differentiating large bowel obstruction from small bowel obstruction

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Differentiating Large Bowel Obstruction from Small Bowel Obstruction David Birks FRACS September 2010 Specialists Without Borders Seminar in Surgery Rwanda, September 2010

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Specialists Without Borders Seminar in Surgery Rwanda, September 2010. Differentiating Large Bowel Obstruction from Small Bowel Obstruction. David Birks FRACS September 2010. Differentiating large bowel obstruction from small bowel obstruction. Objectives - PowerPoint PPT Presentation

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Page 1: Differentiating Large Bowel Obstruction from Small Bowel Obstruction

Differentiating Large Bowel Obstruction from

Small Bowel Obstruction

David Birks FRACSSeptember 2010

Specialists Without BordersSeminar in Surgery

Rwanda, September 2010

Page 2: Differentiating Large Bowel Obstruction from Small Bowel Obstruction

Brisbane

Sydney

Hobart

AdelaideCanberra

MelbourneVictoria

Darwin

Perth

Page 3: Differentiating Large Bowel Obstruction from Small Bowel Obstruction

Differentiating large bowel obstruction from small bowel obstruction

Objectives• Physiology & anatomy of small/large bowel• Causes of bowel obstruction• Symptoms & signs• Investigations (plain xray)• Complications • Management – conservative & operative

Page 4: Differentiating Large Bowel Obstruction from Small Bowel Obstruction

Functions of intestine

• Small intestine – absorption of fluid, food, vitamins

• Large intestine – absorption of water & Na - converts 1000-2000ml into

200ml semisolid faeces

Page 5: Differentiating Large Bowel Obstruction from Small Bowel Obstruction

Fluid replacement - GI loss

• Type Na K Cl HCO3

Gastric 100 10 100

Bile 140 5 80 40

Pancreas 140 5 80 100

Small Bowel 90 10 90 30

Page 6: Differentiating Large Bowel Obstruction from Small Bowel Obstruction

Fluid replacement - GI loss

• Type Volume (litres)

Gastric 2.0

Bile 1.0

Pancreas 1.0

Small bowel 3.5

Total 7.5

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Causes of small bowel obstruction

• adhesions (previous operation)• external hernia• small bowel volvulus (primary)• neoplasms• miscellaneous

Page 13: Differentiating Large Bowel Obstruction from Small Bowel Obstruction

Causes of large bowel obstruction

• carcinoma of colon• volvulus (sigmoid)• diverticular disease• miscellaneous

Page 14: Differentiating Large Bowel Obstruction from Small Bowel Obstruction

Symptoms of bowel obstruction

• abdominal pain• vomiting• distension• constipation (no flatus)

Page 15: Differentiating Large Bowel Obstruction from Small Bowel Obstruction

High small bowel obstruction

• frequent, profuse vomiting• central abdo pain • minimal distension

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Lower small bowel obstruction

• colic pain • moderate vomiting ( may be faeculent)• moderate distension

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Large bowel obstruction

• abdominal distension• constipation• lower abdo pain ( may be minimal)• minimal vomiting

Page 18: Differentiating Large Bowel Obstruction from Small Bowel Obstruction
Page 19: Differentiating Large Bowel Obstruction from Small Bowel Obstruction

Physical Examination

• abdo scars• external hernia• signs strangulation (tenderness, fever, mass)

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Page 21: Differentiating Large Bowel Obstruction from Small Bowel Obstruction

Investigations

• Plain Xray – supine - erect - chest

• Hb, WCC, Urea & Electrolytes

Page 22: Differentiating Large Bowel Obstruction from Small Bowel Obstruction

Further investigations

• CT abdomen• contrast study (via NG )

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Plain x ray SBO

• dilated loops with gas• centrally placed• transverse lines (circular folds)

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Plain x ray LBO

• dilated bowel with gas (caecum)• peripheral • haustra (not lines across bowel)• may have cut-off point

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SBO

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LBO

Supine

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Page 30: Differentiating Large Bowel Obstruction from Small Bowel Obstruction

Carcinoma of Sigmoid – LBO – Decompressed into SB

Prone

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Page 38: Differentiating Large Bowel Obstruction from Small Bowel Obstruction

Complications of bowel obstruction

• fluid & electrolyte loss - small bowel• aspiration – small bowel• respiratory restriction– large bowel• strangulation – small bowel• caecal perforation – large bowel (competent

Ileo-caecal valve)

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Page 40: Differentiating Large Bowel Obstruction from Small Bowel Obstruction

Management of bowel obstruction

• nil orally• IV fluid & electrolyte replacement• NasoGastric drainage (small bowel)

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Operation for bowel obstruction

• external hernia (SBO) – emergency• signs of strangulation – emergency• SBO not settling – within 24-48 hr• LBO due to carcinoma - soon

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Non-operative treatment of bowel obstruction

• sigmoid volvulus – decompress via sigmoidoscope

• post-operative SBO• intussusception in infants (2/12 – 2 yr)• previous operations for SBO• radiation• abdominal carcinomatosis

Page 43: Differentiating Large Bowel Obstruction from Small Bowel Obstruction

Operation - SBO

• midline incisionlook for ileo-caecal valve

• treat cause• external hernia – incision over hernia

- if gangrene convert to midline

Page 44: Differentiating Large Bowel Obstruction from Small Bowel Obstruction

Operation - LBO

• midline and resect bowel pathology +/- anastomosis+/- stoma

• if left sided obstruction – transverse colostomy through right upper trans incision

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Summary of bowel obstruction

• Physiology & anatomy of small/large bowel• Causes of bowel obstruction• Symptoms & signs• Investigations (plain xray)• Complications • Management – conservative & operative

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