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small bowel obstruction

Sigmoid Volvulus

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Gallstone

Appendicitis

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ادامه مطلب

شنبه بیست و دوم فروردین ۱۳۹۴ |

 

small bowel obstruction

·         General considerations

o       Small bowel obstruction, as the term is used here, is due to physical and organic changes which produce mechanical obstruction to the passage of the bowel contents somewhere in the small bowel

o       The bowel proximal to the point of obstruction dilates with swallowed air and secreted fluid,

§         Vomiting may release some of the proximal bowel contents and reduce the amount of proximal dilation

o       The bowel hyperperistalses

o       Bowel distal to the point of obstruction (i.e. colon and sometimes distal small bowel) empties over time

o       Strangulation of the bowel may result from vascular compromise of the affected loops and is a cause of increased mortality

·         Causes

o       Overwhelmingly, the most common cause of a mechanical small bowel obstruction are adhesions related to prior surgery (60%)

§         The most common prior surgeries associated with a subsequent SBO include appendectomy, colorectal surgery and gynecologic surgery

§         Bowel may become kinked under an adhesion

§         The obstruction is frequently partial or intermittent

o       Hernias

§         Most often femoral or inguinal

o       Intussusception

o       Volvulus

o       Tumor, either primary or metastatic

o       Wall lesions such as leiomyomas or strictures

o       Crohn’s disease

o       Foreign bodies

o       Gallstones

§         Such as in gallstone ileus (which is actually a mechanical obstruction, usually at the ileocecal valve)

·         Clinical findings

o       Abdominal pain and distension

§         Most marked in patients with distal SBO although its onset in distal obstructions is later in the course of the disease than in proximal obstruction

§         Typically colicky in nature and progressively worsening over time

o       Nausea

o       Vomiting

§         An earlier sign of a proximal than a distal obstruction

§         Fluid and electrolyte imbalances from vomiting increase mortality

o       Constipation

o       History of prior abdominal or pelvic surgery

o       Bowel sounds are hyperactive and high-pitched

§         Absence of bowel sounds may indicate bowel ischemia or peritonitis

·         Imaging findings

o       Conventional radiography is the study of first choice

§         Loops proximal to the point of obstruction will become dilated and fluid-filled

·         Usually greater than 2.5-3 cm in size

§         Differential height of air-fluid levels in the same loop of small bowel no longer considered reliable sign of mechanical SBO

§         Absence of, or disproportionately smaller amount of, gas in the colon, especially the rectosigmoid

§         Loops of small bowel may arrange themselves in a step-ladder configuration from the left upper to the right lower quadrant in a distal SBO

§         Mostly fluid-filled loops of bowel may demonstrate a string-of-beads sign caused by the small  amount of visible air in those loops

 



Small Bowel Obstruction. Supine view of the abdomen (left) shows several dilated loops of small bowel
in the upper abdomen. The small bowel is disproportionately dilated compared the the large bowel
which is collapsed. The upright view (right) demonstrates multiple air-fluid levels in the dilated loops
in a typical configuration of a small bowel obstruction. The patient had previous bowel surgery.

 



ادامه مطلب

چهارشنبه بیست و پنجم دی ۱۳۹۲ |

 

Sigmoid Volvulus


General Considerations

  • Twisting of loop of intestine around its mesenteric attachment site may occur at various sites in the GI tract
    • Most commonly: sigmoid & cecum
    • Rarely: stomach, small intestine, transverse colon
    • Results in partial or complete obstruction
    • May also compromise bowel circulation resulting in ischemia
  • Sigmoid volvulus most common form of GI tract volvulus
    • Accounts for up to 8% of all intestinal obstructions
  • Most common in elderly persons (often neurologically impaired)
  • Patients almost always have a history of chronic constipation

Pathophysiology

  • Redundant sigmoid colon that has a narrow mesenteric attachment to posterior abdominal wall allows close approximation of 2 limbs of sigmoid colon à twisting of sigmoid colon around mesenteric axis
  • Other predisposing factors
    • Chronic constipation
    • High-roughage diet (may cause a long, redundant sigmoid colon)
    • Roundworm infestation
    • Megacolon (often due to Chagas dz)
  • 20-25% mortality rate
  • Peak age > 50 yrs.
    • Second largest group à children
  • Torsion usually counterclockwise ranging from 180 – 540 degrees
  • Luminal obstruction generally @ 180 degrees
  • Venous occlusion generally @ 360 degrees à gangrene & perforation
  • Signs and symptoms
    • May present as abdominal emergency
      • Acute distension
      • Colicky pain (often LLQ)
      • Failure to pass flatus or stool (constipation is prevailing feature)
      • Vomiting is late sign
    • Distention may compromise respiratory & cardiac function
    • May also present with surprisingly few signs and symptoms in bedridden and debilitated
  • Physical examination
    • Tympanitic abdomen
    • Abdominal distention
    • +/- palpable mass

Diagnosis

  • Abdominal plain films usually diagnostic
    • Inverted U-shaped appearance of distended sigmoid loop
      • Largest  and most dilated loops of bowel are seen with volvulus
    • Loss of haustra
    • Coffee-bean sign à midline crease corresponding to mesenteric root in a greatly distended sigmoid
    • Bird’s-beak or bird-of-prey sign à seen on barium enema as it encounters the volvulated loop
  • CT scan useful in assessing mural wall ischemia

Differential Diagnosis

  • Large bowel obstruction due to other causes à sigmoid colon CA
  • Giant sigmoid diverticulum
  • Pseudo-obstruction
  • Colonic ischemia
  • Perforation
  • Sepsis

Treatment

  • Laparoscopic de-rotation or laparotomy +/- bowel resection
  • De-rotation & decompression by barium enema or with rectal tube, colonoscope, or sigmoidoscope if no signs of bowel ischemia or perforation
  • Cecopexy à suture fixation of bowel to parietal peritoneum may prevent recurrence
  • Recurrence rate after decompression alone à 50%

Sigmoid volvulus


Sigmoid Volvulus.
Dilated loop of sigmoid colon has a "coffee-bean" shape and
the wall between the two volvulated loops of sigmoid (black arrow) "points" towards the right upper quadrant.
There is a considerable amount of stool in the colon from chronic constipation.

جمعه بیستم دی ۱۳۹۲ |

 

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