GASTRO/GENSURG
OBSTRUCTIONS
PromptSMALL BOWEL OBSTRUCTION
Response
PromptCommon causes of SBO
ResponseAdhesions - abdominal wall scars from previous surgeries
Inguinal herniae - presence of inguinal hernia on examination
Malignancy - known histry of malignancy, weight loss
Stricture - Hx Crohns
Gallstone
Foreign body (including bezoar)
Abscess
Intussusception
IBD
Inguinal herniae - presence of inguinal hernia on examination
Malignancy - known histry of malignancy, weight loss
Stricture - Hx Crohns
Gallstone
Foreign body (including bezoar)
Abscess
Intussusception
IBD
PromptExamination findings in SBO
ResponseVital signs - define degree of fluid loss/3rd spacing/shock - guides resuscitation
Hernial orifices - look for cause of SBO
Scars on abdo wall - ? adhesions as cause of SBO
Peritonisim - ? Perforation as complication needing urgent laparotomy
Hernial orifices - look for cause of SBO
Scars on abdo wall - ? adhesions as cause of SBO
Peritonisim - ? Perforation as complication needing urgent laparotomy
Prompt
ResponseMultiple dilated loops of bowel
Multiple air/fluid levels
Small bowel - Valvulae conniventes (=plicae circulares) - “Stacks of coins” which go the full diameter of the small bowel)
central location,
minimal/no large bowel gas
Note large bowel has “Haustra” which are not circumferential
Multiple air/fluid levels
Small bowel - Valvulae conniventes (=plicae circulares) - “Stacks of coins” which go the full diameter of the small bowel)
central location,
minimal/no large bowel gas
Note large bowel has “Haustra” which are not circumferential
PromptUltrasound findings in SBO
ResponseTo and fro appearance of intraluminal contents (from ineffective peristalsis)
Dilated loops of small bowel (>25mm jejunum, >15mm ileum
Bowel wall thickness >4mm (radiopaedia 3mm)
Decreased/absent peristalsis
Tanga sign - extraluminal free fluid
Keyboard sign - prominence of valvule conniventes in dilated jejunal loops
Dilated loops of small bowel (>25mm jejunum, >15mm ileum
Bowel wall thickness >4mm (radiopaedia 3mm)
Decreased/absent peristalsis
Tanga sign - extraluminal free fluid
Keyboard sign - prominence of valvule conniventes in dilated jejunal loops
PromptComplications of SBO
ResponseIschaemia, perforation - Urgent surgery and antibiotics
Metabolic alkalosis - loss of HCL due to vomiting
Hypovolaemia - IV fluids replacement required
Electrolytes - Hyponatraemia - 3rd spacing in gut, Hypokalaemia requiring replacement
Lactaemia - from hypoperfusion from dehydration - 3rd spacing/gut losses/poor intake
Metabolic alkalosis - loss of HCL due to vomiting
Hypovolaemia - IV fluids replacement required
Electrolytes - Hyponatraemia - 3rd spacing in gut, Hypokalaemia requiring replacement
Lactaemia - from hypoperfusion from dehydration - 3rd spacing/gut losses/poor intake
PromptFurther investigations in SBO
ResponseCTAP - transition point, presence of mass/tumours
VBG - Lactic acidosis - ? Ischaemic bowel as complication
Electrolytes - Loss into third spacing in bowel - likely need replacement
Renal function - exclude pre-renal renal failure due to dehydration
Coags - if on thinners - prior to surgery
G+H - preop
VBG - Lactic acidosis - ? Ischaemic bowel as complication
Electrolytes - Loss into third spacing in bowel - likely need replacement
Renal function - exclude pre-renal renal failure due to dehydration
Coags - if on thinners - prior to surgery
G+H - preop
PromptContraindications to nasogastric tube (NGT)
ResponseSuspected base of skull fracture
Nasal perforation
Oesophageal perforation
Aorto-enteric fistula
Patient refusal
List holes in anatomy - Start at nose and work down
Nasal perforation
Oesophageal perforation
Aorto-enteric fistula
