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2463807640955Management00Management15208257640955IV fluids, analgesia, antiemetics, NBM, NG if vomitingVolvulus: sigmoidoscopy if sigmoid volvulus (90% success rate); do OT if caecal / failure of decompression / ?strangulationDo laparotomy if: guarding / rigidity / ? WBC ++ / ?mesenteric ischaemia / ?perforation / ? strangulation / failure to improve in 24 hours / large bowel obstruction >13cm00IV fluids, analgesia, antiemetics, NBM, NG if vomitingVolvulus: sigmoidoscopy if sigmoid volvulus (90% success rate); do OT if caecal / failure of decompression / ?strangulationDo laparotomy if: guarding / rigidity / ? WBC ++ / ?mesenteric ischaemia / ?perforation / ? strangulation / failure to improve in 24 hours / large bowel obstruction >13cm2463805557520Investigations00Investigations15170155554345AXR: sensitivity 75-80%, specificity 50% (for small bowel obstruction); >5 air-fluid levels abnormal (may be none in incomplete; also occurs in ileus, gastro); dilated bowel loops Small bowel obstruction: >2.5cm; different fluid levels in same loop; jejunal = ladder pattern; ileum = parallel walls Large bowel obstruction: >5cm; peripheral; larger; haustral pattern (sigmoid may resemble ileum) Sigmoid Volvulus: single dilated LOB; both end of loops orientated towards pelvis in sigmoid Caecal volvulus: single AF level in dilated caecum in mid-abdomen / LUQ; relatively empty distal bowelUSS: dilated SB loops = 95% sensitivity and specificity for small bowel obstructionCT: 90% sensitivity, 95% specificityBloods: maybe abnormal Na, K, renal failure; ? lactate suggests strangulation; WCC <15 in uncomplicated; WCC >20 suggests gangrene / abscess / peritonitis; mild ? amylase in small bowel obstruction00AXR: sensitivity 75-80%, specificity 50% (for small bowel obstruction); >5 air-fluid levels abnormal (may be none in incomplete; also occurs in ileus, gastro); dilated bowel loops Small bowel obstruction: >2.5cm; different fluid levels in same loop; jejunal = ladder pattern; ileum = parallel walls Large bowel obstruction: >5cm; peripheral; larger; haustral pattern (sigmoid may resemble ileum) Sigmoid Volvulus: single dilated LOB; both end of loops orientated towards pelvis in sigmoid Caecal volvulus: single AF level in dilated caecum in mid-abdomen / LUQ; relatively empty distal bowelUSS: dilated SB loops = 95% sensitivity and specificity for small bowel obstructionCT: 90% sensitivity, 95% specificityBloods: maybe abnormal Na, K, renal failure; ? lactate suggests strangulation; WCC <15 in uncomplicated; WCC >20 suggests gangrene / abscess / peritonitis; mild ? amylase in small bowel obstruction15208254376420Symptoms: small bowel obstruction severe earlier; colicky abdominal pain 1st symptom becomes constant; loose bowel motions and ? flatus early ? bowel motions late (maybe normal bowel motions in incomplete); bilious vomiting in complete (maybe not in incomplete; faecal in large bowel obstruction)Examination: dehydration; abdominal distension (may be absent in incomplete); tympanic bowel sounds (may be absent late)00Symptoms: small bowel obstruction severe earlier; colicky abdominal pain 1st symptom becomes constant; loose bowel motions and ? flatus early ? bowel motions late (maybe normal bowel motions in incomplete); bilious vomiting in complete (maybe not in incomplete; faecal in large bowel obstruction)Examination: dehydration; abdominal distension (may be absent in incomplete); tympanic bowel sounds (may be absent late)2463804376420Assessment00Assessment15201904000500Dehydration, electrolyte disturbance, mesenteric ischaemia, perforation00Dehydration, electrolyte disturbance, mesenteric ischaemia, perforation2463804000500Complications00Complications2463803491865Classification00Classification15208253491865Partial / complete Strangulating (suggested if fever, marked tenderness or guarding) / non-strangulating00Partial / complete Strangulating (suggested if fever, marked tenderness or guarding) / non-strangulating15208252938780Proximal bowel distends hypersecretion, ? absorption, systemic volume loss, local vascular compromise00Proximal bowel distends hypersecretion, ? absorption, systemic volume loss, local vascular compromise2463802938145Patho-physiology00Patho-physiology246380964565Aetiology00Aetiology1520190963294Small bowel obstruction: adhesions > hernias > Crohn’s disease, intussusception, tumours, SMA syndrome SMA syndrome: dilation of proximal duodenum from 3rd partLarge bowel obstruction: cancer > diverticulitis > volvulus (10%) > adhesions > hernia; faecal impaction Volvulus: twisting of intestinal segment on mesenteric axis Sigmoid volvulus: 2/3 all volvuli; occurs with chronic constipation; most common in elderly; often presents late; 90% recurrence rate after reduction Caecal volvulus: 1/3 all volvuli; more common in young adults; 15% population have congenital absence of fixation of terminal ileum, caecum and ascending colon; pregnancy and previous abdominal surgery are other risk factors; perforation common; gangrene in 20%; mortality 10-40%Paralytic ileus: ? K / Na / Mg / albumin, tricyclic antidepressants, opiates, anti-hypertensives, beta- blockers, quinidine00Small bowel obstruction: adhesions > hernias > Crohn’s disease, intussusception, tumours, SMA syndrome SMA syndrome: dilation of proximal duodenum from 3rd partLarge bowel obstruction: cancer > diverticulitis > volvulus (10%) > adhesions > hernia; faecal impaction Volvulus: twisting of intestinal segment on mesenteric axis Sigmoid volvulus: 2/3 all volvuli; occurs with chronic constipation; most common in elderly; often presents late; 90% recurrence rate after reduction Caecal volvulus: 1/3 all volvuli; more common in young adults; 15% population have congenital absence of fixation of terminal ileum, caecum and ascending colon; pregnancy and previous abdominal surgery are other risk factors; perforation common; gangrene in 20%; mortality 10-40%Paralytic ileus: ? K / Na / Mg / albumin, tricyclic antidepressants, opiates, anti-hypertensives, beta- blockers, quinidine246380330200Bowel Obstruction00Bowel Obstruction ................
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