differentiating large bowel obstruction from small bowel obstruction david birks fracs september...
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Differentiating Large Bowel Obstruction from
Small Bowel Obstruction
David Birks FRACSSeptember 2010
Specialists Without BordersSeminar in Surgery
Rwanda, September 2010
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Brisbane
Sydney
Hobart
AdelaideCanberra
MelbourneVictoria
Darwin
Perth
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Differentiating large bowel obstruction from small bowel obstruction
Objectives• Physiology & anatomy of small/large bowel• Causes of bowel obstruction• Symptoms & signs• Investigations (plain xray)• Complications • Management – conservative & operative
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Functions of intestine
• Small intestine – absorption of fluid, food, vitamins
• Large intestine – absorption of water & Na - converts 1000-2000ml into
200ml semisolid faeces
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Fluid replacement - GI loss
• Type Na K Cl HCO3
Gastric 100 10 100
Bile 140 5 80 40
Pancreas 140 5 80 100
Small Bowel 90 10 90 30
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Fluid replacement - GI loss
• Type Volume (litres)
Gastric 2.0
Bile 1.0
Pancreas 1.0
Small bowel 3.5
Total 7.5
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Causes of small bowel obstruction
• adhesions (previous operation)• external hernia• small bowel volvulus (primary)• neoplasms• miscellaneous
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Causes of large bowel obstruction
• carcinoma of colon• volvulus (sigmoid)• diverticular disease• miscellaneous
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Symptoms of bowel obstruction
• abdominal pain• vomiting• distension• constipation (no flatus)
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High small bowel obstruction
• frequent, profuse vomiting• central abdo pain • minimal distension
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Lower small bowel obstruction
• colic pain • moderate vomiting ( may be faeculent)• moderate distension
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Large bowel obstruction
• abdominal distension• constipation• lower abdo pain ( may be minimal)• minimal vomiting
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Physical Examination
• abdo scars• external hernia• signs strangulation (tenderness, fever, mass)
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Investigations
• Plain Xray – supine - erect - chest
• Hb, WCC, Urea & Electrolytes
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Further investigations
• CT abdomen• contrast study (via NG )
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Plain x ray SBO
• dilated loops with gas• centrally placed• transverse lines (circular folds)
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Plain x ray LBO
• dilated bowel with gas (caecum)• peripheral • haustra (not lines across bowel)• may have cut-off point
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SBO
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LBO
Supine
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Carcinoma of Sigmoid – LBO – Decompressed into SB
Prone
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Complications of bowel obstruction
• fluid & electrolyte loss - small bowel• aspiration – small bowel• respiratory restriction– large bowel• strangulation – small bowel• caecal perforation – large bowel (competent
Ileo-caecal valve)
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Management of bowel obstruction
• nil orally• IV fluid & electrolyte replacement• NasoGastric drainage (small bowel)
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Operation for bowel obstruction
• external hernia (SBO) – emergency• signs of strangulation – emergency• SBO not settling – within 24-48 hr• LBO due to carcinoma - soon
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Non-operative treatment of bowel obstruction
• sigmoid volvulus – decompress via sigmoidoscope
• post-operative SBO• intussusception in infants (2/12 – 2 yr)• previous operations for SBO• radiation• abdominal carcinomatosis
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Operation - SBO
• midline incisionlook for ileo-caecal valve
• treat cause• external hernia – incision over hernia
- if gangrene convert to midline
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Operation - LBO
• midline and resect bowel pathology +/- anastomosis+/- stoma
• if left sided obstruction – transverse colostomy through right upper trans incision
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Summary of bowel obstruction
• Physiology & anatomy of small/large bowel• Causes of bowel obstruction• Symptoms & signs• Investigations (plain xray)• Complications • Management – conservative & operative
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