Patient refusal
List holes in anatomy - Start at nose and work down
PromptVOLVULUS
(note: Spelled with 2 L’s)
(note: Spelled with 2 L’s)
Responsetwisting of a part of the digestive tract, usually leating to a partial or complete obstruction and often reducing the blood supply causing gangrene. A volvulus may untwist spontaneously or by maniupation, but surgical exploration is usually performed. Gastric volvulus is a twist of the stomach, usually in a hiatus hernia. Small intestinal volvulus is twisting of part of the bowel around an adhesion. Sigmoid volvulus is a twisting of the sigmoid colon, usually when this part of the colon is particularly long. Compound volvulus (or ileosigmoid knotting) involves both the small and large bowel - Oxford med dictionary
Most patients in Stem are from nursing homes - ensure goals of care in mgmt, and favour non op over heroics. (Eg scope over lap)
Most patients in Stem are from nursing homes - ensure goals of care in mgmt, and favour non op over heroics. (Eg scope over lap)
Prompt
ResponseGASTRIC volvulus
Hiatus hernia
Multiple loops seen intrathoracic suggestive of volvulus
Air fluid in lower loop suggestive of obstruction
Rightward mediastinal shift suggestive of mass effect
No gas under diaphragm or in mediastinum, no ptx
Hiatus hernia
Multiple loops seen intrathoracic suggestive of volvulus
Air fluid in lower loop suggestive of obstruction
Rightward mediastinal shift suggestive of mass effect
No gas under diaphragm or in mediastinum, no ptx
PromptManagement of Gastric volvulus
ResponseAnaglesia - opioids + dose
Antiemetics - Ondansetron 4mg
IV fluids, correction of electrolytes
Surgical intervention
Gastroscopy
Agressive with laparotomy
Antiemetics - Ondansetron 4mg
IV fluids, correction of electrolytes
Surgical intervention
Gastroscopy
Agressive with laparotomy
PromptNasogastric tube in gastric volvulus
ResponseDiagnositic (wont’ pass) but not theraputic
Prompt
ResponseVolvulus (probably Coecal but sigmoid accepted in answer)
Distal large bowel loops
Coffee bean sign - The coffee bean sign is a classic conventional radiographic finding of sigmoid volvulus -?favours sigmoid
No air in rectum
Distal large bowel loops
Coffee bean sign - The coffee bean sign is a classic conventional radiographic finding of sigmoid volvulus -?favours sigmoid
No air in rectum
Prompt
ResponseSIGMOID volvulus
Massively dilated loops of signomoid colon
axis pointing to LIF
LBO - dilated large bowel proximal to volvulus with no gas distal (ie in rectum)
Massively dilated loops of signomoid colon
axis pointing to LIF
LBO - dilated large bowel proximal to volvulus with no gas distal (ie in rectum)
PromptManagement options for Sigmoid Volvulus
ResponsePR deflation - rectal tube or sigmoidoscope
Laparotomy + surgical resection/collectomy
Percutaneous deflation/percutaneous endoscopic colectomy
Conservative
Analgesia - IV opioid + dose
IV fluids - correct shock then maintenance for urine output >0.5 mL/kg/hr
Communication to patient/family
Laparotomy + surgical resection/collectomy
Percutaneous deflation/percutaneous endoscopic colectomy
Conservative
Analgesia - IV opioid + dose
IV fluids - correct shock then maintenance for urine output >0.5 mL/kg/hr
Communication to patient/family
PromptImportant considerations when deciding treatment options
ResponseVascular compromise/ischaemia - Opt for resection over detorsion
Co-morbidities - Medical fitness for surgical intervention
Anticoagulation and need for reversal
Patient preference
Quality of life, frailty, ADL’s etc.
Co-morbidities - Medical fitness for surgical intervention
Anticoagulation and need for reversal
Patient preference
Quality of life, frailty, ADL’s etc.