gastrointestinal complications

GASTROINTESTINAL COMPLICATIONS

scope

1. Early Postoperative Bowel Obstruction2. Acute Abdominal Compartment Syndrome3. Postoperative Gastrointestinal Bleeding4. Stomal Complications5. Anastomotic Leak6. Intestinal Fistula7. Pancreatic Fistulas

Early Postoperative Bowel Obstruction

Early Postoperative Bowel Obstruction

Obstruction occurring within 30 days after surgery Functional Obstruction

adynamic or paralytic ileus Mechanical Obstruction

luminal, mural, or extraintestinal

Postoperative bowel motilitySmall bowel motility within several hoursGastric motility within 24 to 48 hoursColonic motility within 48 to 72 hours

Presence of bowel sounds, flatus, and bowel movements.

Causes of Intestinal Paralytic Ileus• prolonged surgical procedure and exposure of abdominal

contents • Intra-abdominal infection (peritonitis or abscess) • Retroperitoneal hemorrhage and inflammation • Electrolyte abnormalities • Medications (narcotics, psychotropic agents)

Causes of Mechanical postoperative small bowel obstruction

• Adhesions (92%)• Phlegmon or abscess• Internal hernia• Intestinal ischemia• Intussusception

Differentiation between adynamic ileus and mechanical obstruction

Adynamic ileus -Diffuse discomfort -No sharp colicky pain and distended abdomen. -Quiet abdomen with few

bowel sounds- Radiographs : reveal diffusely dilated bowel throughout the intestinal tract

Mechanical obstruction -High-pitched -Tinkling sounds -Fever and sepsis -Tachycardia -Hypovolemia - Radiographs : small bowel dilation with air-fluid levels and thickened valvulae conniventes in the bowel proximal to the point of obstruction and little or no gas in the bowel distal to the obstruction

Management

Three-step approach – Resuscitation– Investigation– Surgical intervention

Treatmento Adynamic ileus

o expectantly waiting for resolution

o Partial mechanical small bowel obstruction o initially managed expectantly 7 to 14 days, o If stable and clinical and radiologic improvement continues

o Emergency relaparotomy o (closed-loop, high-grade, or complicated small bowel obstruction,

intussusception, or peritonitis)

During this time nutritional support and surgical intervention are signs of deterioration or no improvement.

scope


Acute Abdominal Compartment Syndrome

Acute Abdominal Compartment Syndrome

• Increased intra-abdominal pressure greater than 12 mm.Hg • Associated with

– Rising peak airway pressure– Hypoxia– Difficult ventilation– Oliguria or anuria

Most commonAbdominal Compartment Syndrome

Multiple traumaileus, coagulopathy, capillary leak, and massive fluid

resuscitation and transfusion

ICU setting (nontrauma setting)ascites, retroperitoneal hemorrhage

Presentation and DiagnosisDifficulty breathing ,elevated peak airway pressure,

hypoxia, worsening hypercapniaAbdomenal distention and tenseReduced Cardiac outputOliguriaNeurologic deterioration

Prevention of Abdominal Compartment Syndrome

Organ function is monitored and assessed: Lungs: hypercapnia, hypoxia, difficult ventilation, elevated pulmonary artery

pressure, drop in PaO2/FIO2 ratio, decreased compliance, intrapulmonary shunt, increased dead space

Heart: decreased cardiac output and cardiac index and need for vasopressors

Kidneys: oliguria unresponsive to fluid therapy Central nervous system: Glasgow Coma Scale score less than 10 or neurologic

deterioration in the absence of neurotrauma Abdomen: distention. Computed tomography scan to check for fluid

collections, narrowing of the inferior vena cava, compression of the kidneys, and rounding of the abdomen

Treatmentsurgical

organ dysfunction + intra-abdominal hypertension (15 to 20 mm Hg )

Decompression abdomen is tense + signs of extreme ventilatory

dysfunction + oliguria

scope


Postoperative Gastrointestinal Bleeding

Postoperative Gastrointestinal Bleeding

• Stress ulceration is a serious complication• Clinically significant bleeding

o Hemodynamic instabilityo Transfusion of blood productso Operative intervention less than 5% o Associated with significant mortality

Risk Factors for Stress Erosions

• Multiple trauma • Head trauma • Major burns • Clotting abnormalities • Severe sepsis • Systemic inflammatory response syndrome • Cardiac bypass • Intracranial operations

Presentation and DiagnosisMelenaHematemesisHematocheziaHemodynamic compromiseDecrese hematocrit

TreatmentThe basic principles of management of postoperative GI bleeding include the following:

1. Fluid resuscitation2. Checking and monitoring clotting parameters and correcting abnormalities3. Identification and treatment of aggravating factors 4. Transfusion of blood products 5. Identification and treatment of the source of the bleeding

scope


Stomal Complications

EtiologyStomas are widely used in the treatment of

colorectal, intestinal, and urologic diseasesileostomy, colostomy, or urostomyoccur within 30 days after surgery

Stomal ComplicationsEarly Late

Stoma Poor location Prolapse

Retraction Stenosis

Ischemic necrosis Parastomal hernia

Detachment Fistula formation

Abscess formation Gas

Peristomal skin Excoriation Parastomal varices

Dermatitis Dermatoses

Cancer

Skin manifestations of inflammatory bowel disease

Systemic High output Bowel obstruction

Nonclosure

Treatment Surgical technique is imperative Ischemia immediate revision

Necrosis beyond the fascia immediate reoperation. Ischemia limited to a few millimeters is observed

