Highlights of patient’s history

1
Highlights of patients 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

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Highlights 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

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Describing bowel sounds

• Frequency
• absent, present, increased (hyperactive)
• Intensity
• normal, loud
• Quality
• high-pitched, musical, tinkling
• normal
• rumbling, gurgling, rushes (borborygmi)

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Physician accuracy bowel sounds Gade et al.
Scand J Gastro 33773, 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

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Physician accuracy bowel sounds Gade et al.
Scand J Gastro 33773, 1998

• NORMALS (n400 ratings)
• 25 were called abnormal 75 specificity
• OBSTRUCTION (n600 ratings)
• 64 abnormal (69 for surgeons, 50 for GIs)
• PERITIONITIS (n200 ratings)
• 43 abnormal (50 for surgeons, 25 for GIs)

Conclusion Our patients bowel sounds are
certainly compatible with SBO, LBO, and
peritonitis with ileus.
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Highlights of laboratory tests

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

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

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

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DIABETES
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GI SYMPTOMS
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GI 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
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Hospital 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

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ACUTE ABDOMEN
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DKA in a previously stable diabetic patient
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FILM REVIEW ADMISSION ABDOMINAL FILMS AND OF
ARTERIOGRAMS
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Summary of radiological exams

• Plain films dilated loops of small bowel and
  right colon, compatible with LBO or ileus
• CT same as above, with probablcut 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

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Separating pseudo- obstruction from true
obstruction

• Ileus of small bowel intestinal
  pseudoobstruction can mimic SBO
• Ileus of colon Ogilvies syndrome can mimic
  LBO and can affect the right side prodominately
• Ileus involving small and large intestine can
  also mimic LBO ??

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Conditions that may ? pseudo-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, Parkinsons, 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

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Radiology workup of obstruction vs. 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
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Typical SBO
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Ileus involving small and large intestine
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Hyapaque enema complete sigmoid obstruction in
patient with diverticulitis and obstipation
20
Hyapaque enema complete obstruction to
retrograde dye at the descending colon (Ca)
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Differential Diagnosis, in 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

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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

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Clinical features of Intestinal 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

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Common causes of SBO/LBO
(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.

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Miscellaneous causes of SBO/LBO

• Atresia/stenosis/ bands
• IBD (Crohns)
• Radiation injury
• Ischemic stricture
• Endometriosis
• Anastomotic stricture
• Intussusception
• Gallstones
• Foreign body/bezoar
• Meconium
• Meckels 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 gt adults SgtgtL
• Biliary colicpneumobilia S
• Ingestion history S
• Neonate, cystic fibrosis S,L
• Male, young, recurrences S
• Fever, chills, ? mass SgtL

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Historical/demographic factors which aid in
assessing the etiology 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

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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 obstn
• 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 ??

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(No Transcript)
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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)

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Annular adenocarcinoma of the colon, the apple
core
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Sigmoid diverticulitis can mimic colon cancer
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BE complete retrograde obstruction at the
rectosigmoid junction due to diverticulitis
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Distal small bowel obstruction 2º to cecal
volvulus
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LBO from sigmoid volvulus
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Miscellaneous causes of SBO/LBO

• Atresia/stenosis/ bands
• IBD (Crohns)
• Radiation injury
• Ischemic stricture
• Endometriosis
• Anastomotic stricture
• Intussusception
• Gallstones
• Foreign body/bezoar
• Meconium
• Meckels 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 gt adults SgtgtL
• Biliary colicpneumobilia S
• Ingestion history S
• Neonate, cystic fibrosis S,L
• Male, young, recurrences S
• Fever, chills, ? mass SgtL

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Final 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 (promomconage/history)
• Another 1º colonic malignancy (e.g., lymphoma)
• Sigmoid or (less likely) or cecal volvulus

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What was the 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

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Therapy of Intestinal Obstruction

• MEDICAL
• NPO
• fluid and electrolyte support
• NG decompression
• analgesia p.r.n.
• meds. for underlying disease, if indicated
• e.g., steroids for Crohns 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

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