CASE
PRESENTATION AND DISCUSSION ON ACUTE SURGI
CAL ABDOMEN
Roberto N.
Gonzales Jr. MD.
Department of Surgery
Ospital ng Maynila
Medical Center
K.F.
12/M
From Sta.
Cruz Manila
CHIEF COMPLAINT:
Abdominal
Pain
HISTORY OF
PRESENT ILLNESS
2 days PTA (+)
Abdominal pain
(+) consult at
OMMC pedia-ER
PFA: Normal gas pattern,
fecal retention
Dx: Fecal impaction
Sent Home
HISTORY OF
PRESENT ILLNESS
1 day PTA
(+) Abdominal pain
(+) Nausea and vomiting
(+) Anorexia
(+) Passed flatus
(+) Consult at OMMC
Pedia- ER
PFA: Ileus w/ interserosal wall
thickening
Referred to surgery ER
ADMITTED
AT PEDIA WARD
nPast
Medical History:
S/P Appendectomy march 2005- OMMC
nFamily
History
Unremarkable
nPersonal
and Social History
Unremarkable
PHYSICAL EXAMINATION
nConscious, weak looking mild respiratory distress
nBP
90/60 PR 110 RR 40 T 37.6’C
nHEENT:
pink palpebral conjunctiva, anicteric sclerae, no TPC, no CLAD
nCHEST/LUNGS:
SCE, no retractions, clear BS
nHEART: adynamic precordium, NRRR, no murmur
PHYSICAL EXAMINATION
nABDOMEN:
(+) incision scar, RLQ
(+) distended abdomen hypoactive bowel sounds
(+) Direct tenderness
(-) Muscle guarding
nEXTREMITIES:
full equal pulses
nRECTAL EXAM:
good sphincteric tone, non-collapsed rectal
vault, (+) feces on tactating finger
SALIENT FEATURES
•12/M
•Abdominal pain
•Nausea and vomiting
•Passed flatus
•Incision scar, RLQ
•Abdominal distention
•Hypoactive bowel sounds
•Tenderness all quadrant
•DRE: non-collapsed
rectal vault, (+) feces on tactating finger
•S/P Appendectomy march
2005
SALIENT FEATURES
•12/M
•Abdominal pain
•Nausea and vomiting
•Passed flatus
•Incision scar, RLQ
•Abdominal distention
•Hypoactive bowel sounds
•Tenderness all quadrant
•DRE: collapsed rectal
vault, (+) feces on tactating finger
•S/P Appendectomy march
2005
PARACLINICAL
DIAGNOSTIC PROCEDURE
nDO I NEED A PARACLINICAL DIAGNOSTIC PROCEDURE?
NO
nThere
is no difference in the treatment of my primary and secondary diagnosis
PRE-TREATMENT
DIAGNOSIS
nPRIMARY
DIAGNOSIS:
PARTIAL SMALL BOWEL
OBSTRUCTION 2º TO POA (95%)
nSECONDARY
DIAGNOSIS:
NON-MECHANICAL SMALL BOWEL OBSTRUCTION (5%)
GOALS OF TREATMENT
nRELIEVE
THE OBSTRUCTION/ DECOMPRESS THE ABDOMEN
nPrevent
complication
TREATMENT
OPTIONS
TREATMENT
OPTIONS
TREATMENT
OPTIONS
TREATMENT
PLAN
NON-SURGICAL
DECOMPRESSION
PREPARATION and MONITORING
nPSYCHOSOCIAL SUPPORT
nSCREENING
FOR MEDICAL PROBLEMS:
nCHEST
X-RAY
nSERUM
ELECTROLYTES
nCBC
PREPARATION and MONITORING
nOPTIMIZE
PHYSICAL CONDITION
nFLUID
RESUSCITATION
nNASOGASTRIC
DECOMPRESSION
nPROPHYLACTIC
ANTIBIOTICS – Ampicillin 500 mg q 6, Metronidazole 500 mg q 8, Gentamycin 80 mg q 8
COURSE IN
THE WARDS
1ST
HD:
BP 90/60 PR
120 RR 40 T 38.0’C
(-) BM, (-) FLATUS
(-)VOMITING
(+) ABDOMINAL DISTENTION
HYPOACTIVE BS
(+) TENDERNESS ALL QUADRANT
COURSE IN
THE WARDS
1ST
HD:
