Jonathan B. Yuval MD General Surgery Hadassah Medical Center Bowel Obstruction Jonathan B. Yuval MD General Surgery Hadassah Medical Center

1. SBO Causes Pathophysiology Clinical manifestations Physical Exam Labs and radiology Treatment Management of specific problems

2. Ogilvie’s Disease and Ileus History Clinical and radiological presentation How to differentiate from bowel obstruction Treatment

3. Large Bowel Obstruction Is medical emergency!! Always necessitates an intervention Causes Treatment

4. Radiology Quiz

5. Cases from Access Surgery

SBO- Causes Extraluminal Intrinsic to bowel wall Intraluminal Adhesion, hernia, carcinomatosis, abscess Intrinsic to bowel wall Primary tumors, enteritis, strictures Intraluminal Bezoar, foreign body, gallstones, intussusceptions

SBO - causes

SBO- Pathophysiology motility stasis dilatation fluid accumulation High Pressure

SBO - Pathophysiology Fluid accumulation  Hypovolemia and electrolyte imbalances. Increased intraluminal pressure  Venous congestion  arterial compromise  Ischemia  Perforation (CLOSED LOOP) Increased abdominal pressure  Decreased pre-load/CO and restriction of breathing.

SBO – Clinical Manifestations Colicky Pain Vomiting Distension Obstipation Diarrhea Previous surgeries?

SBO – Physical Exam VS Scars, Distension Active BS to no BS Tenderness Peritonitis Hernias? PR – Mass, Blood?

SBO – Labs and Radiology AXR – Dx Labs – Severity AXR, CT, Barium Studies Cr, Urea, Elec’, WBC, BG, LAC, DIA CT- (Pneumatosis, Portal gas, Fecalization)

Red Flags Hx PEx Labs No previous surgeries Old surgeries wo/previous SBO PEx Abnormal VS Peritonitis Hernia Labs WBC LAC, DIA BG

SIMPLE OR STRANGULATING? The most important question in management. Conservative or Surgical Tx. Hernia? No previous surgery? Disturbed VS? Peritonitis? Disturbed labs? Large bowel obstruction?

SBO – Conservative Treatment Fluid Resuscitation Catheter and urine output monitoring NGT ABX?

SBO-Surgical Treatment Closed loop/Strangulation  immediate surgery Simple obstruction  watch and wait. The second most important question in SBO: How long can you wait? 12-24h, 72h, more? Exp. Laparotomy / Exp. Laparoscopy

2. Ogilvie’s and Ileus Functional NOT Mechanical obstruction Ogilvie’s – Large bowel pseudo-obstruction Ileus – Small (and Large) bowel Etiology: Post op Elec’ (hypo-K, Mg, Na, uremia, high G, Ca) Drugs (opiates, psych) Abdominal inflammation Sepsis SLE, Scleroderma Parkinson

Oglivie’s an Ileus- Treatment Tx of underlying condition Ogilvie’s Neostigmine Epidural Anasthesia Surgery

Large Bowel Obstruction Causes: Cancer Volvulus Diverticulitis Hernia Intussusception

Dx Hx Physical AXR Ct – Enema Barium Enema

LBO LBO w/competent ileo-cecal valve will always be closed loop Resection w/ or wo/ anastamosis Volvulus – Cecal  Resection, Sigmoid  Decompresion trial

Sigmoid Volvulus

LBO - Radiology

Radiology - Quiz

Take Home Messages Recognize “red flag” situations in SBO LBO is a surgical emergency Conservative management of SBO has a time limit