Transcript 3Lower GI Disease_Gentile

Bowel Obstruction
Lower GI Disease
Lori F Gentile
Bowel Obstruction
Lower GI Disease
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Diverticular disease
Bowel Obstruction
Appendicitis
Colon Cancer
Inflammatory Bowel Disease
Volvulus
Olgilvie’s Syndrome
Lower GI Bleed
Ischemic Bowel Disease
Bowel Obstruction
Obstruction
• LGI-distal to the Ligament of Trietz
• Ileus = obstruction 2/2 dysfunctional motility of bowel
• Mechanical obstruction = 85% SB, 15% large bowel
– Simple obstruction, closed loop obstruction, Strangulation
• Most Common Cause
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Pt with previous surgery
Small bowel – Adhesions
Large Bowel – Cancer
• Pt without previous surgery
Small bowel – Hernia
Large Bowel - Cancer
Bowel Obstruction
SBO: Etiology
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Adhesion
Hernia
Tumor
Abscess
Hematoma
Annular pancreas
SMA syndrome
Congenital lesions
Gallstone ileus
Intussusception
Foreign body (bezoars, worms, etc)
Meconium ileus
Malrotation
Bowel Obstruction
Colonic Obstruction: Etiology
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Cancer #1 (60%)
Volvulus (sigmoid > cecum)
Adhesions
Hernia
UC
Diverticulitis
Congenital lesions
Fecal impaction
Adynamic ileus
Hirschsprung’s
Meconium ileus
Foreign body
Bowel Obstruction
History & DDx
• Proximal obstruction: early bilious vomiting, +/- flatus/BM
• Distal obstruction: obstipation, distension, vomiting feculent material
(2/2 bacterial overgrowth of SB contents)
• Pain w/obstruction: begins as cramping pain, changes to continuous
severe pain w/strangulation & peritonitis
• Bowel Movements- Cabliber, Blood, Pain
• PMHx: remember to ask about cardiac history (arrhythmias, prior MI,
Afib - think about intestinal ischemia), IBD, gallstones, cancer
• PSHx: remember to ask about ostomy output
• Meds: narcotics (ileus), antipsychotics (ileus), diuretics (hypoK a/w
ileus)
• ROS: recent weight loss (CA)
Bowel Obstruction
PE
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Start with ABCs
Look for surgical scars
Bowel sounds
Distention-> tympany to percussion
Localized tenderness
Look for hernias/masses
Do a rectal exam
Bowel Obstruction
Labs
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WBC (nml in uncomplicated SBO)
CBC (anemia w/CA)
BMP (hypoK)
Alkalosis (a/w proximal obstruction)
Acidosis (a/w bowel infarction)
Lactic acid- may be indication of bowel
ischemia
Bowel Obstruction
Studies
• Upright CXR/KUB: look for free air
• Flat and upright/left lateral decubitus: look for
dilated bowel loops, air-fluid levels
• Note: if cecal diameter >12cm, there is a risk
of perforation. At 12-14cm, the wall tension >
perfusion pressure, increasing risk of
necrosis
• Barium enema
• UGI series w/SB follow-through
• CT scan- with PO/IV contrast
Bowel Obstruction
SBO: Management
• “Bowel Rest” - NPO, NGT, Foley, IVF-Cures >80%
SBOs
• Electrolyte replacement
• “Don’t let the sun set on a (complete) SBO” 
Complete bowel obstruction w/concern for
strangulation/perforation requires immediate operative
intervention (resuscitate first)
• Indications for Surgery -> Failure to resolve,
progressing pain, peritoneal signs, fever,
increasing WBCs
Bowel Obstruction
A 72-year-old woman presented with a 2-day history of abdominal pain associated with nausea
and vomiting
Dedouit F and Otal P. N Engl J Med 2008;358:1381
Bowel Obstruction
A 48-year-old healthy woman presented with anorexia of 2 days' duration and abdominal pain in
the right lower quadrant
Liu K and Lin B. N Engl J Med 2007;356:1152
Bowel Obstruction
Colon Cancer
• Asymptomatic – Screening Colonoscopy @ age 50
• Adenoma->TVA (50% harbor cancer)
– Sessile, high grade dysplasia increase cx risk
– Polypectomy for pathology, adequate for T1 if margins clear
• Symptoms – abdominal pain, anemia, constipation, bleeding,
weight loss
• Sigmoid colon-most common site of primary, constipation
• Right colon cancer – anemia, asymptomatic
• Work-up - staging
• CT C/A/P, CEA
• If rectal mass-> EUS
Bowel Obstruction
Case
• 76 year old man, mass in LLQ, gradual
growth, intermittent abdominal pain
– Last BM 3 days ago, Nausea, Vomiting
– Weight loss
– Gradually narrowing caliber stools
Bowel Obstruction
Case
• Imaging: air fluid
levels (obstruction)
• “Apple core” lesion in
colon
• Dx: colon CA
• Tx: NPO, NGT, lytes
– Staging/monitoring:
• Colonoscopy
• CEA
• Chest CT
– Neoadjuvant therapy,
Resection
– Diverting ostomy
http://allbleedingstops.blogspot.com
Bowel Obstruction
Diverticular Disease
• Herniation of mucosa through colon call at points where arteries enter,
increased intra-luminal pressure
• 80% Left side, sigmoid colon
– Diverticulitis – left
– Bleeding – right
Diverticulitis- infection/inflammation of colonic wall
• Sx- LLQ pain, tenderness, fevers, leukocytosis, emesis, diarrheah
• Work-up – CT scan
Hinchey Classification – Stage 1-4
Bowel Obstruction
Diverticular Disease
Treatment :
Uncomplicated – Bowel rest, Bactrim/Flagyl (PO or IV)
• Increase fiber in diet, stool softeners
• Consider elective surgery if second attack occurs (50% chance of
recurrence)
Complicated – obstruction, fluctuant mass, abscess, peritonitis,
fistula, sepsis, Hinchey 3,4
• Abscess-percutaneous drainage, abx
• Peritonitis – OR->Hartmann’s procedure
Needs colonoscopy in 6-8 weeks when sx resolve – r/o cancer,
other diseases
Bowel Obstruction
Case
• A previously healthy 45-year-old man presents with severe
lower abdominal pain on the left side, which started 36 hours
earlier. He has noticed mild, periodic discomfort in this region
before but has not sought medical treatment. He reports
nausea, anorexia, and vomiting associated with any oral intake.
On physical examination, his temperature is 38.5°C and his
heart rate is 110 beats per minute. He has abdominal
tenderness on the left side without peritoneal signs. CT scan
shows Hinchey 2 with 4 cm peri-rectal contained abscess. How
should his case be managed?
Bowel Obstruction
Case
• Complete H&P
• Admit – pt unable to hydrate himself
– NPO, IVFs, IV abx
• Percutaneous Drainage of Abscess
• As pt improves, ADAT, convert to PO abx
• Colonoscopy 6 weeks after discharge
• Surgery referral should pt have recurrent diverticulitis