Topic: Small Bowel Obstruction – PPT Notes

Case:

A 62 year old man presents to the ED with severe abdominal pain, nausea, and vomiting. He can’t recall his last bowel movement or when he last passed gas. His past medical history is significant for Type 1 Diabetes, and he also has an open appendectomy in his 30’s. His temperature is 101.4 and on physical exam you hear loud, high-pitched bowel sounds.

- 62 yo man presents to ED- Symptoms:

o Severe, intermittent abdominal paino N/V

- No recent BM or flatus - Pertinent Past Medical History

o T1DMo Open appendectomy when he was 35 yo

- PEo Temperature: 101.8 Fo Loud-high pitched bowel sounds on auscultation

What do you want to order?

- Abdominal XR shows partial SBOo Air-fluid levelso Large diameter of bowels

Teaching point:

- The best initial test abdominal X-Ray- The gold standard Abdominal CT w/ contrast

o Clear transition zone correlates with obstructiono Accentuates intestinal wall vs other structures and may help to approximate the

location of obstruction

What is the best next step in management?

a. Laxativesb. Place an NG tubec. Emergent laparotomyd. Antibioticse. Colonoscopy

Answer: NG tube to suction gastric contents and relieve pressure

Pathophysiology

- Mechanical or functional obstruction of the intestineso Leads to fluid/gas accumulation proximal to site of obstructiono Resulting pressure increase leads to:

Colicky pain Possible decreased perfusion risk of ischemia / necrosis

- Obstruction can be partial or complete

Causes and Risk factors:

- Adhesions - #1 in developed countries- Hernia - #1 in underdeveloped countries- Volvulus- Crohn’s Disease- Neoplasms- Intussusception- Foreign Bodies- Intestinal Atresia

Signs and Symptoms:

- Severe, crampy, colicky, abdominal pain- N/V- Fever- High-pitched bowel sounds

Labs:

- Increased WBCs- Increased Lactate- Decreased pH

Diagnosis

- Abdominal XR (Best initial test)- Abdominal CT w/ Oral Contrast (Gold standard)

o Accentuates intestinal wall vs other structureso Better to approximate location

Management

- NPOo Prevents further increase in bowel pressure

- NG tube w/ suctiono Lowers bowel pressure proximal to obstruction

- IV Fluidso Because volume is lost due to third spacing

- Surgical decompression (if indicated)o Complete obstruction is emergento Or if there is lack of improvement with medical management