Bowel Obstruction

Classification

o       Open vs Closed

o       Incomplete vs Complete

o       Extrinsic (tumor, volvulus, adhesions, hernias) vs Intramural (tumor, stricture, Crohn’s, ischemia) vs Intraluminal (constipation, FB, bezoar – tricho, phyto)

o       Small bowel vs Large bowel

Ddx SBO

o       Adhesions

o       Hernias

o       Neoplasm (Adenocarcinoma, Carcionid)

o       IBD, Volvulus, Intussusception, Gallstone ileus, Bezoars

Ddx LBO (usually sigmoid)

o       Carcinoma

o       Diverticulitis

o       Volvulus

o       IBD, Radiation, Intussusception, Olgilvie’s, Paralytic ileus, Metabolic ileus, Drugs

History

o       Presentation: obstipation, N/V, cramping, distension, typanism, dehydration, tinkling dowel sounds, pain, visible peristalsis

o       Last meal

o       B symptoms: fevers, night sweats, weight loss

o       PMHx – previous surgeries, diet (high fibre, high bulk = volvulus), IBD, tumors, bleeding problems, hernias

o       Rx

o       FHx – cancer, bleeding

o       Social Hx – smoking, EtOH

Physical exam

o       Vitals (if dehydrated – tachycardia, postural hTN, low U/O)

o       Inspection: distension, visible peristalsis

o       Percussion: tympanic, pain

o       Palpation: masses, distension, pain (complicated)

o       Auscultation: loud Borborygmus (tinkling), lack of BS

Labs

o       CBCD, lytes, BUN, Cr

o       Beta HCG

o       Amylase, Lipase

o       Low sodium

o       Low potassium

o       Low volume

o       WBC if strangulated

o       Metabolic alkalosis with vomiting (hypokalemic, hypochloremic)

Imaging

o       Abdominal X rays

·        Great Big FART

o       Gas pattern

o       Bowel wall air

o       Free air

o       Air fluid levels

o       Air in Rectum

o       Thickened bowel wall

§         60% will be normal

§         upright CXR or LLD to R/O free air

§         No air in rectum and many air fluid levels

§         If ischemic look for free air, pneumatosis, thicked bowel wall, air in portal vein

§         No air in RLQ, bubble in LUQ – cecal volvulus

§         Omega or kidney bean in RLQ with bird’s beak – sigmoid volvulus

§         Double bubble – duodenal atresia

§         Air in biliary tree plus SBO – gallstone ileus

§         Cecum >12cm, Transverse colon >6cm, SB >5cm à OR

o       Ultrasound – for closed loop

o       CT – for questionable patients

o       Contrast studies – enema, not from above!

Do not take to OR if:

§         Post-op

§         Carcinomatosis

§         Recurrent adhesive bowel obstruction

§         Post RT

Treatment

o       Stabilize vitals, fluid and electrolyte resuscitation

o       NG tube

o       Foley catheter to monitor in/outs

o       Manage conservatively if partial – take to OR if does not resolve

o       If strangulated/complicated – to OR

Orders

o       NPO, ice chips

o       AAT

o       Vitals q2h

o       IV RL bolus 500cc-2000cc then run at 150cc/hr

o       CBCD, lytes, BUN, Cr, amylase, lipase

o       AXR 3 views, repeat in 8 hrs

o       NG to low gomco

o       Foley to urometer

o       Ins/Outs q1hr, call if <60cc over 2 hr

o       Flagyl 500mg IV on call to OR

o       Ancef 1g IV on call to OR