Highlights of patient’s historyHighlights of patient’s history

• 53 year old man with longstanding diabetes mellitus

• One-week illness, characterized by:– Nausea, for 6 days– More nausea, vomiting, bloating, and crampy

lower abdominal pain for 1 day– No BM for 2 days pta and for hospital days 1-5

Highlights of his physical examHighlights of his physical exam

• Temp 98.5, Resp 24 (depth?), BP 157/82, Pulse 103; tilt test ?

• Oropharynx: slightly dry• Abdomen: slightly distended; mildly tender

in the “lower abdomen” (RLQ?, LLQ?, suprapubic region?); “quiet” bowel sounds– Quiet. adj. making very little sound

Describing bowel soundsDescribing bowel sounds

• Frequency– absent, present, increased (hyperactive)

• Intensity– normal, loud

• Quality– high-pitched, musical, tinkling– normal– rumbling, gurgling, rushes (borborygmi)

Physician accuracy: bowel soundsPhysician accuracy: bowel sounds [Gade et al. Scand J Gastro 33:773, 1998][Gade et al. Scand J Gastro 33:773, 1998]

• Bowel sounds recorded from 4 normals, 6 pts. with obstruction [SBO(4), LBO(2)], and 2 pts. with peritonitis (perforated viscus)

• Recorded sounds from these 12 people were amplified and transmitted through a dummy and listened to with a stethoscope by 100 physicians of different specialty and experience {normal vs. abnormal}

Physician accuracy: bowel soundsPhysician accuracy: bowel sounds Gade et al. Scand J Gastro 33:773, 1998Gade et al. Scand J Gastro 33:773, 1998

• NORMALS (n=400 ratings)– 25% were called abnormal [75% specificity]

• OBSTRUCTION (n=600 ratings)– 64% abnormal (69% for surgeons, 50% for GIs)

• PERITIONITIS (n=200 ratings)– 43% abnormal (50% for surgeons, 25% for GIs)

Conclusion: Our patient’s bowel sounds are certainly compatible with SBO, LBO, and peritonitis with ileus.

Highlights of laboratory testsHighlights of laboratory tests

• WBC 15.9, with 94% neutrophils• Glucose 430’s• Anion gap 14; bicarbonate 22• Urine + for glucose and ketones; no UTI• Lactate normal• LFTs, serum lipase/amylase normal• EKG, cardiac enzymes normal

Summary of clinical presentation Summary of clinical presentation (prior to his X-ray studies):(prior to his X-ray studies):

• Middle-aged diabetic man with nausea and vomiting, constipation, lower abdominal pain, tenderness, and distention

• Mild diabetic ketoacidosis

DIABETESDIABETES

GI SYMPTOMSGI SYMPTOMS

?

GI Symptoms in DiabeticsGI Symptoms in Diabetics

OUTPATIENTS*

Constipation 60%

Abdominal pain 34%

Nausea, vomiting 29%

Dysphagia 27%

Diarrhea 22%

Fecal incontinence 20%

None of the above 24%* Feldman and Schiller. Ann Int Med 1983

INPATIENTS, DKA “Abdominal pain, nausea and vomiting are common and may be caused by the

ketoacidosis, but assoc-iated disorders such as

pyelonephritis, pancrea-titis, or an acute abdomen

must always be suspected.”

Williams textbook. Unger and Foster. 1998

Hospital course: days 1-5Hospital course: days 1-5

• No BMs or flatus production

• Abdominal distention did not resolve and instead increased despite NG suction

• Diabetic ketoacidosis treated successfully with insulin, fluids and electrolytes

““ACUTE ABDOMEN”ACUTE ABDOMEN”

DKA in a previouslyDKA in a previouslystable diabetic patientstable diabetic patient

FILM REVIEW:ADMISSIONABDOMINAL FILMS AND OF ARTERIOGRAMS

Summary of radiological examsSummary of radiological exams

• Plain films: dilated loops of small bowel and right colon, compatible with LBO or ileus

• CT: same as above, with probabl”cut off” at the level of the transverse colon; “probable” filling defect in SMV; no abscesses or evidence of diverticulitis/ mass

