ABD. PAIN, VOMITING, CH. CONSTIPATION & ABD.

DISTENSIONMUSADAQ ASRAR

Shifa College of Medicine2013-051

CASE

A 95 yr old woman is sent to the ER from nursing home with complaints of abdominal pain and distension. It is unclear, but staff at nursing home thinks it has been about 4 days since she had a bowel movement.

Examination

The woman has an expressive aphasia and rt. hemiparesis from a previous stroke.

Her vitals; pulse 90, B.P 120/80, afebrile. Her abdomen is markedly distended with

hyperactive bowel sounds and tympanitic throughout.

There is no abdominal tenderness. Rectal exam reveals large quantities of soft,

brown stool. KUB and upright images reveal marked

dilated colon consistent with obstruction.

Mechanical intestinal obstruction

Classification.Can be divided into paralytic and

mechanical. Mechanical is further classified according

to,1. Speed of onset: acute, chronic, acute

on chronic2. Site: high or low.3. Nature: simple or strangulated4. Aetiology.

Speed of onset

In acute obstruction, the onset is rapid and the symptoms are severe.

In chronic obstruction, symptoms are insidious and slowly progressive e.g most case of carcinoma of large bowel.

A chronic obstruction may develop acute symptoms as obstruction becomes complete. e.g narrow lumen occluded by inspissated bowel contents.

Site and Nature

Small intestine Large intestine

Simple: when bowel is occluded without damage to its blood supply. Closed loop obstruction

Strangulated: blood supply of involved segment is cut off. e.g strangulated hernia, volvulus, intussusception.

Gangrene is inevitable if left untreated.

Aetiology

Causes in the lumen; fecal impaction, gallstone ‘ileus’, food bolus, parasites, intussusception.

Causes in the wall; congenital atresia, Crohn’s, tumors, diverticulitis.

Causes outside the wall; strangulated hernia, volvulus and obstruction due to adhesions or bands.

Age group

Neonatal; congenital atresia, stenosis, imperforate anus, volvulus neonatorum, hirschsprung’s and meconium ileus.

Infants; intussusception, hirschsprung’s, strangulated hernia, and meckel’s diverticulum.

Young & middle age; strangulated hernia, adhesion, bands and Crohn’s disease.

Elderly; strangulated hernia, carcinoma of bowel, colonic diverticulitis, impacted faeces.

Pathology

Simple occlusion causes Intestine distal to obstruction to empties rapidly and collapsed. The bowel above the obstruction becomes dilated with gas and secretions, increased peristalsis to over come obstruction causes which intestinal colic.

Impaired blood supply due to distention may cause mucosal ulceration and perforation.

Strangulating obstruction

Integrity of mucosal barrier lost due to ischemia.

Secondary peritonitis occurs due to transudation of organisms in gut.

Strangulation is followed by gangrene of the ischemic bowel with perforation.

Lethal effects

Fluid and electrolyte depletion occur due to copious vomiting and loss into the bowel lumen.

Protein loss into the gut and toxemia due to migration of toxins and intestinal bacteria into the peritoneal cavity.

Clinical features

Colicky abdominal pain. Distension. Absolute constipation. Vomiting.

Pain

Small bowel; pariumbilical Distal colonic; suprapubic in location Postoperative obstruction; colic may be

disguised by general discomfort.

Distension

Usually seen in chronic large bowel obstruction.

Volvulus of the sigmoid colon. In high intestinal obstruction distension

will not be marked.

Absolute constipation

Failure to pass flatus or faeces. It is an early feature in large bowel

obstruction. Late feature in small bowel obstruction. Pt. may pass 1 or 2 stools after onset of

obstruction as bowel completely empties below obstruction.

Vomiting

Usually occurs in high obstruction, but late in low bowel obstruction, or may be absent.

In late stages vomiting becomes faeculent but not faecal.

True vomiting of faeces occurs only in gestrocolic fistula.

Clinical examination

Dehydration Elevated pulse Temperature usually raised in

strangulation. Distention and visible peristalsis Any hernia or presence of any abdominal

scar suggests adhesions or bands as a cause.

Mass in intussuseption or carcinoma Digital rectal examination.

Features suggesting strangulation

Strangulation verses simple must be distinguished because strangulation ensuing peritonitis has a high mortality of up to 15%.

