Intestinal Obstdeuxieme

Large Bowel Clinical History 1) Obtain history of bowel movements, flatus, constipation (i.e., no gas or bowel movement), and symptoms ► Major complaints include abdominal distention nausea vomiting and crampy abdominal pain

Large Bowel Clinical History Abrupt onset of symptoms makes an acute obstructive event (e.g.: cecal or sigmoid volvulus) a more likely diagnosis

Large Bowel Clinical (History) History of chronic constipation, long-term cathartic (laxative) use, and straining at stools implies: diverticulitis or carcinoma Change in caliber of stools strongly suggests carcinoma When associated with weight loss, likelihood of carcinoma increases

Clinical (History) 2) Colonic lesion development history Right-sided colonic lesions can grow quite large before obstruction occurs because of the: large capacity of the right colon and soft stool consistency Sigmoid colon and rectal tumors cause colonic obstruction much earlier in their development because: the colon is narrower and the stool is harder in that area

Large Bowel Clinical History 3) Obstruction secondary to intussusception Patients may describe: intermittent crampy abdominal pain that is colicky and relieved by assuming fetal position Weight loss and fatigue are common

Large Bowel Clinical History 4) pneumaturia mucinuria or fecaluria may occur when fistulization of the sigmoid colon to the bladder occurs

Physical Examination Large bowel Abdominal distention may be significant in patients with a large-bowel obstruction Bowel sounds may be normal early on but usually become quiet Abdomen is hyperresonant to percussion

Physical Examination Large bowel Palpation of the abdomen reveals tenderness fever severe tenderness and abdominal rigidity ►They are findings that suggest peritonitis secondary to perforation

Physical Examination Large bowel Remember Sigmoid diverticulitis and a perforated sigmoid secondary to carcinoma are clinically difficult to differentiate Patients may have guaiac-positive stool if carcinoma is the etiology

Physical Examination Large bowel Remember Rectal or lower sigmoidal mass may be palpated on rectal examination

A mass or fullness may be appreciated if a tumor is present in the cecum

Differential Diagnosis Large bowel Abdominal Pain in Elderly Persons Constipation Diverticular Disease Obstruction, Small Bowel

Lab Studies Large bowel Obtain a blood sample for: a CBC electrolyte levels prothrombin time (PT) blood type and crossmatch

Emergency Department Care Initial therapy includes: 1) gastric decompression (Insert a nasogastric tube if the patient has been vomiting) 2) volume resuscitation 3) appropriate preoperative antibiotics 4) timely surgical consultation

Imaging Studies Large bowel Obtain an upright chest radiograph and flat and upright abdominal radiographs Chest radiographs demonstrate free air if perforation has occurred Abdominal radiographs may be diagnostic of: sigmoid or cecal volvulus air-fluid levels ►► sign that suggests colonic obstruction

Imaging Studies Illustration

Imaging Studies Large bowel The absence of free air does not exclude perforation (this finding may be absent in half of all perforations) Additional contrast studies may include: * an enema with water soluble contrast(e.g: gastrographin: * CT examination

Imaging Studies Large bowel Contrast studies that reveal a column of contrast ending in a "bird’s beak" are suggestive of colonic volvulus

INTESTINAL OBSTRUCTION

Pediatrics, Intussusception Background Intussusception is the telescoping or prolapse of one portion of the bowel into an immediately adjacent segment Contrast enema can reduce the intussusception in approximately 75% of cases

INTESTINAL OBSTRUCTION Pediatrics, Intussusception Pathophysiology Intussusception most commonly occurs at the terminal ileum (i.e., ileocolic) The telescoping proximal portion of bowel (i.e., intussusceptum) invaginates into the adjacent distal bowel (i.e., intussuscipiens)

Pediatrics, Intussusception Pathophysiology The mesentery of the intussusceptum is compressed, and the ensuing swelling of the bowel wall quickly leads to obstruction Venous engorgement and ischemia of the intestinal mucosa cause bleeding and an outpouring of mucous, which results in the classic description of red "currant jelly" stool Most cases (90%) are idiopathic

Pediatrics, Intussusception Mortality/Morbidity Most patients recover if treated within 24 hours Mortality with treatment is 1-3% If left untreated, this condition is uniformly fatal in 2-5 days Recurrence is observed in 3-11% of cases Most recurrences involve intussusceptions that were reduced with contrast enema

INTESTINAL OBSTRUCTION Sex Overall, the approximately 3:1

male-to-female

ratio

is

With advancing age, gender difference becomes marked in patients older than 4 years, the male-tofemale ratio is 8:1 Age Intussusception is most common in infants aged 3-12 months

Pediatrics, Intussusception Clinical Examination History The typical presentation is a previously healthy infant boy aged 6-12 months with sudden onset of colicky abdominal pain with vomiting Paroxysms of pain occur 10-20 minutes apart Initially, loose or watery stools are present concurrent with vomiting and within 12-24 hours, blood or mucous is passed rectally

INTESTINAL OBSTRUCTION Pediatrics, Intussusception Clinical Examination History Early in the course, the patient appears completely well between the episodes of abdominal pain Lethargy may dominate the initial presentation, however, lethargy usually occurs later in the process The classic triad of colicky abdominal pain, vomiting, and red currant jelly stools occurs in only 21% of cases

INTESTINAL OBSTRUCTION Pediatrics, Intussusception Physical Examination Usually, the abdomen is soft and nontender early, but it eventually becomes distended and tender A vertically oriented mass may be palpable in the right upper quadrant

INTESTINAL OBSTRUCTION Pediatrics, Intussusception Physical Examination Currant jelly stools are observed in only 50% of cases Most patients (75%) without obviously bloody stools have stools that test positive for occult blood Fever is a late finding and is suggestive of enteric sepsis

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