1. James Zeng

2. Bowel Obstruction A blockage of bowel lumen prohibiting the passage of materials[1] 8% of abdo pain in ED (3 rd leading cause)[2] 24% require surgery[3] 300,000 admissions, 800,000 in-pt days, $1.3bil[4]

3. Causes Extrinsic (extraluminal) Intrinsic (luminal) Intraluminal

4. Extrinsic Causes Adhesions Hernias Volvulus

5. Intrinsic Neoplastic Inflammatory Congenital

6. Intraluminal Faeces Gallstones Intussception Bezoar

7. Bowel Obstruction Small v. Large Acute v. subacute

8. Differential Paralytic -ileus Pseudo-obstruction Constipation

9. Diagnosis Clinical Radiological

10. Symptoms Pain Distension Obstructive symptoms Vomiting Inability to pass motions/slowing Inability to pass flatus

11. Past history Past abdominal surgery Past obstructions Hernias Crohn’s Malignancy

12. Signs Volume status Scars, volume Guarding, peritonitis “Tinkling” bowel sounds, no BS Hernias PR

13. Investigations Abdo pain bloods Lactate

14. Radiology (AxR)

15. Large bowel obs

16. Radiology (AxR) Size Walls Distal collapse Empty rectum

17. Radiology (AxR) SmallLarge Central Smaller calibre Valvulae coniventes More loops Long fluid levels Peripheral Larger calibre Haustra 1-2 loops Short fluid levels

18. Radiology (CT) Inconclusive XR Systemically unwell, local peritonitis Helps to determine cause >2.5cm with distal collapse High accuracy

19. Conservative Management Fluids NBM Analgesia NG tube

20. Complications Electrolytes

21. Specific Management Adhesions - conservative ± gastrograffin Perforation, hernia – urgent theatre Strictures, colitis – surgical resection Sigmoid volvulus – rectal tube Beware of ischaemia – test intraoperatively

22. Obstruction in Cancer Patients Various opinions Depends on when last operation was Trial of conservative treatment Gastrograffin/CT Consider early resection, stent+resection Non-operative candidates

25. References 1. www.medical-dictionary.com www.medical-dictionary.com 2. Lewis LM et al. Etiology and clinical course of abdominal pain in senior patients: a prospective, multicenter study. Gerontol A Biol Sci Med Sci. 2005. 60:8 (1071-6). 3. Foster NM; McGory ML; Zingmond DS; Ko CY. Small bowel obstruction: a population-based appraisal. J Am Coll Surg. 2006. 203:2 (170-6). 4. Ray NF; Denton WG; Thamer M; Henderson SC; Perry S. Abdominal adhesiolysis: inpatient care and expenditures in the United States in 1994. J Am Coll Surg. 1998. 186:1 (1- 9).