What to Do if a Pt. Suspected of Small Bowel Obstruction Starts Passes Out

Continuing Education Activeness

A bowel obstacle can either be a mechanical or functional obstruction of the small or large intestines. Obstacle frequently causes intestinal pain, nausea, airsickness, constipation, obstipation, and distention. This activity explains the pathophysiology, classification, evaluation, and management in patients with bowel obstruction. It highlights the role of the interprofessional squad in treating and decreasing long term morbidity in patients with bowel obstacle.

Objectives:

• Describe the pathophysiology, epidemiology, and classification of bowel obstacle.

• Outline the evaluation in a patient with bowel obstacle.

• Explicate the conservative and surgical management strategies in patients with bowel obstruction.

• Explicate the importance of a cohesive, interprofessional team approach to caring for patients with bowel obstruction.

Admission free multiple pick questions on this topic.

Introduction

A bowel obstruction can either exist a mechanical or functional obstruction of the pocket-size or large intestines. The obstruction occurs when the lumen of the bowel becomes either partially or completely blocked. Obstacle frequently causes intestinal hurting, nausea, vomiting, constipation-to-obstipation, and distention. This, in turn, prevents the normal movement of digested products. Small bowel obstructions (SBOs) are more common than large bowel obstructions (LBOs) and are the virtually frequent indication for surgery on the small intestines. Bowel obstructions are classified as a partial, complete, or airtight loop. A airtight-loop obstruction refers to a type of obstruction in the small or big bowel in which at that place is complete obstruction distally and proximally in the given segment of the intestine.[1][two][3]

Etiology

In that location are many potential etiologies of small and large bowel obstructions that are classified as either extrinsic, intrinsic, or intraluminal. The most common cause of SBOs in industrialized nations is from extrinsic sources, with post-surgical adhesions beingness the nearly common. Significant adhesions tin cause kinking of the bowel leading to obstruction. Information technology is estimated that at least two-thirds of patients with previous intestinal surgery accept adhesions. Other common extrinsic sources include cancer, which causes compression of the small bowel leading to obstruction. Less common but still prevalent extrinsic causes are inguinal and umbilical hernias. Untreated or symptomatic hernias may eventually become kinked as the small bowel protrudes through the defect in the abdominal wall and becomes entrapped in the hernia sack. Hernias that are not identified or are not reducible may progress to obstruction of the bowel and are considered a surgical emergency with the strangulated or incarcerated bowel becoming ischemic over time. Other causes of SBO include intrinsic disease, which tin can create an insidious onset of bowel wall thickening. The bowel wall slowly becomes compromised, forming a stricture. Crohn disease is the about common cause of benign stricture seen in the adult population.  [4][five]

Intraluminal causes for SBOs are less mutual. This process occurs when at that place is an ingested strange trunk that causes impaction within the lumen of the bowel or navigates to the ileocecal valve and is unable to pass, forming a bulwark to the large intestine. However, it is noted that most strange bodies that pass through the pyloric sphincter will be able to laissez passer through the rest of the gastrointestinal tract. LBOs are less common and compromise but 10% to 15% of all abdominal obstructions. The well-nigh mutual cause of all LBOs is adenocarcinoma, followed by diverticulitis and volvulus. Colonic obstruction is most usually seen in the sigmoid colon.

Epidemiology

Pocket-sized and large bowel obstructions are similar in incidence in both males and females. The overriding gene affecting incidence and distribution depends on patient risk factors, including but not express to: prior abdominal surgery, colon or metastatic cancer, chronic intestinal inflammatory disease, existing abdominal wall and/or an inguinal hernia, previous irradiation, and foreign body ingestion. [half-dozen][7]

Pathophysiology

The normal physiology of the small intestine consists of the digestion of food and the assimilation of nutrients. The large bowel continues to help in digestion and is responsible for vitamin synthesis, water assimilation, and bilirubin breakdown. Any obstructive mechanism will hinder these physiologic components. Obstruction causes dilation of the bowel proximal to the transition point and collapses distally. A upshot of partial or complete blockage of digested products during obstruction is emesis. Frequent emesis tin can lead to fluid deficits and electrolyte abnormalities. Equally the condition is left untreated and worsens, a bowel wall edema forms, and 3rd-spacing begins. A serious and life-threatening complication of bowel obstacle is strangulation. Strangulation is more unremarkably seen in airtight-loop obstructions. If the strangulated bowel is not treated promptly, it eventually becomes ischemic, and tissue infarction occurs. Tissue infarction progresses to bowel necrosis, perforation, and sepsis/septic stupor.

History and Physical

Suspected bowel obstruction requires the practitioner to obtain a detailed medical history inquiring near significant risk factors related to bowel obstacle. Small and large bowel obstruction have many overlapping symptoms. However, quality, timing, and presentation differ. Commonly in SBO, abdominal pain is described as intermittent and colicky just improves with vomiting, while the pain associated with LBO is continuous. The vomiting in SBO tends to be more frequent, in larger volumes, and ailing, which is in contrast to vomiting during an LBO, which typically presents as intermittent and feculent when nowadays. Tenderness to palpation is present in both conditions, but with SBO, it is more focal, and with LBO, it is more diffuse.

Additionally, distention is marked in LBO with obstipation more commonly present. It is important to note that in certain situations, an LBO will mimic an SBO if the ileocecal valve is incompetent. An incompetent ileocecal valve tin can allow for the insufflation of air from the large bowel into the small bowel producing symptoms of an SBO.