(+) BILLOUS NGT OUTPUT
400 CC/12HRS
UO= 40 CC/HR
IVF:D5LRS 1 L X 6º + 30 mEqs KCL
Ampicillin 250 mg q 6,
Metronidazole
250 mg q 8,
Gentamycin 80 mg q 8
PLAIN ABDOMINAL X-RAY RESULT:
nDISTENTION
OF THE SMALL BOWEL
nINCREASED
INTERSEROSAL THICKENING
nMINIMAL
GAS NOTED AT THE COLON AND PRESACRAL AREA
GOALS OF TREATMENT
nRELIEVE
THE OBSTRUCTION/ DECOMPRESS THE ABDOMEN
TREATMENT
OPTIONS
TREATMENT
OPTIONS
TREATMENT
PLAN
EXPLORATORY
LAPAROTOMY
SURGICAL TREATMENT
(INTRA-OP)
nINCISION:
MIDLINE
nEXPOSURE
nINTRA-OPERATIVE
EVALUATION
nFORMAL
EXPLORATION
INTRA-OP FINDINGS
INTRA-OP DIAGNOSIS
COMPLETE SMALL
BOWEL OBSTRUCTION 2’’ TO POSTOPERATIVE ADHESIONS W/ STRANGULATION
GOALS OF TREATMENT
nRELIEVE
THE OBSTRUCTION/ DECOMPRESS THE ABDOMEN
nRESTORE
CONTINUITY / FUNCTION OF THE BOWEL
TREATMENT
OPTIONS
TREATMENT
OPTIONS
TREATMENT
PLAN
ILEAL RESECTION -
ANASTOMOSIS
OPERATIVE
TECHNIQUE
nAdhesiolysis
done with blunt and sharp dissection
nKattel
maneuver done over the cecal area
nIleal
resection and re anastomosis by Gambi maneuver done
nHemostasis
nCorrect
instrument and sponge count
nClosure
OPERATION
DONE
EXPLORATORY LAPAROTOMY, RESECTION-ANASTOMOSIS
ILEUM, ADHESIOLYSIS
POSTOPERATIVE
DIAGNOSIS
COMPLETE SMALL BOWEL OBSTRUCTION 2’ TO POSTOPERATIVE ADHESIONS WITH STRANGULATION S/P APPENDECTOMY(MARCH 2005) S/P EX-LAP,
ADHESIOLYSIS ILEAL RESECTION- ANASTOMOSIS
SURGICAL TREATMENT
POST-OPERATIVE
CARE
nSUPPLY
THE BASIC NEEDS OF THE PATIENT
nCOMFORT
nANALGESICS
nMEDICATIONS
– ANTIBIOTICS
nFLUIDS
AND ELECTROLYTES
nDECOMPRESSION
nSUPPORT
ORGAN FUNCTION
nWOUND
CARE
nMONITORING
FOR COMPLICATIONS
nADVICE
ON
nHOME
CARE
nFOLLOW-UP
PLAN
SURGICAL TREATMENT
POST-OPERATIVE
CARE
nRESOLUTION
OF THE HEALTH PROBLEM
–LIVE PATIENT
–NO COMPLICATION
–NO DISABILITY
–SATISFIED PATIENT
–NO MEDICO-LEGAL SUIT
DISCUSSION
SMALL BOWEL OBSTRUCTION
DEFINITION
INTESTINAL OBSTRUCTION INVOLVES A PARTIAL
OR COMPLETE BLOCKAGE OF THE BOWEL THAT RESULTS IN THE FAILURE OF THE INTESTINAL CONTENTS TO PASS THROUGH
Non-mechanical
obstruction
nObstruction
of the bowel may be caused by ileus, in which the bowel doesn´t function correctly but there is no "mechanical" (anatomic)
problem, or by mechanical causes.
nParalytic
ileus/ pseudo-obstruction
- infants and children
- there is abdominal distention, absent bowel sounds, minimal abdominal pain
The causes
of paralytic ileus may include the following:
nMedications,
especially narcotics
nIntraperitoneal
infection
nMesenteric
ischemia (decreased blood supply to the support structures in the abdomen)
nInjury
to the abdominal blood supply
nComplications
of intra-abdominal surgery
nKidney
or thoracic disease
nMetabolic
disturbances (such as decreased potassium levels)
Mechanical
obstruction
Occurs when movement of material through the intestines is physically blocked.