• Visceral arteriogram: normal vessels; dila-ted bowel as above

Separating pseudo- Separating pseudo- obstruction from true obstructionobstruction from true obstruction

• Ileus of small bowel = intestinal pseudoobstruction [can mimic SBO]

• Ileus of colon = Ogilvie’s syndrome [can mimic LBO] and can affect the right side prodominately

• Ileus involving small and large intestine [can also mimic LBO]

Conditions that may Conditions that may pseudo-obstruction or ileuspseudo-obstruction or ileus

• Electrolyte disturbance, esp. hypokalemia– DKA can be a cause, but should improve with rx of DKA

• Medications that suppress GI transit, especially anti-cholinergics and opiates

• Neurological disease (CVA, Parkinson’s, dementia, CP), bedridden, institutionalized

• Severe intra-abdominal inflammatory and infectious diseases:– pancreatitis - bowel ischemia/infarction

– cholecystitis - bowel or GB perf., incl. perf. ulcer

– diverticulitis - appendicitis

– strangulated obstruction - peritonitis

Radiology workup of obstruction Radiology workup of obstruction vs. ileus in acutely ill inpatientsvs. ileus in acutely ill inpatients

• Plain films: is there disproportionate bowel distention with gas or with gas/fluid levels?

• CT with oral ± rectal contrast: is there a cut-off, transition point or site of blockage?

• Water-soluble contrast enema (e.g., diatrizoate meglumine [HyapaqueR, GastrografinR])*

* barium sulfate enema is relatively contraindicated

Typical SBOTypical SBO

Ileus involving Ileus involving small and large intestinesmall and large intestine

Hyapaque enema: complete sigmoid Hyapaque enema: complete sigmoid obstruction in patient with obstruction in patient with

diverticulitis and obstipationdiverticulitis and obstipation

Hyapaque enema: Hyapaque enema: complete obstruction to retrograde complete obstruction to retrograde

dye at the descending colon (Ca)dye at the descending colon (Ca)

Differential Diagnosis, Differential Diagnosis, in order of likelihoodin order of likelihood

• Intestinal Obstruction– MORE LIKELY, BASED ON HIS

DRAMATIC XRAY STUDIES and that THIS IS A CPC “INTESTINAL OBSTRUCTION”

• Ileus– LESS LIKELY, SINCE NO EVIDENCE FOR

AN UNDERLYING PRECIPITATOR

Intestinal Obstruction (SBO/LBO)Intestinal Obstruction (SBO/LBO)

• Common cause for admission to hospital (20% of acute admissions to surgical services are for SBO)

• SBO and LBO can be either partial or complete• Strangulation (ischemic infarction of the bowel) is

the most dreaded and lethal consequence• SBO and LBO have many causes, making a

specific diagnosis of the cause challenging• Ideal therapy is dictated by knowledge of the

cause, although this is often not known at the time of surgery

Clinical features of Clinical features of Intestinal ObstructionIntestinal Obstruction

• Crampy abdominal pain in waves (intestinal colic)• Nausea • Bilious or feculent vomiting• Abdominal distention• Constipation with decreased flatus production• High pitched (musical, tinkling) hyperactive bowel

sounds • Symptoms and signs of intravascular volume

depletion due to external losses, reduced oral intake, and 3rd space losses into the bowel wall and/or abdominal cavity

Common causes of SBO/LBOCommon causes of SBO/LBO

• Adhesions are most common cause of SBO, but are rare cause of LBO.• Hernia is a common cause of SBO, but rearely LBO.• Neoplasm is most common cause of LBO, and accounts for 10% of SBO.• Volvulus and diverticulitis are common causes of LBO, but rarely SBO.