Evaluation

Although bowel obstruction alone can be suspected with an accurate patient history and presentation, the electric current standard of care to confirm the diagnosis in small and large bowel obstruction is an abdominal CT with oral contrast. CT allows for visualization of the transition point, the severity of obstruction, potential etiology, and cess of any life-threatening complications. This information enables the provider to be more effective in identifying patients who volition require surgical intervention.  Laboratory evaluation is essential to evaluate for whatever leukocytosis, electrolyte derangements that may be present as a effect of the emesis. Labs also evaluate for elevated lactic acrid that may be suggestive of sepsis or perforation, which at times may not be visible on CT if information technology is a microperforation and early in the course, blood cultures, or other signs of sepsis/septic shock. Although the lactic acid is often looked to in order to make up one's mind if there is a sign of perforation or ischemic gut, it should be noted this can be normal even with a microperforation nowadays, initially. Physical examination of the patient remains an essential diagnostic tool regarding the patient's severity and the need for emergent surgery vs. medical management.[8]

Treatment / Direction

Initial management should always include an assessment of the patient'south airway, breathing, and circulation. If resuscitation is required, information technology should exist performed with isotonic saline and electrolyte replacement. A Foley catheter should be inserted to monitor the patient's urine output if the patient is unstable or septic. Nasogastric tube insertion volition let for bowel decompression to relieve distention proximal to the obstruction. Nasogastric tube insertion will as well assistance control emesis, permit for accurate cess of intake and output, and lower the risk of aspiration.

Management ultimately depends on the etiology and severity of the obstacle. Stable patients with fractional or low-form obstruction resolve with nasogastric tube decompression and supportive measures. Patients who present with reducible hernias volition require not-emergent surgical intervention to prevent futurity recurrence. Non-reducible or strangulated hernias require emergency surgical intervention. Consummate or high-grade obstructions often require urgent or emergent surgical intervention as the risk of ischemia increases. Chronic disease states such as Crohn affliction and malignancy crave initial supportive measures and longer periods of nonoperative management. Treatment will ultimately depend on the patient'south disposition and surgeon's acumen.

Differential Diagnosis

• Abdominal hernias

• Abdominal pain in elderly people

• Appendicitis

• Chronic megacolon

• Colonic polyps

• Diverticulitis

• Diverticulitis empiric therapy

• Pseudomembranous colitis surgery

• Small bowel obstacle

• Toxic megacolon

Prognosis

When bowel obstacle is managed promptly, the outcome is skilful. In general, when bowel obstruction is managed not surgically the recurrence charge per unit is much college than those treated surgically.

Complications

• Intraabdominal abscess

• Sepsis

• Disability

• Wound dehiscence

• Aspiration

• Short bowel syndrome

• Pneumonia

• Bowel perforation

• Respiratory failure

• Anastomotic leak

• Renal failure

• Death

Postoperative and Rehabilitation Intendance

The postoperative recovery, in most cases of bowel obstruction, is tiresome. These patients demand prophylaxis confronting deep venous thrombosis and prevention of atelectasis. Ambulation is necessary. Time to feeding can vary depending on the ileus.

Consultations

• Full general surgeon

• Radiologist for drainage of whatever abscess

• Stoma nurse

• Communicable diseases

Pearls and Other Issues

Virtually bowel obstructions will require infirmary access and surgical consultation. Prompt recognition and diagnosis are critical in improving morbidity and mortality. The most of import footstep in the initial direction of bowel obstruction is identifying the type, severity, and cause. Understanding the difference betwixt emergent and non-emergent surgical intervention is essential in improving outcomes and preventing sequelae of complications, including bowel necrosis, perforation, and sepsis. Disposition ultimately depends on the type and etiology of the obstacle, as well every bit the patient's past medical history, current health status, and risk factors.

Enhancing Healthcare Squad Outcomes

The key to preventing the loftier mortality following a bowel obstruction is the early diagnosis, resuscitation, and operative intervention. An interprofessional squad is vital to ensure that the patient receives prompt attending. The triage nurse must be fully aware of the signs of bowel obstruction and expedite the admission. The emergency doc, nurse practitioner, or doc assistant must examine the patient and get the appropriate radiological test. The surgeon must be consulted even if no intervention is planned. While awaiting surgery, the bowel may need to be decompressed with a nasogastric tube, and the nurse is essential for monitoring of vital signs and worsening of the obstruction. Communication between healthcare workers is critical. [9][4] [Level Five]

Outcomes

The morbidity and mortality of bowel obstacle are dependent on early diagnosis and management. If whatsoever strangulated bowel is left untreated, there is a mortality charge per unit of close to 100%. Nevertheless, if surgery is undertaken within 24-48 hours, the mortality rates are less than 10%. Factors that make up one's mind the morbidity include the age of patient, comorbidity, and filibuster in treatment. Today, the overall bloodshed of bowel obstacle is however well-nigh five%-8%.[three][x] [Level 3]

Review Questions

Figure

Ultrasound of a small bowel obstacle with dilated bowel, thick bowel wall, adjacent intra-peritoneal fluid, and back and forth peristalsis. Contributed by Michael Schick Practice, MA

Effigy

Effigy five: Coronal CT belly reveals cecal volvulus. Unremarkably a patient with a cecal volvulus will present with small and large bowel obstructions, with collapse of the distal large bowel, and with extensive dilation of the proximal small bowel. Contributed (more...)

Figure

Sigmoid vulvulus. Contributed by Sunil Munakomi, MD

Figure

adhesive abdominal obstruction. Contributed by Sunil Munakomi, Doc

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Source: https://www.ncbi.nlm.nih.gov/books/NBK441975/

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