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Obstruction
Epidemiology
Cardinal signs:
Colicky abdominal pain
Abdominal distension
Emesis (feculent if with bacterial overgrowth)
Obstipation
Distal obstruction: more distension and discomfort,
delayed emesis
More proximal obstruction: less distension, more vomiting
Important in history: prior surgery, cancer, IBD
History and PE
Most appear critically ill
Severe intravascular depletion oliguria, hypotension,
tachycardia
Strangulation or systemic inflammation fever
History and PE
Bowel sounds are difficult to interpret
early SB obstruction: high-pitched, musical, tinkling bowel sounds
and perisltaltic rushes (borborygmi) Late SB obstruction:
absent or hypoactive
Ileus: absent/hypoactive from beginning
Partial blockage: continues to pass flatus/stool
Complete blockage: evacuates contents of bowel downstream
beyond obstruction
History and PE
Examine all surgical incisions
Tender abdominal/groin mass highly suggestive of
incarcerated hernia causing obstruction
Tenderness ischemia, necrosis, peritonitis
Localized severe pain/peritoneal irritation strangulated
or closed-loop obstruction
Discomfort may be out of proportion to PE (mimics acute
mesenteric ischemia)
History and PE
Colonic volvulus
Severe abdominal pain
Vomiting obstipation
Asymmetric abdominal distension
Tympanic mass
Ileus or pseudo-obstruction
Similar to SBO
Abdominal distension
Pain typically absent
May not have nausea or emesis
Regular discharge of stool/latus help distinguish from CGO
Labs and Imaging
Complete blood count
Mild hemoconcentration
Slight WBC elevation
Serum electrolytes and Creatinine
Hypokalemia, hypochloremia, hyponatremia, elevated BUN-Crea
ratio, metabolic alkalosis
Guaiac positive stool and IDA strongly suggestive of
malignancy
Higher WBC and metabolic acidosis possible severe
volume depletion, ischemic necrosis, sepsis
Labs and Imaging
Do not delay surgical consult and operative intervention
if strongly suggest high grade or complete obstruction of
bowel compromise
Abdominal xray
Must include upright or cross-table lateral views
Quick to complete
Labs and Imaging
Abdominal x-ray
Small bowel obstruction
staircasing pattern
Dilated air and fluid-filled SB
loops
>2.5 cm diameter
Little/no air in colon
Labs and Imaging
Abdominal x-ray
Large bowel obstruction
Colon dilation
Labs and Imaging
Abdominal x-ray
Perforation
free air
Labs and Imaging
Abdominal x-ray
Volvulus
gas-filled, coffee bean-shaped
dilated shadow
Labs and Imaging
Computed tomography
May be time-consuming and expensive
Beneficial in unclear diagnosis
95% sensitivity and 96% specificity for high-grade obstruction
Lower accuracy for closed-loop obstruction (60%)
Contrast appearing in cecum within 4-24h of oral water-soluble contrast
expected to improve (95% sens and spec)
Ultrasound
Difficult to interpret
Appropriate for pregnant patients/xray exposure contraindicated
Barium studies
Contraindicated in complete/high-grade bowel obstruction
NEVER give barium orally in patient with possible obstruction
Treatment
Pelvic appendicitis:
Dysuria
Urinary frequency
Diarrhea
Tenesmus
Pain may only be present on palpation of suprapubic region or
rectal/pelvic examination
Rectocecal appendix/below pelvic brim: little tenderness in
anterior abdomen
Simple appendicitis: Mildly ill
Acute Appendicitis: PE
Examine WHOLE abdomen
Classical tenderness found at McBurney’s point
One-third along line from anterior iliac spine to umbilicus
Acute Appendicitis: PE
Rovsing’s sign: gentle pressure in LLQ elicits pain in RLQ
Acute Appendicitis: PE
Obturator sign: pain with hip internal rotation (pelvic
appendicitis)
Iliopsoas sign: pain along posterolateral back and hip with
R hup extension (retrocecal appendicitis)
Acute Appendicitis: PE
ALL patients must undergo rectal examination
Pelvic examination mandatory in women (rule out
urogynecologic etiology: PID, ectopic pregnancy, ovarian
torsion)
Acute Appendicitis: Laboratory Testing
Plain films
not routine
r/o intestinal obstruction, perforated viscus, ureterolithiasis
Ultrasound
operator-dependent (86% sensitivity, 81% specificity)
Findings: wall thickening, increased appendiceal diameter,
free fluid
Current practice: used as first-line imaging (use others if
findings are equivocal)
Acute Appendicitis: Imaging
CT scan
94% sensitivity, 95% specificity
Useful if diagnosis is doubtful
Helps assess severity of appendicitis in the absence of
peritoneal findings
Suggestive: dilatation >6mm with wall thickening, lumen
not filled with enteric contrast, fatty tissue stranding, air
surrounding appendix
Appendicitis: Treatment
Laparoscopic appendectomy
Accounts for majority of procedures in Western world
Useful in uncertain diagnosis, obese patients
Less post-operative pain
Shorter length of stay
Faster return to normal activity
Fewer superficial wound complications
Higher risk of intraabdominal abscess formation
Common complications: fever, leukocytosis (>5 days:
consider intraabdominal abscess)
Appendicitis: Treatment
Aseptic peritonitis
Abnormal presence of physiologic fluids (gastric juice, bile,
pancreatic enzymes, blood, urine) or sterile foreign bodies
(surgical sponges, instruments)
Complication of SLE, porphyria, familial Mediterranean fever
Acute Peritonitis: Clinical Features
Cardinal signs and symptoms
Acute, severe abdominal pain
Tenderness
Fever
Less response in elderly and immunosuppressed patients
Generalized peritonitis
Diffuse abdominal tenderness
Local guarding
Rigidity
Acute Peritonitis: Clinical Features
Localized presentation in specific region of abdomen if
intraperitoneal inflammatory process is limited or
contained
Bowel sounds absent to hypoactive
Signs of volume depletion: tachycardia, hypotension
Acute Peritonitis: Labs
Significant leukocytosis
Severe acidosis
Radiographs
Dilation of bowel and associated bowel wall edema
Free air: possible surgical emergency
Diagnostic paracentesis in stable patients with ascites
Test for protein, LDH, cell count
Acute Peritonitis: Therapy and Prognosis
Treatment:
Correct electrolyte abnormalities
Restore fluid volume and stabilization of cardiovascular system
Appropriate antibiotic therapy
Surgical correction of underlying abnormalities
Mortality rate:
Uncomplicated localized peritonitis in reasonably healthy patients:
<10%
Elderly/immunocompromised: >40%