Stenosis can be repaired via laparotomy

Chemical dermatitis cleaning, barriersCandida dermatitis NystatinTraumatic dermatitis patient education ,application of a skin barrier Allergic dermatitis symptomatic relief with oral antihistamine,

topical or oral steroid therapy

Technical Aspects of Stoma Construction

Abdominal Wall Aperture Excision of a circular piece of skin about 2 cm in size Preservation of subcutaneous fat to provide support for the stoma Transrectus muscle placement of the stoma Fascial aperture to admit two fingers

Stoma Selection of normal bowel for the stoma Adequate mobilization of bowel to avoid tension on the stoma Preservation of blood supply to the end of bowel (the marginal artery of the colon and the last vascular arcade of the small bowel mesentery must be preserved) The small bowel serosa must not be denuded of more than 5 cm of mesentery

Maturation Primary maturation of the end stoma or the afferent limb of the loop ileostomy Avoidance of traversing the skin with sutures during maturation

Other ManeuversTunneling of bowel through the extraperitoneal space of the abdominal wall Mesenteric-peritoneal closure Fixation of mesentery/bowel to the fascial ring Use of a supportive rod with loop stomas

scope


Anastomotic Leak

Etiologylevel of the anastomosis

o esophageal, pancreatico-enteric, and colorectalMicrocirculation at resection marginsIntraluminal distentionEmergency bowel surgery

Presentation and Diagnosis The clinical manifestations result of intestinal contents

o purulent discharge o Malaise, fever, abdominal pain, ileus, localized erythema

around the surgical incision, and leukocytosis, o Bowel obstruction, pneumaturia, fecaluria, and pyuria

Treatment Resuscitation is started immediately

crystalloid fluids , blood transfusion NPO NG tube Incised and drained Reoperation (peritonitis, intra-abdominal

hemorrhage, suspected intestinal ischemia)

scope


Intestinal Fistula

Intestinal FistulaAbnormal communication between

o two epithelialized surfaces or o two digestive organs or o hollow organ and the skin

most commonly iatrogenic

Presentation and DiagnosisSeverity depend on the surgical anatomy and physiology of the fistula

Anatomy-enteroenteric fistula-Enterovesical-enterocutaneous and pancreatic fistula-enterovaginal fistula

Physiology-low output (<200 mL/24 hr)-moderate output (200-500 mL/24 hr)-high output (>500 mL/24 hr)

Hypovolemia and dehydration, electrolyte and acid-base imbalance, loss of protein and trace elements, and malnutrition

Skin and surgical wound -irritation, excoriation, ulceration, and infection of the skin

Treatment• IV fluid and electrolyte imbalance is corrected.• NPO• Broad-spectrum IV antibiotic• H2 antagonists or proton pump inhibitors • Somatostatin analogues• Skin protection• surgical procedure

scope


Pancreatic Fistulas

Pancreatic Fistulas

o Diagnosis o Cloudy fluid with a high amylase content

o management o Octreotide therapyo ERCPo Fistuloenterostomy

HEPATOBILIARY COMPLICATIONS

Bile Duct InjuriesThe most dreaded complication of gallbladder

surgery is injury to the extrahepatic bile duct

o Iaparoscopic cholecystectomy 0.4% to 0.7%

o Open cholecystectomy 0.2%

Bile Duct Injuries Presentation– Bile leak upper quadrant pain, fever, nausea,

abdominal distention, and malaise– Bile duct strictures cholangitis, pain, fever,

chills,jaundice,leukocytosis and elevated bilirubin

Diagnosis CT scan ERCP Percutaneous transhepatic cholangiography Magnetic resonance cholangiopancreatography

Bile Duct InjuriesPrevention

proper surgical technique + adequate identification of the anatomy

Treatment adequate resuscitation, antibiotics, and drainage,Sphincterotomy or stentSurgical intervention

EAR, NOSE, THROAT COMPLICATIONS

scope• Epistaxis• Acute Hearing Loss• Nosocomial Sinusitis• Parotitis

EpistaxisAssociated with leukemia and hemophilia, excessive

anticoagulation, and hypertension.Two general categories:

o anterioro Posterior

Management o Firm pressure to the nasal ala and held for 3 to 5 minutes o packing with strip gauze for 10 to 15 minuteso Foley catheter with a 30-mL balloon o ligation of the sphenopalatine a. or anterior ethmoidal a.

Acute Hearing Loss Abrupt loss of hearing in the postoperative period is an

uncommon event

Unilateral hearing loss o obstruction or edema related to an NG or feeding tube

Bilateral hearing losso Neural , pharmacologic (aminoglycosides and diuretics)

Nosocomial Sinusitiso Majority occurs in the second week of hospitalizationo Maxillary sinuses are the most commono classic signs

o facial pain, malaise, fever, and purulent nasal dischargeo CT scan

o thickened mucosa and air-fluid level or opacification of the sinus

Managemento Remove Nasal tubes, decongestant, antibiotic therapy (S. aureus and

Pseudomonas spp.)o Surgical drainage

Parotitis• Obstruction or infection of the salivary ducts• Edema and focal tenderness the parotid gland, edema of the

floor of the mouth• Sepsis mediastinum and partial airway obstruction

• Management– High-dose, IV broad-spectrum antibiotics (Staphylococcus spp.)– Incision and drainage– Emergency tracheostomy

gastrointestinal complications

Documents

bowel movements

bowel proximal

dilated bowel

bowel distal

small bowel dilation

bowel sounds radiographs

hours presence of bowel

abdominal pressure greater