General Surgery (29nov)

Management of 73 year old lady with SBO S0897200 The first step that I will take for this 73 year old lady would be to take a second and look at her from the end of the bed and decide whether she appears distressed or comfortable, as that will direct my initial management along two paths; 1) traditional method of historyexaminationmanagement 2) simultaneous resuscitation and history taking using ABCD approach Presuming the lady is haemo-dynamically stable my approach would be as follows: History: Pain Type, nature, onset, radiation, shifting, alleviating/exacerbating factors, associated symptoms, previous occurrence VomitingType, colour, amount, contents, association with pain/food intake Important to ask about bowel habits, ability to pass flatus at present , urinary symptoms, known hernias, Weight loss, fatigue, food intake, health of other family members Also ask about history of gallstones, volvolus Other Hospital Admissions Past History: Already known as above Allergies and medications If any Social History: Already known EXAMINATION: Signs of dehydration/ GCS/Observations( pulse, SaO2, BP, Resp Rate, Temp) Abdominal Examination: InspectionDistension, pattern of respiration, scar marks, visible swelling Palpation tenderness, rebound tenderness, rigidity, peritonism, any clinically palpable Hernia, mass in the abdomen Percussion dull/tympanatic/peritonism Auscultation present/absent, tinkling/non-tinkling Per-Rectal Examination: Palpable mass, empty rectum/full, distended/collapsed Also examine the RESPIRATORY/CVS systems Investigations: FBC WCC, HGB, Platelet levels U&E Renal Function/electrolyte abnormality LFT Liver Function Amylase pancreatitis Coagulation Screen need for Vitamin K CRP ABG’s degree of acidosis ECG MI

Erect CXRair under diaphragm/Pneumonia/aspiration ABD-XR distended loop of bowel/ cut off point Urine dipstick nitrates/ketones BM hyperglycemia Differential Diagnosis: 1) Obstruction secondary to Adhesions (60%) Hernia (20%) Malignancy (5%) Volvulus Gallstone Ileus Carcinoid Intussusception Stricture (Ischaemic, Crohn’s, TB) SMA Syndrome 2)Ileus 3)Pseudo-Obstruction 4)Sepsis Initial Management: The decision to perform surgery or not plus its urgency would depend on the findings on history, examination and investigative results, however the initial management stays the same in either case. This would include: IV Fluids upto 5 litre of them may be required N-saline/hartmans O2 therapy if appropriate Urinary catheter with hourly urine output monitoring to assess resuscitation Analgesia for pain opioids/paracetamol (nsaids avoided at this stage) Anti-emeticscentral/peripheral acting NG suctionto empty stomach contents Broad spectrum Antibiotics if appropriate Regular observations 1-4 hourly Regular clinical review for signs of deterioration/peritonism Further Imaging: If no immediate indication for surgery then further imaging would be of benefit: CT: imaging of choice intra luminal/extra luminal cause Gastrograffin contrast imaging: if contrast passes through small bowel in 6 hours unlikely absolute obstruction plus shown to decrease hospital stay in adhesive obstruction conservatively managed MRI: not as sensitive as CT and not readily available Indication for Surgery: Strangulated obstruction Peritonitis Failure to improve within 72 hours

Deterioration in clinical state Incision incase of Surgery Depending on cause Incision of indecision commonly employed References: “SBO: optimising radiological investigation and non-surgical management” Maglinte DD; Radiology 218(1):39-46 “Guidelines for management of SBO” Diaz JJ junior; J TRAUMA. Jun 2008;64(6): 1651-64 “Acute Intestinal Obstruction: Diagnosis and Managament” Burke M; Hosp Med 2002; 63:104-107 Total words:500