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

3. GOO
Gastric outlet obstruction
Etiology
Benign
Malignant

4. 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

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

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

7. Clinical Presentation
Tympanitic mass in the epigastric area
Volume depletion

8. Differential diagnosis
Gastroparesis
Intestinal obstruction

9. Diagnosis Clinical features Physical examination Laboratory tests
Radiologic tests
Endoscopy

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

11. Radiologic tests
Plain AXR
Contrast studies 
CT scan 

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

13. 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)

14. Barium meal studies were suggestive of deformed and spastic duodenum

15. 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.

16. 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.

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

18. Endoscopy

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

21. 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

22. 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)

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

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

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

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

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

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

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

31. 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

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

33. 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

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

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

40. 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

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

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

44. Etiologies
colon cancer 60%
Diverticulitis
Volvulus
Cecal
Sigmoid

45. 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

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

47. Pathophysiology Colonic distention Abdominal pain Anorexia
Feculent vomiting
Dehydration
Electrolyte disturbances

48. Clinical Presentation
Symptoms
colicky abdominal pain
Nausea
vomiting
Obstipation

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

50. Vomiting
GOO
Food particles
SBO
Billous
LBO
Fecaloid

51. Abdominal Distension
SBO
Less Distention
LBO
More Distension

52. 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

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

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

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

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

58. 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.

59. Therapy
Medical
Surgical