Tehran Medical SchoolSina HospitalMahmoud Najafi

GOO, SBO, LBO

Gastric outlet obstructionEtiologyo Benigno Malignant

GOO

PUDGastric polypsIngestion of

causticsPancratitisGastric TBGastric vulvulusGastric Bezoars

pyloric stenosisBouveret

syndromeCrohn's disease congenital

duodenal webs

Benign causes of GOO

Pancreatic cancerDistal gastric cancer Ampullary cancerDuodenal cancerCholangiocarcinomasMetastases

Malignant causes of GOO

Nausea and VomitingAnorexiaEarly satietyBloating or Epigastric fullnessIndigestionEpigastric painWeight loss

Clinical Presentation

Tympanitic mass in the epigastric area

Volume depletion

Clinical Presentation

GastroparesisIntestinal obstruction

Differential diagnosis 

Clinical featuresPhysical examinationLaboratory tests Radiologic testsEndoscopy

Diagnosis

Electrolyte abnormalitiesHypokalemic hypochloremic

metabolic alkalosisAnemiaElevated serum gastrin levels Serum tumor markers

Laboratory findings 

Plain AXRContrast studies CT scan 

Radiologic tests

Chronic pancreatitis: calcifications in the pancreas (X-ray of abdomen)

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.

Barium meal studies were suggestive of deformed and spastic duodenum

Gastric outlet obstruction caused by Crohn's disease. There is tapered narrowing of the distal antrum due to Crohn's disease involving the stomach.

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.

Abdominal CT in a patient with gastric outlet obstruction due to peptic ulcer disease showing a distended and fluid filled stomach

Endoscopy

Medical TherapyoHydrationocorrection of electrolyte

abnormalitiesoNG tubeoParenteral PPI

• Surgical Therapy

Treatment

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)

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

Most Common Causeso Intra-abdominal adhesions (75%)

• Less prevalent etiologiesoherniasoCrohn's diseaseoCanceroCongenital abnormalities

Etiologies

Accumulation of gas and fluidIncreases of intestinal activityocolicky pain

Distendion of bowelRises of intraluminal and intramural pressures

Pathophysiology

Simple obstructionopartialoComplete

Strangulated obstructionClosed loop obstruction (e.g., with

volvulus)

Kinds of SBO

Symptomso colicky abdominal paino Nauseao vomitingo Obstipation

• Signsoabdominal distentionoBowel sounds may be hyperactive

Clinical Presentation

Reflect intravascular volume depletion

Consist of hemoconcentration and electrolyte abnormalities

Mild leukocytosis

Laboratory findings

TachycardiaLocalized abdominal tendernessFeverMarked leukocytosisAcidosisPositive stool blood test

Features of strangulated obstruction

Distinguish mechanical obstruction from ileus

Determine the etiology of the obstruction

Discriminate partial from complete obstruction

Discriminate simple from strangulating obstruction

Diagnosis

functional obstructionSame symptoms and signsPostoperative ileusmotility returning to normal after laparotomyo small intestinal 24 hoursoGastric 48 hours o colonic 3 to 5 days

Ileus

Historyo prior abdominal operationso presence of abdominal disorders

Examinationo search for hernias

Diagnosis

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

80 to 90% sensitive 70 to 90% specificdiscrete transition zoneo dilation of bowel proximallyo decompression of bowel distally

Computed tomography (CT)

Fluid resuscitationMonitor urine outputBroad-spectrum antibioticsNG tubeExpeditious surgery

Therapy

NG decompression & fluid resuscitation

Partial small bowel obstructionObstruction occurring in the early postoperative period

Intestinal obstruction due to Crohn's disease

Carcinomatosis

Conservative Therapy

Perioperative mortality:For Nonstrangulating Less than

5%For strangulating 8 to 25%

Prognoses

20% all mechanical intestinal obstruction

The etiology of LBO is age dependent

LBO (Large-bowel obstruction)

colon cancer 60% DiverticulitisVolvulus

CecalSigmoid

Etiologies

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

Recurent LLQ pain over yearso Diverticulitis

Abrupt onset of symptomso Vulvulus

History

Colonic distentionAbdominal painAnorexiaFeculent vomitingDehydration Electrolyte disturbances

Pathophysiology

Symptomso colicky abdominal paino Nauseao vomitingo Obstipation

Clinical Presentation

SBOo More severeo Shorter intervalo Shorter duration

LBOo Less severeo Longer intervalo Longer duration

Colicky Abdominal Pain

GOOo Food particles

SBOo Billous

LBOo Fecaloid

Vomiting

SBOo Less Distention

LBOo More Distension

Abdominal Distension

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)

by diminished or, in later stages, absent bowel sounds

The abdomen is distendedThe abdomen may be tender

Ph/Ex

Reflect intravascular volume depletion

Consist of hemoconcentration and electrolyte abnormalities

Mild leukocytosis

Laboratory findings

AXRdemonstrates dilation of the small

and/or large bowel air fluid levels

barium enema CT scan

Imaging Studies

Large-bowel obstruction. Gastrografin study in a patient with obstipation reveals colonic obstruction at the rectosigmoid level.

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.

MedicalSurgical

Therapy