Distal Gas
UGI / SBFT: Identify mechanical obstruction
Enteroclysis: Independent of gastric emptying
CT Scan: ? Free Air, ? Pneumatosis, ? Tumor

15. Small Bowel Obstruction Etiologies
Adhesions
Malignancy
External or Internal Hernia
Volvulus
Crohn’s Disease
Intra-abdominal Abscess

16. Small Bowel Obstruction Etiologies (Cont.)
Radiation Stricture
Foreign Body
Gallstone Ileus
Meckel’s Diverticulum
Intramural Hematoma
Mesenteric Ischemia
Intussusception

17. Intestinal Ileus Etiologies
Postoperative State
Sepsis
Electrolyte Imbalance
Drugs
Ureteral and Biliary Colic
Retroperitoneal Hemorrhage
Spinal Cord Injury
Myocardial Infarction
Pneumonia

18. Case 1
What is the initial management plan?

19. Small Bowel Obstruction Partial vs. Total
Why Not Just Wait??
Potential for Closed Loop Obstruction
Risk of Ischemia / Perforation (4-6 hrs)

20. Small Bowel Obstruction Treatment
Correct intravascular volume deficit
NGT vs. Miller-Abbott or Cantor Tubes
Serial Exams
Operation if no improvement or if signs of complete (closed loop) obstruction or incarceration.
Evaluation of Bowel Viability

22. Small Bowel Obstruction Special Cases
Early Postoperative SBO
<1% risk in first month
Must be considered after 7 days of “ileus” since adhesions become dense in 2-3 weeks.
Recurrent SBO (5-15%)
Malignant Obstruction
Radiation Fibrosis

23. Case 2
A 72-year-old man presents with a two month history of gradually increasing constipation.
Key Points in History?

24. Large Bowel Obstruction Diagnosis
Crampy Pain
Onset may be acute or insidious
Distension (50-60% have competent ileo-cecal valve and develop severe distension)
Xrays: cm cecum, perforation risk
Contrast enema: Obstruction vs Oglive’s
Consider rigid sigmoidoscopy to r/o and treat sigmoid volvulus

25. Case 2
Physical Exam
What further tests are indicated

26. Case 2 Differential Diagnosis Colonic Obstruction Colonic Dysfunction
Malignant
Benign
Colonic Dysfunction

27. Large Bowel Obstruction

28. Large Bowel Obstruction Etiologies
Colon Cancer
Diverticulitis
Extrinsic Cancer
Fecal Impaction
Intussusception
Volvulus
Incarcerated Hernias

29. Large Bowel Obstruction Colon Cancer
20% of colon cancers present with obstruction
Left-sided lesions are more prone to obstruct (more narrow lumen, more solid fecal stream)

34. Large Bowel Obstruction Treatment
IVF
NGT
Operation
Emergently if signs of peritonitis / perforation
Prep bowel if possible
Is an ostomy necessary?
Right vs. Left-sided Lesions
Traditional vs. Newer Attitudes
right colon - can reanastamose
transverse colon - extended right hemi
left colon
3 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)

35. Large Bowel Dysfunction
Inflammation
Colonic Inertia
Etc

37. Oglive’s Syndrome (Colonic Pseudo-Obstruction)
May mimic mechanical obstruction
Associated Conditions
Treatment:
Rectal tube / enemas /exams (work in most)
Colonoscopic decompression (80-90% eff.)
Surgery (Cecostomy vs. Resection) - cecum >12 cm or peritoneal signs
Associated Conditions:
Amyloidosis
Blunt trauma
Cardiopulmonary Bypass
C-section
Chemotherapy
Dermatofibrosis
Diabetes
Electrolyte abnormalities
Hypothyroidism
Medications (anticholinergics, ganglionic blockers, narcotics, phenothiazines, tricyclic antidepressants)
Ortho or Neurologic Procedures
Renal Failure
RenalTransplantation
Scleroderma
Dementia / Stroke
SLE

38. Case 3
A 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

39. What Is Crohn’s Disease?
Crohn’s disease (CD) is an inflammatory bowel disorder that may affect any part of the gastro-intestinal (GI) tract
The inflammation penetrates the lining of the GI tract and often causes ulcers to form
Esophagus
Small
Intestine
Stomach
Large
Intestine
(Colon)
Rectum
Appendix

41. Case 3
Key Points in History

42. Case 3 Key Points in History Crohn’s disease Previous surgical history
No Crohn’s Rx
Chronic symptoms
Weight loss
No fevers
Crampy pain

43. Case 3
Physical Exam
Diagnostic Studies?
Differential Dx

44. Crohn’s Disease

45. Crohn’s Disease

46. Crohn’s Disease
Medical vs Surgical Management

51. Case 4
22yo UNC student presents with 3 mos of increasing “bloody diarrhea”, going to the bathroom 15-20x/day. “It rules my life!”
Key Points in History

52. Case 4
22yo UNC student presents with 3 mos of increasing “bloody diarrhea”, going to the bathroom 15-20x/day. “It rules my life!”
Key Points in History
Diarrhea
Bleeding

53. Case 4
Physical Exam
Diagnostic Studies?

56. Ulcerative Colitis