Friday, February 24, 2017

Bowel obstruction

emDocs - February 23, 2017 - Authors: Mancuso N and Sweeney M 
Edited by: Koyfman A and Long B
  • For the unstable patient with bowel obstruction early surgical consultation and laparotomy are crucial. Manage ABCs, administer resuscitative IV fluids, and place a nasogastric tube to decrease chance of aspiration and for pain control. Abdominal upright x-ray is not as sensitive as CT; if x-ray unremarkable and clinical concern still exists, obtain CT. CT first may be warranted.
  • Ultrasound is a viable newer alternative that appears to take place between X-ray and CT in sensitivity and specificity, is faster, but will be difficult to convince surgeons for now.
  • If peritonitic or septic, cover with antibiotics (institution-specific, not a lot of evidence).
  • Be wary of nonspecific findings in early presentations of bowel obstruction. Labwork directed to detect signs of ischemia (lactate, blood gas). Ongoing passage of stools or flatus does not rule out an obstruction.
  • Closed loop obstruction represents both a diagnostic challenge and a complication with high morbidity and mortality. These patients may present with very little distention but can be very ill. Look for C or U signs, whirl sign, or beak sign on CT.
  • For LBOs, most common cause is by far malignancy (~60%). Sigmoid volvulus shows up as the “coffee-bean” sign, more common in elderly and nursing home patients. Cecal volvulus points to the left upper quadrant and is typically seen in a younger patient (20-60 years old)."