Small Bowel Obstruction David Birks FRACS September 2010 Specialists Without Borders Seminar in Surgery Rwanda September 2010 Differentiating large bowel obstruction from small bowel obstruction ID: 177317
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Differentiating Large Bowel Obstruction from
Small Bowel Obstruction
David Birks FRACSSeptember 2010
Specialists Without Borders
Seminar in Surgery
Rwanda, September 2010Slide2Slide3
Differentiating large bowel obstruction from small bowel obstruction
ObjectivesPhysiology & anatomy of small/large bowelCauses of bowel obstructionSymptoms & signsInvestigations (plain xray)Complications Management – conservative & operativeSlide4
Functions of intestineSmall intestine – absorption of fluid, food, vitamins
Large intestine – absorption of water & Na - converts 1000-2000ml into 200ml semisolid faecesSlide5
Fluid replacement - GI lossType
Na
K
Cl
HCO
3
Gastric
100
10
100
Bile
140
5
80
40
Pancreas
140
5
80
100
Small Bowel
90
10
90
30Slide6
Fluid replacement - GI lossType
Volume
(litres)
Gastric
2.0
Bile
1.0
Pancreas
1.0
Small bowel
3.5
Total
7.5Slide7Slide8Slide9Slide10Slide11Slide12
Causes of small bowel obstruction adhesions (previous operation) external hernia
small bowel volvulus (primary) neoplasms miscellaneousSlide13
Causes of large bowel obstruction carcinoma of colon volvulus (sigmoid)
diverticular disease miscellaneousSlide14
Symptoms of bowel obstruction abdominal pain vomiting
distension constipation (no flatus)Slide15
High small bowel obstruction frequent, profuse vomiting central abdo pain
minimal distensionSlide16
Lower small bowel obstruction colic pain moderate vomiting ( may be faeculent)
moderate distensionSlide17
Large bowel obstruction abdominal distension constipation
lower abdo pain ( may be minimal) minimal vomitingSlide18Slide19
Physical Examination abdo scars external hernia
signs strangulation (tenderness, fever, mass)Slide20Slide21
Investigations Plain Xray – supine
- erect - chest Hb, WCC, Urea & ElectrolytesSlide22
Further investigations CT abdomen contrast study (via NG )Slide23
Plain x ray SBO dilated loops with gas centrally placed
transverse lines (circular folds)Slide24
Plain x ray LBO dilated bowel with gas (caecum) peripheral
haustra (not lines across bowel) may have cut-off pointSlide25Slide26Slide27
SBOSlide28
LBO
SupineSlide29Slide30
Carcinoma of Sigmoid – LBO – Decompressed into SB
ProneSlide31Slide32Slide33Slide34Slide35Slide36Slide37Slide38
Complications of bowel obstruction fluid & electrolyte loss - small bowel
aspiration – small bowel respiratory restriction– large bowel strangulation – small bowel caecal perforation – large bowel (competent Ileo-caecal valve)Slide39Slide40
Management of bowel obstruction nil orally IV fluid & electrolyte replacement
NasoGastric drainage (small bowel)Slide41
Operation for bowel obstruction external hernia (SBO) – emergency signs of strangulation – emergency
SBO not settling – within 24-48 hr LBO due to carcinoma - soonSlide42
Non-operative treatment of bowel obstruction sigmoid volvulus – decompress via sigmoidoscope
post-operative SBO intussusception in infants (2/12 – 2 yr) previous operations for SBO radiation abdominal carcinomatosisSlide43
Operation - SBO midline incision
look for ileo-caecal valve treat cause external hernia – incision over hernia - if gangrene convert to midlineSlide44
Operation - LBO midline and resect bowel pathology
+/- anastomosis +/- stoma if left sided obstruction – transverse colostomy through right upper trans incisionSlide45Slide46Slide47
Summary of bowel obstructionPhysiology & anatomy of small/large bowelCauses of bowel obstruction
Symptoms & signsInvestigations (plain xray)Complications Management – conservative & operativeSlide48
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