Toxic appearance Colicky pain Tenderness & abdominal rigidity Absent bowel sounds Raised white cell count

Investigations

Abdominal x rays; erect and supine Barium follow through; in cases of small

bowel barium enema. Sigmoidoscopy; chronic obstruction Colonoscopy; chronic obstruction CT scan

Small bowel obstructionLadder pattern of dilated loops

Large bowel obstructionhaustrations in large bowel obstruction

Conservative treatment

IV fluids and nasogastric aspiration. (dip and suck) Nil orally 2 hourly temperature and pulse Abdominal examination 8 hourly.

Indications for surgery

Strangulating obstruction Dip and suck regimen failure Also require for simple obstruction which fails to

settle. Caecum >10 cm in diameter on radiograph. At the surgery bowel is inspected for viability. Non viability includes

1. Absence of peristalsis2. Loss of normal sheen

3. Loss of pulsation in mesentry4. Color; green or black, purple may recover

General principles

Small bowel; can be resected and primary anastomosis performed with safety because of rich blood supply

Large bowel; resection of obstructing lesion & primary ileocolic anastomosis (lesion proximal to splenic flexure). Left sided lesions; excision of affected segment and exteriorizing the two ends of colon as a temporary colostomy and mucus fistula.

If not reached to surface it is closed ( hartmann’s procedure)

hartmann’s procedure

Causes of obstruction

T.B Meckel’s diverticulum Tumours

Sigmoid volvulus

Occurs in elderly, constipated patients 4 time common in men X ray shows distended loop of a bowel

the shape of a ‘coffee bean’ arising out of the pelvis on the left side. Barium enema gives bird beak appearance.

Treatment; decompression by sigmoidoscopy.

Rectal flatus tube placed in situ for 48 h. later elective resection.

Sigmoid volvulus

If decompression is unsuccessful or there are signs of gangrene or perforation, laparotomy with resection is under taken, the two ends of the colon being brought out as a double barrelled colostomy. Paul- Mikulicz procedure which is later closed.

Paul- Mikulicz

Caecal volvulus

Usually associated with congenital malformation. Excessively mobile caecum and ascending colon, defect in rotation, caecum retain its mesentry.

AXR; dilated caecum in left upper quadrant

Treatment; laparotomy, if bowel is viable, untwisting with caecostomy. Right hemicolectomy is necessary if the caecum is infarcted, and to prevent recurrence.

The mortality rate is high

Mesenteric vascular occlusionsaetiology

Mesenteric embolus; AF, vegetation on valves.

Mesenteric arterial thrombosis; atheroma, aortic dissection.

Mesenteric venous thrombosis; portal hypertension, may follow splenectomy. Crohn’s disease, OCPs.

Mesenteric vascular occlusions

Vascular occlusion results in infarction of the affected gut, leads to bleeding.

Gangrene and perforation occurs Classic triad; acute abdominal pain, rectal

bleeding, shock in an elderly who has AF. Treatment; early embolectomy and

revascularization before gangrene sets up.

Diverticular disease

Lower abdominal colicky pain Alternating constipation and diarrhoea Abdominal distension Sigmoidoscopy to exclude carcinoma D.D’s; Ca colon, crohn’s, ischemic colitis Complications; large bowel obstruction,

hemorrhage, fistula, perforation and stricture.

Diverticular disease

Treatment; resection either by Hartmann’s procedure followed by subsequent restorative surgery or a primary anastomosis protected by a temporary defunctioning loop ileostomy.

Intussuseption

Telescoping of the one segment of bowel into adjacent segment.

Ileo-colic Ileo-ileal Ileo-caecal Colo-colic

Intussuseption

Intussuseption

Most common in children 5-10month of age

70-90% idiopathic Other association; meckel’s diverticulum,

polyp in children Adult intussuseption is associated with

peutz-jegher’s syndrome, lipoma or tumor

Redcurrent jelly stool. Sausage shaped hump in the abdomen

and emptiness in RIF.

Intussuseption

USG diagnostic Barium enema give claw sign CT-scan Treatment; resuscitation, hydrostatic

reduction, surgery (cope’s method)

Neonatal intestinal obstruction

Intestinal atresia Volvulus neonatorum Meconium ileus Necrotizing enterocolitis Hirschsprung’s disease Anorectal atresias