(LBO)(SBO)

Miscellaneous causes of SBO/LBOMiscellaneous causes of SBO/LBOAtresia/stenosis/ bands

IBD (Crohn’s)

Radiation injury

Ischemic stricture

Endometriosis

Anastomotic stricture

Intussusception

Gallstones

Foreign body/bezoar

Meconium

Meckel’s diverticulum

Intra-abdominal abscess

[Children, young adults] S

[History of fever, diarrhea] S

[History of cancer/XRT] S,L

[Vascular disease] L,S

[Premenopausal female] S,L

[Prior anastomosis] S,L

[Children > adults] S>>L

[Biliary colic;pneumobilia] S

[Ingestion history] S

[Neonate, cystic fibrosis] S,L

[Male, young, recurrences] S

[Fever, chills, ? mass] S>L

Historical/demographic factors Historical/demographic factors which aid in assessing the which aid in assessing the etiology of SBO and LBOetiology of SBO and LBO

• Age and gender of the patient

• History of abdominal or pelvic surgery

• History of intra-abdominal disease

• History of recent abdominal surgery/trauma

• History of abdominal radiotherapy

• History of overt rectal bleeding/ weight loss

• History compatible with undiagnosed IBD

If obstruction, SBO or LBO?If obstruction, SBO or LBO?• Pain before nausea/vomiting is typical in SBO • History of prior surgery or abdominal trauma

would favor SBO over LBO• Bilious vomiting favors SBO; feculent vomiting

favors LBO • No mass on digital exam excludes distal rectal

cause of LBO, but not high rectal/colon obst’n• Right colon distention on radiographs favors LBO,

especially as there is a distinct cut-off • Periumbilical pain (SMA distribution ) favors

SBO, while suprapubic pain favors LBO

LBO (adults)LBO (adults)• Neoplasms (60%)

– Adenocarcinoma– Others

• Volvulus (20%)– sigmoid– cecal (SBO)– others are rare

• Diverticulitis with stricture (10%)– Sigmoid, descending colon– Cecal– Others are rare

• Miscellaneous causes (10%)

Annular adenocarcinoma of Annular adenocarcinoma of the colon, the “apple core”the colon, the “apple core”

Sigmoid diverticulitis can Sigmoid diverticulitis can mimic colon cancermimic colon cancer

BE: complete retrograde BE: complete retrograde obstruction at the obstruction at the

rectosigmoid junction due to rectosigmoid junction due to diverticulitisdiverticulitis

Distal small bowel obstruction Distal small bowel obstruction 2º to cecal volvulus2º to cecal volvulus

LBO from sigmoid volvulusLBO from sigmoid volvulus

Miscellaneous causes of SBO/LBOMiscellaneous causes of SBO/LBOAtresia/stenosis/ bands

IBD (Crohn’s)

Radiation injury

Ischemic stricture

Endometriosis

Anastomotic stricture

Intussusception

Gallstones

Foreign body/bezoar

Meconium

Meckel’s diverticulum

Intra-abdominal abscess

[Children, young adults] S

[History of fever, diarrhea] S

[History of cancer/XRT] S,L

[Vascular disease] L,S

[Premenopausal female] S,L

[Prior anastomosis] S,L

[Children > adults] S>>L

[Biliary colic;pneumobilia] S

[Ingestion history] S

[Neonate, cystic fibrosis] S,L

[Male, young, recurrences] S

[Fever, chills, ? mass] S>L

Final diagnosisFinal diagnosis

• Most likely: large bowel obstruction due to adenocarcinoma of the colon– “He has not seen a PCP in over 4 years and has

never had a colonoscopy.”

• Less likely:– Diverticular stricture (pro:mom;con:age/history)

– Another 1º colonic malignancy (e.g., lymphoma)

– Sigmoid or (less likely) or cecal volvulus

What was the What was the diagnostic procedure?diagnostic procedure?

• PREFERRED: Flexible sigmoidoscopy or colonoscopy following enema preparation

• ACCEPTABLE ALTERNATIVES: Diatrizoate meglumine (not barium) enema or CT with rectal contrast

• LESS ATTRACTIVE APPROACH

(at this point -may do later for therapy): Laparoscopy or exploratory laparotomy

Therapy of Intestinal ObstructionTherapy of Intestinal ObstructionMEDICAL

– NPO– fluid and electrolyte

support– NG decompression– analgesia p.r.n.– meds. for underlying

disease, if indicatede.g., steroids for Crohn’s

disease

– 48-72 hour trial with frequent bedside exams

SURGICAL– laparoscopy

– laparotomy

OPTIONS INCLUDE:• adhesiolysis

• resection/ anastomosis

• stricturoplasty

• removal of intraluminal obturation (FB, stone)

• bypass

• untwist volvlus/ “pexy”

• “open and close”