PANCE Blueprint GI and Nutrition (9%)

Small bowel obstruction (ReelDx)

VIDEO-CASE-PRESENTATION-REEL-DX

small bowel obstruction

4-day-old with constant vomiting and failure to pass meconium since birth (watch video)

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?
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

  • 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.
  • KUB shows dilated loops of bowel with air fluid levels with little or no gas in the colon.
  • Most small bowel obstructions are caused by adhesions or hernias; other causes include neoplasm, inflammatory bowel disease, and volvulus.
  • Intussusception is the most common cause in children
  • Tx with decompression with an NGT
"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

  • Most common location in 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 location
What finding on abdominal x-ray should make you think of bowel obstruction?
Air fluid levels

Upright radiographs may demonstrate:

Treatment includes hospitilzation, IV fluids, nothing by mouth, and nasogastric suctioning.

  • Urgent surgical consultation is necessary when mechanical obstruction is suspected, especially of the large bowel.

Small Bowel 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.

Intestinal Obstruction Picmonic

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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