PANCE Blueprint GI and Nutrition (9%)

Small bowel obstruction (ReelDx)

VIDEO-CASE-PRESENTATION-REEL-DX

61 y/o with acute onset severe abdominal pain and vomiting

Patient will present as → a 65-year-old female with diffuse abdominal pain and vomiting. She has not had a bowel movement in three days. PE reveals high-pitched, hyperactive bowel sounds, tympany to percussion, no rebound tenderness, and a temperature of 100.4 F. Abdominal radiograph reveals distended loops of bowel with a step ladder pattern of differential air-fluid levels.

What is the #1 cause of small bowel obstruction in adults?
Postoperative adhesions
What will the bowel sounds be early on in a small bowel obstruction? What will they be later on?
Early they are hyperactive. Late they are absent.

Small Bowel Obstruction (SBO)

  • Small bowel obstruction presents with abdominal pain, distention, vomiting of partially digested food, and obstipation
  • Bowel sounds are high-pitched and come in rushes. Later in the process, the bowel becomes silent
  • Most small bowel obstructions are due to mechanical obstructions caused by adhesions or hernias; other causes include neoplasm, intussusception, foreign body, inflammatory bowel disease, and volvulus
  • Functional causes of SBO include postoperative ileus (transient paralysis of smooth muscle), infection or inflammation, hypothyroidism, electrolyte abnormalities (hypokalemia and hypercalcemia), and medications (i.e. opioids)
  • Intussusception is the most common cause in children
  • KUB shows dilated loops of bowel with air-fluid levels with little or no gas in the colon.
  • Treat with decompression with an NGT, surgery if a mechanical obstruction is suspected
"Early versus late obstruction: Obstipation and absent bowel sounds are seen late in intestinal obstruction. Hyperactive bowel sounds are very common early in the course of intestinal obstruction. They are described as high-pitched with occasional rushes."

Large Bowel Obstruction

  • The most common location is the sigmoid colon due to neoplasms, fecal impaction, and diverticulitis
  • Presents with distention and pain. Patients may be febrile and tachycardic. Shock may ensue.
  • KUB shows dilated large intestine
  • Barium enema to confirm and establish the location
  • Treatment includes NGT, fluids, pain management and urgent surgery if mechanical obstruction is suspected
What finding on abdominal x-ray should make you think of bowel obstruction?
Air fluid levels

Upright radiographs may demonstrate:

Additional imaging includes an abdominal CT scan with contrast in order to identify the potential cause of obstruction. Abdominal ultrasonography may be useful for individuals with contraindications to CT scanning, like those with contrast allergies and pregnant females.

Small Bowel Obstruction

Treatment includes hospitalization, IV fluids, nothing by mouth, and nasogastric suctioning to remove the fluid and gasses that have built up

  • Urgent surgical consultation is necessary when a mechanical obstruction is suspected

osmosis Osmosis
Picmonic
Intestinal obstruction

IM_NUR_Intestinal-Obstruction_V1.3_

An intestinal obstruction occurs when the contents of the gastrointestinal tract cannot pass through the intestines. Signs and symptoms of an obstruction include severe abdominal pain, vomiting, abdominal distension, high-pitched or absent bowel sounds, and increased or absent peristalsis. Fluid and acid-base problems accompany an intestinal obstruction with metabolic alkalosis occurring when an obstruction is high (upper duodenum) due to loss of HCl from vomiting and/or nasogastric suction and dehydration when the obstruction is located in the small intestine. Typically, dehydration and electrolyte imbalance does not usually occur with a large intestine bowel obstruction.

Play Video + Quiz

Question 1
Which of the following is not a radiographic feature of intestinal obstruction?
A
Multiple air-fluid levels on erect film.
B
Thumbprinting sign.
C
The jejunum is characterized by its valvulae conniventes.
D
Large bowel, except for the caecum, shows haustral folds.
Question 1 Explanation: 
Thumbprinting is a radiographic sign of large bowel thickening caused by edema, related to an infective or inflammatory process.
Question 2
The initial management of intestinal obstruction includes all of the following except
A
Passage of nasogastric tube for decompression.
Hint:
See D for explanation 
B
Placing of intravenous line for rehydration and electrolyte correction.
Hint:
See D for explanation 
C
Administering intravenous antibiotics.
Hint:
See D for explanation 
D
Surgery
Question 2 Explanation: 
Treatment is fluid resuscitation, nasogastric suction, and, in most cases of complete obstruction, surgery. If bowel ischemia or infarction is suspected, antibiotics should be given (eg, a 3rd-generation cephalosporin, such as cefotetan 2 g IV) before operative exploration. Surgery, when indicated for acute intestinal obstruction is done after the patient has been adequately resuscitated. All other options are resuscitative measures.
Question 3
Which of the following is associated with the ‘double bubble’ sign on abdominal radiograph?
A
Duodenal atresia
B
Pyloric atresia
Hint:
its radiographic signs are single gas bubble sign, pyloric dimple sign, and absence of a ‘beak’ sign.
C
Hirschsprung’s disease
Hint:
In the neonate, this will show dilated loops of bowel with air-fluid levels.
D
Sigmoid volvulus
Hint:
Abdominal radiograph shows Frimann Dahl’s sign.
Question 3 Explanation: 
Abdominal plain films in neonates with duodenal atresia will demonstrate dilated stomach and duodenum giving the characteristic ‘double bubble’ sign with no gas distal to the duodenum.
Question 4
Which of the following is not a cause of paralytic ileus
A
Gastrointestinal surgery
Hint:
See D for explanation
B
Hypokalemia
Hint:
See D for explanation
C
Intra-abdominal sepsis
Hint:
See D for explanation
D
Hyperkalemia
Question 4 Explanation: 
Hyperkalemia does not cause paralytic ileus. It can cause cardiac arrhythmia. All other options are correct.
Question 5
Which of the following is correct concerning large bowel obstruction
A
Vomiting occurs early and is profuse with rapid dehydration
Hint:
Seen in high small bowel obstruction.
B
Pain is predominant with central distension.
Hint:
Seen in high small bowel obstruction.
C
Distension is minimal.
Hint:
Distension is minimal in small bowel obstruction.
D
Vomiting and dehydration are late.
Question 5 Explanation: 
In large bowel obstruction, distension is early and pronounced. Pain is mild and vomiting and dehydration are late.
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Intussusception (ReelDx) (Prev Lesson)
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