tehran medical school sina hospital mahmoud najafi
TRANSCRIPT
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Tehran Medical SchoolSina HospitalMahmoud Najafi
GOO, SBO, LBO
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Gastric outlet obstructionEtiologyo Benigno Malignant
GOO
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PUDGastric polypsIngestion of
causticsPancratitisGastric TBGastric vulvulusGastric Bezoars
pyloric stenosisBouveret
syndromeCrohn's disease congenital
duodenal webs
Benign causes of GOO
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Pancreatic cancerDistal gastric cancer Ampullary cancerDuodenal cancerCholangiocarcinomasMetastases
Malignant causes of GOO
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Nausea and VomitingAnorexiaEarly satietyBloating or Epigastric fullnessIndigestionEpigastric painWeight loss
Clinical Presentation
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Tympanitic mass in the epigastric area
Volume depletion
Clinical Presentation
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GastroparesisIntestinal obstruction
Differential diagnosis
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Clinical featuresPhysical examinationLaboratory tests Radiologic testsEndoscopy
Diagnosis
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Electrolyte abnormalitiesHypokalemic hypochloremic
metabolic alkalosisAnemiaElevated serum gastrin levels Serum tumor markers
Laboratory findings
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Plain AXRContrast studies CT scan
Radiologic tests
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Chronic pancreatitis: calcifications in the pancreas (X-ray of abdomen)
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Gastric Volvulus (Pediatric)
Figure 4 : Gastric volvulus. Plain film shows a large, air-filled structure with an unusual configuration in the left upper quadrant. Absence of gas distal to the stomach suggests gastric outlet obstruction.
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Barium meal studies were suggestive of deformed and spastic duodenum
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Gastric outlet obstruction caused by Crohn's disease. There is tapered narrowing of the distal antrum due to Crohn's disease involving the stomach.
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Gastric outlet obstruction caused by an annular carcinoma of the antrum. There is irregular narrowing of the distal antrum (arrow) with proximal dilatation of the stomach.
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Abdominal CT in a patient with gastric outlet obstruction due to peptic ulcer disease showing a distended and fluid filled stomach
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Endoscopy
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Medical TherapyoHydrationocorrection of electrolyte
abnormalitiesoNG tubeoParenteral PPI
• Surgical Therapy
Treatment
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the most frequently encountered surgical disorder of the small intestine
80% all mechanical intestinal obstruction
It has a wide range of etiologies
SBO (Small Bowel Obstruction)
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Intraluminal (e.g., foreign bodies, gallstones, or meconium)
Intramural (e.g., tumors, Crohn's disease–associated inflammatory strictures)
Extrinsic (e.g., adhesions, hernias, or carcinomatosis)
Etiologies
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Most Common Causeso Intra-abdominal adhesions (75%)
• Less prevalent etiologiesoherniasoCrohn's diseaseoCanceroCongenital abnormalities
Etiologies
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Accumulation of gas and fluidIncreases of intestinal activityocolicky pain
Distendion of bowelRises of intraluminal and intramural pressures
Pathophysiology
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Simple obstructionopartialoComplete
Strangulated obstructionClosed loop obstruction (e.g., with
volvulus)
Kinds of SBO
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Symptomso colicky abdominal paino Nauseao vomitingo Obstipation
• Signsoabdominal distentionoBowel sounds may be hyperactive
Clinical Presentation
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Reflect intravascular volume depletion
Consist of hemoconcentration and electrolyte abnormalities
Mild leukocytosis
Laboratory findings
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TachycardiaLocalized abdominal tendernessFeverMarked leukocytosisAcidosisPositive stool blood test
Features of strangulated obstruction
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Distinguish mechanical obstruction from ileus
Determine the etiology of the obstruction
Discriminate partial from complete obstruction
Discriminate simple from strangulating obstruction
Diagnosis
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functional obstructionSame symptoms and signsPostoperative ileusmotility returning to normal after laparotomyo small intestinal 24 hoursoGastric 48 hours o colonic 3 to 5 days
Ileus
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Historyo prior abdominal operationso presence of abdominal disorders
Examinationo search for hernias
Diagnosis
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Triado dilated small bowel loops (>3 cm in
diameter)o air-fluid levels seen on upright filmso a paucity of air in the colon
Sensitivity 70 to 80% Specificity is low
Radiographic Examination
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80 to 90% sensitive 70 to 90% specificdiscrete transition zoneo dilation of bowel proximallyo decompression of bowel distally
Computed tomography (CT)
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Fluid resuscitationMonitor urine outputBroad-spectrum antibioticsNG tubeExpeditious surgery
Therapy
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NG decompression & fluid resuscitation
Partial small bowel obstructionObstruction occurring in the early postoperative period
Intestinal obstruction due to Crohn's disease
Carcinomatosis
Conservative Therapy
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Perioperative mortality:For Nonstrangulating Less than
5%For strangulating 8 to 25%
Prognoses
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20% all mechanical intestinal obstruction
The etiology of LBO is age dependent
LBO (Large-bowel obstruction)
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colon cancer 60% DiverticulitisVolvulus
CecalSigmoid
Etiologies
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Chronic weight lossMelanotyc bloody stoolChange of caliber of stoolColonic lesion development history
o Right side Late obstruction
o Left side Early obstruction
History of Cancer
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Recurent LLQ pain over yearso Diverticulitis
Abrupt onset of symptomso Vulvulus
History
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Colonic distentionAbdominal painAnorexiaFeculent vomitingDehydration Electrolyte disturbances
Pathophysiology
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Symptomso colicky abdominal paino Nauseao vomitingo Obstipation
Clinical Presentation
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SBOo More severeo Shorter intervalo Shorter duration
LBOo Less severeo Longer intervalo Longer duration
Colicky Abdominal Pain
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GOOo Food particles
SBOo Billous
LBOo Fecaloid
Vomiting
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SBOo Less Distention
LBOo More Distension
Abdominal Distension
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Acute Colonic pseudo-obstruction
colon becomes massively dilated in the absence of mechanical obstruction
occurs in hospitalized patientsassociated with the use of narcotics, bedrest, and comorbid disease
Ogilvie syndrome (ACPO)
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by diminished or, in later stages, absent bowel sounds
The abdomen is distendedThe abdomen may be tender
Ph/Ex
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Reflect intravascular volume depletion
Consist of hemoconcentration and electrolyte abnormalities
Mild leukocytosis
Laboratory findings
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AXRdemonstrates dilation of the small
and/or large bowel air fluid levels
barium enema CT scan
Imaging Studies
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Large-bowel obstruction. Gastrografin study in a patient with obstipation reveals colonic obstruction at the rectosigmoid level.
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Large-bowel obstruction. Contrast study of patient with cecal volvulus. The column of contrast ends in a "bird's beak" at the level of the volvulus.
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MedicalSurgical
Therapy
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