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

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

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

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

5. 4. Radiology Quiz

6. 5. Cases from Access Surgery

7. 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

8. SBO - causes

9. SBO- Pathophysiology motility stasis dilatation fluid accumulation
High Pressure

10. 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.

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

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

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

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

16. 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?

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

18. 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

19. 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

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

21. Large Bowel Obstruction
Causes:
Cancer
Volvulus
Diverticulitis
Hernia
Intussusception

22. Dx Hx
Physical
AXR
Ct – Enema
Barium Enema

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

24. Sigmoid Volvulus

26. LBO - Radiology

27. Radiology - Quiz

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