GOO, SBO, LBO Tehran Medical School Sina Hospital Mahmoud Najafi

GOO Gastric outlet obstruction Etiology Benign Malignant

Benign causes of GOO PUD Bouveret syndrome Gastric polyps Crohn's disease  Ingestion of caustics congenital duodenal webs Pancratitis Gastric TB Gastric vulvulus Gastric Bezoars pyloric stenosis

Malignant causes of GOO Pancreatic cancer Distal gastric cancer Ampullary cancer Duodenal cancer Cholangiocarcinomas Metastases

Clinical Presentation Nausea and Vomiting Anorexia Early satiety Bloating or Epigastric fullness Indigestion Epigastric pain Weight loss

Clinical Presentation Tympanitic mass in the epigastric area Volume depletion

Differential diagnosis Gastroparesis Intestinal obstruction

Diagnosis Clinical features Physical examination Laboratory tests Radiologic tests Endoscopy

Laboratory findings Electrolyte abnormalities Hypokalemic hypochloremic metabolic alkalosis Anemia Elevated serum gastrin levels Serum tumor markers

Radiologic tests Plain AXR Contrast studies  CT scan 

Chronic pancreatitis: calcifications in the pancreas (X- ray of abdomen)

Gastric Volvulus (Pediatric) Figure 4 : Gastric volvulus. Plain film shows a large, air-filled structure with an unusual configuration in the left upper quadrant. Absence of gas distal to the stomach suggests gastric outlet obstruction. Gastric Volvulus (Pediatric)

Barium meal studies were suggestive of deformed and spastic duodenum

Gastric outlet obstruction caused by Crohn's disease Gastric outlet obstruction caused by Crohn's disease. There is tapered narrowing of the distal antrum due to Crohn's disease involving the stomach.

Gastric outlet obstruction caused by an annular carcinoma of the antrum. There is irregular narrowing of the distal antrum (arrow) with proximal dilatation of the stomach.

Abdominal CT in a patient with gastric outlet obstruction due to peptic ulcer disease showing a distended and fluid filled stomach

Endoscopy

Treatment Medical Therapy Hydration correction of electrolyte abnormalities NG tube Parenteral PPI Surgical Therapy

SBO (Small Bowel Obstruction) the most frequently encountered surgical disorder of the small intestine 80% all mechanical intestinal obstruction It has a wide range of etiologies

Etiologies Intraluminal (e.g., foreign bodies, gallstones, or meconium) Intramural (e.g., tumors, Crohn's disease– associated inflammatory strictures) Extrinsic (e.g., adhesions, hernias, or carcinomatosis)

Etiologies Most Common Causes Less prevalent etiologies hernias Intra-abdominal adhesions (75%) Less prevalent etiologies hernias Crohn's disease Cancer Congenital abnormalities

Pathophysiology Accumulation of gas and fluid Increases of intestinal activity colicky pain Distendion of bowel Rises of intraluminal and intramural pressures

Kinds of SBO Simple obstruction partial Complete Strangulated obstruction Closed loop obstruction (e.g., with volvulus)

Clinical Presentation Symptoms colicky abdominal pain Nausea vomiting Obstipation Signs abdominal distention Bowel sounds may be hyperactive

Laboratory findings Reflect intravascular volume depletion Consist of hemoconcentration and electrolyte abnormalities Mild leukocytosis

Features of strangulated obstruction Tachycardia Localized abdominal tenderness Fever Marked leukocytosis Acidosis Positive stool blood test

Diagnosis Distinguish mechanical obstruction from ileus Determine the etiology of the obstruction Discriminate partial from complete obstruction Discriminate simple from strangulating obstruction

Ileus motility returning to normal after laparotomy functional obstruction Same symptoms and signs Postoperative ileus motility returning to normal after laparotomy small intestinal 24 hours Gastric 48 hours colonic 3 to 5 days

Diagnosis History Examination search for hernias prior abdominal operations presence of abdominal disorders Examination search for hernias

Radiographic Examination Triad dilated small bowel loops (>3 cm in diameter) air-fluid levels seen on upright films a paucity of air in the colon Sensitivity 70 to 80%  Specificity is low

Computed tomography (CT) 80 to 90% sensitive 70 to 90% specific discrete transition zone dilation of bowel proximally decompression of bowel distally

Therapy Fluid resuscitation Monitor urine output Broad-spectrum antibiotics NG tube Expeditious surgery

Conservative Therapy NG decompression & fluid resuscitation Partial small bowel obstruction Obstruction occurring in the early postoperative period Intestinal obstruction due to Crohn's disease Carcinomatosis

Prognoses Perioperative mortality: For Nonstrangulating Less than 5% For strangulating 8 to 25%

LBO (Large-bowel obstruction) 20% all mechanical intestinal obstruction The etiology of LBO is age dependent

Etiologies colon cancer 60% Diverticulitis Volvulus Cecal Sigmoid

History of Cancer Chronic weight loss Melanotyc bloody stool Change of caliber of stool Colonic lesion development history Right side Late obstruction Left side Early obstruction

History Recurent LLQ pain over years Abrupt onset of symptoms Diverticulitis Abrupt onset of symptoms Vulvulus

Pathophysiology Colonic distention Abdominal pain Anorexia Feculent vomiting Dehydration Electrolyte disturbances

Clinical Presentation Symptoms colicky abdominal pain Nausea vomiting Obstipation

Colicky Abdominal Pain SBO More severe Shorter interval Shorter duration LBO Less severe Longer interval Longer duration

Vomiting GOO Food particles SBO Billous LBO Fecaloid

Abdominal Distension SBO Less Distention LBO More Distension

Ogilvie syndrome (ACPO) Acute Colonic pseudo-obstruction colon becomes massively dilated in the absence of mechanical obstruction occurs in hospitalized patients associated with the use of narcotics, bedrest, and comorbid disease

Ph/Ex by diminished or, in later stages, absent bowel sounds The abdomen is distended The abdomen may be tender

Laboratory findings Reflect intravascular volume depletion Consist of hemoconcentration and electrolyte abnormalities Mild leukocytosis

Imaging Studies AXR barium enema CT scan demonstrates dilation of the small and/or large bowel air fluid levels barium enema CT scan

Large-bowel obstruction Large-bowel obstruction. Gastrografin study in a patient with obstipation reveals colonic obstruction at the rectosigmoid level.

Large-bowel obstruction. Contrast study of patient with cecal volvulus Large-bowel obstruction. Contrast study of patient with cecal volvulus. The column of contrast ends in a "bird's beak" at the level of the volvulus.

Therapy Medical Surgical