Professional Documents
Culture Documents
Robert R. Zaid
November 30th, 2005
Genesys Regional Medical Center
Etiology
Age dependent
Serosa can expand to only a variable but limited diameter
Rupture and fecal soilage of the peritoneal cavity can occur
Pathophysiology:
Caused by anatomic abnormality
Leads to
Colonic distention
Abdominal pain
Anorexia
Sigmoid volvulus
Usually occurs in older individuals
History of straining at stool
Cecal volvulus
Features a congenital defect in the
peritoneum
Inadequate fixation of the cecum
It generally occurs in much younger
individuals
Venous drainage and arterial inflow are
compromised by a closed loop obstruction
As the colon twists on its mesentery
In neonates
Colonic obstruction may be caused by
An imperforate anus
or other anatomic abnormalities
May be secondary to meconium ileus
In pediatrics
Hirschsprung disease resembles colonic obstruction
Complete obstruction
Characterized by
Failure to pass either stools or flatus
Presence of an empty rectal vault upon rectal examination
Partial obstruction
Patient appears obstipated but continues to pass some gas or stools
Less urgent condition.
Ileus
Distinguishing colonic ileus from organic obstruction is important
Ileus may be suggested by
Abdominal pain as a dominant feature of the clinical presentation
Peritoneal signs
Fever and leukocytosis.
Constipation also may be accompanied by some degree of fever or
leukocytosis
Fistulization
Sigmoid colon to the bladder
Pneumaturia
Mucinuria
Fecaluria
Abdominal examination
Standard
Inspection
Auscultation
Percussion
Palpation
Bowel sounds
Diminished or
Absent bowel sounds.
Late stages
Quality of abdomen
Distended
May be tender.
Hard stools
Suggests impaction.
Soft stools
Suggest obstipation.
Empty vault
Suggests obstruction
Proximal to the level that the examining finger can reach
Diverticulitis
Muscular hypertrophy of the colonic wall
Repetitive episodes of inflammation
Lumen becomes narrow as the colonic wall becomes fibrotic and
thickened
Intussusception
Commonly involves a tumor
Volvulus
Incarcerated hernia
Ogilvie syndrome
Symptoms and definition
May occur in elderly individuals who abuse cathartics or have
diabetes
Loss of peristalsis.
No obstruction is evident
Colon becomes significantly and dangerously dilated.
Constipation
Diverticulitis
Intestinal Perforation
Intestinal Pseudo-obstruction:
Surgical Perspective
Megacolon, Chronic
Megacolon, Toxic
Mesenteric Artery Ischemia
Pseudomembranous Colitis
Pseudomembranous Colitis
Rectal Cancer
Imaging Studies:
Upright chest radiograph
Will demonstrate free air of perforated
CT
Gastrografin
An enema with water-soluble contrast
Procedures:
Nasogastric tube
If the patient has been vomiting
Leukocytosis
Mild leukocytosis may be seen with obstruction or constipation
Severe leukocytosis should prompt reconsideration of the diagnosis
Ileus, secondary to an intra-abdominal or extra-abdominal infection or another process, is
a possibility.
Demonstrates dilation of
the small and/or large
bowel and air fluid levels
Sigmoid volvulus
Radiopaque contrast
Imaging of the colon may be performed under the following circumstances.
Perform it if the diagnosis of large bowel obstruction is suspected but not proven.
If differentiation between obstipation and obstruction is required, imaging with contrast is indicated.
If localization is required for surgical intervention, imaging with contrast is indicated.
Barium enema
If large bowel perforation is ruled out using a Gastrografin study and
More detailed anatomic definition is required (particularly of the right colon)
CT scanning
Generally is not used initially in patients with large bowel obstruction unless a diagnosis has been made
CT scan, particularly with rectal contrast, may demonstrate a mass or evidence of metastatic disease.
Generally, the findings do not alter management because these patients will be explored and operatively decompressed,
regardless of the CT scan findings.
Rigid sigmoidoscope
May be used if a flexible instrument is not available
Adults
Success is far less likely, and patients still require surgery to
deal with their pathology.
Cleansing enemas
Used if obstipation is suspected rather than true large bowel
obstruction
Also perform them to prepare the distal colon for endoscopic
evaluation.
Medical Care:
Resuscitation
Correction of fluid and electrolyte imbalance
Nasogastric decompression
Treat temporarily
Obstruction and prevent vomiting and aspiration
Youth
Some surgeons would consider primary anastomosis, rather than ileostomy, in the right colon, assuming no
intraoperative hypotension, blood loss, or other complications are present.
Diet
Complete obstruction NPO
Partial obstruction Clear liquids
Specific cases
Sigmoid volvulus
First choice is sigmoidoscopy with volvulus reduction.
Second choice is sigmoid colectomy.
Cecal volvulus
First choice is hemicolectomy.
Second choice is colonoscopy.
Chemotherapy?
Temporary or permanent colostomy?
Complications:
Perforation
Sepsis
Intra-abdominal abscess
Death
Prognosis:
If treated early, outcome is generally good.
If secondary to carcinoma
Outcome is dependent on the carcinoma prognosis
References
www.emedicine.com
Any questions?