Mechanical
Obstruction
INTRINSIC
to the Intestinal Wall
nCongenital
nInflammatory
nNeoplastic
nTraumatic
nOthers
Mechanical
Obstruction
INTRALUMINAL
n FOREIGN
BODY
n BENZOARS
n PARASITES
n GALLSTONE
n Others
Mechanical
Obstruction
EXTRINSIC
to the Intestinal Wall
n Adhesions
n Hernia
n Congenital
n Neoplastic
n Inflammatory
n Others
CLINICAL PRESENTATION
nObstruction
can be characterized as either partial or complete verses simple or strangulated.
nAbdominal
pain (characteristic with most patients)
nNausea
and Vomiting, which are associated more with proximal obstructions
nDiarrhea
(early)
CLINICAL PRESENTATION
nConstipation
(late) as evidenced by the absence of flatus or bowel movements
nFever
and tachycardia - Occur late and may be associated with strangulation
nPrevious
abdominal or pelvic surgery and/or previous radiation therapy (may be part of patient’s medical history)
nHistory
of malignancy (particularly ovarian and colonic)
PHYSICAL EXAMINATION
nAbdominal
distention
–Duodenal or proximal
small bowel has less distention when obstructed than the distal bowel has when obstructed.
–Hyperactive bowel sounds
occur early as GI contents attempt to overcome the obstruction.
–Hypoactive bowel sounds
occur late.
PHYSICAL EXAMINATION
–Look for the following during rectal examination:
nGross
or occult blood, which suggests late strangulation or malignancy
nMasses,
which suggest obturator hernia
–Check for symptoms commonly believed to be more diagnostic of
intestinal ischemia, including the following:
nFever
(>100°F)
nTachycardia
(>100 beats/min)
nPeritoneal
signs
CARDINAL SIGNS
AND SYMPTOMS OF INTESTINAL OBSTRUCTION
•ABDOMINAL PAIN
•NAUSEA AND VOMITING
•OBSTIPATION
•ABDOMINAL DISTENTION
Clinical Features
are Function of:
nLevel
of obstruction
nDegree
of luminal obstruction
nDuration
of obstruction
nAmount
of distension
Clinical Scenario
nComplete
SBO
nHigh
grade partial SBO
nLow
grade partial SBO
nVirgin
abdomen w/ SBO
nRecurrent
SBO
nPost
Operative BO
nMalignancy
related BO
nCrohn’s
related BO
Complete SBO
•ABDOMINAL PAIN
•NAUSEA AND VOMITING
•OBSTIPATION
•ABDOMINAL DISTENTION
•TETRAD OF STRANGULATION
•Leukocytosis
•Fever
•Tachycardia
•Severe abdominal pain
DICTUM
“ Sun
should never set on complete small bowel obstruction”
IMAGING STUDIES
nPlain radiography
–supine or flat and upright
–sensitivity of plain radiographs was reported as 75%, and
specificity was reported to be 53%.
- Dilated small-bowel loops
with air fluid levels and presence of colonic gas indicates indicate partial
SBO
–Absent or minimal colonic gas indicates complete SBO.
IMAGING STUDIES
nEnteroclysis
–detects presence of
obstruction and in differentiating partial from complete blockages.
–useful when plain radiographic
findings are normal in the presence of clinical signs of SBO or if plain radiographic findings are nonspecific
IMAGING STUDIES
nEnteroclysis
–It distinguishes adhesions
from metastases, tumor recurrence, and radiation damage.
–Enteroclysis offers
a high negative predictive value and can be performed with 2 types of contrast
-
Barium is the classic contrast agent
IMAGING STUDIES
nCT
scanning
–study of choice if
the patient has fever, tachycardia, localized abdominal pain, and/or leukocytosis.
–capable of revealing
abscesses, inflammatory processes, extraluminal pathology resulting in obstruction, and mesenteric ischemia.
IMAGING STUDIES
nCT
scanning
–One small series reported
a sensitivity of 93%, specificity of 100%, and accuracy of 94% in diagnosing obstruction.
–Another reported a
sensitivity of 92% and specificity of 71% in correct identification of partial or complete SBO.
IMAGING STUDIES
nUltrasonography
–less costly and less invasive than CT scanning.
–may reliably exclude SBO in as many as 89% of patients
–Specificity is reportedly 100%.
THANK YOU!
