large bowel obstruction

Large Bowel Obstruction::

Large Bowel Obstruction: Dynamic/adynamic Simple/Closed loop/Strangulated Chronic/Acute on Chronic/Acute Intraluminal/Wall/Extra luminal

Mechanical( Dynamic) BO Causes:

Mechanical( Dynamic) BO Causes Intraluminal Faeces Wall Stricture Benign: Diverticular TB/Crohn’s Malignant: Extra luminal Volvulus Intussusception

Symptoms:

Symptoms Distention Constipation: Faeces/flatus Abdominal pain Vomiting (late)

Clinical Findings:

Clinical Findings General Hydration Anaemia Local Inspect: Distension/Scars/Hernia Palpate: Mass/Tenderness Percuss Auscultate: BS PR

Investigations:

Investigations Haemotological : FBC/PCV Biochemical : Urea/Electrolytes, amylase Radiological Xray chest Xray abdomen: supine and erect US abdomen CT scan Water Soluble Contrast Enema Special Colonoscopy

X-ray abdomen:

X-ray abdomen Supine Dilated colon Peripheral Haustral folds Erect Multiple fluid levels

Small Vs Large:

Small Vs Large

Large bowel obstruction:

Large bowel obstruction

Treatment:

Treatment Conservative How Drip and Suck Enema Outcome Patient asymptomatic and passing faeces and flatus Pt remains symptomatic or worsens Laparotomy

Laparotomy:

Laparotomy Pre operative optimization Midline incision Thorough laparotomy Find out etiology and pathology and treat accordingly Problems: Malignancy Unprepared bowel Sick patient Solutions; Resection and Anastomosis: 1 stage Resection and anastomosis and Colostomy: 2 stage Colostomy alone: 3 stage

Complications of Large bowel obstruction:

Complications of Large bowel obstruction Perforation Hypovolumic shock Sepsis Renal failure

1.Sigmoid Volvulus:

1.Sigmoid Volvulus Pathogenesis Long narrow sigmoid mesocolon Loaded sigmoid colon Anti clockwise rotation of sigmoid Symptoms Pain, distension & absolute constipation Signs: Grossly distended, tender abdomen Investigation X ray abdomen Flexible Sigmoidoscopy Gastrograffin Enema Management Colonoscopic decompression Laparotomy: sigmoid colectomy/Colostomy Hartmann’s colostomy Paul Mikulicz operation

Sigmoid volvulus:

Sigmoid volvulus Inner tube sign Bird beak sign

Colonoscopic Decompression:

Colonoscopic Decompression

Sigmoid Volvulus with Gangrene:

Sigmoid Volvulus with Gangrene

2.Intussusception Pathology:

2.Intussusception Pathology Children : 90% idiopathic: Payer’s Patch Adult :90% secondary to underlying lesion Lead point Polyps Meckel’s Tumour Benign: Lipoma Leiomyoma Malignant: Ca, Lymphoma Intussusceptum Advancing loop Intussuscipien Receiving loop

Instussusception:

Instussusception Symptoms Colicky pain, Vomiting Signs Sausage Mass : Peri umbilical Sign de Dance: Empty RIF Investigation X ray abdomen: Obstruction/ ?perf US abdomen: Doughnut sign/Target lesion Ba Enema: Coiled spring appearence CT abdomen: Bull’s eye Treatment Image guided Hydrostatic reduction using Saline Laparotomy/ Reduce/resect if need be Laparoscopy

Plain X ray abdomen:

Plain X ray abdomen Mass Cresent sign

Imaging:

Imaging Bull’s Eye Coiled spring appearance/ Meniscus sign or Claw sign US Abdomen Ba Enema CT Abdomen Pseudokidney /Target sign

Laparotomy/ Reduction & Resection/Anastomosis:

Laparotomy/ Reduction & Resection/Anastomosis Squeeze from Apex See for Lead point pathology Resect, if need be

Laparoscopic Reduction of Intussusception:

Laparoscopic Reduction of Intussusception

3.Colonic Ca :

3.Colonic Ca

Ca colon with obstruction:

Ca colon with obstruction Left colon : Schirrous stenosing tumour Investigation X ray abdomen Water soluble enema Colonoscopy CT abdomen Management Pre operative optimization Colonic Stent? Definite surgery: 1 stage/ 2 stage/ 3 stage : On table lavage

Types of Colostomy: End/Loop:

Types of Colostomy: End/Loop

Adynamic Obstruction:

Adynamic Obstruction Paralytic Ileus Absence of neural activity Pseudo obstruction Imbalance of neural activity Sympathetic over activity Parasympathetic suppression

Paralytic Ileus:

Paralytic Ileus Causes Post operative Abdominal sepsis Metabolic: Uremia and Hypokalemia Reflex: CVA/Spinal injury Clinical Features Distended and silent abdomen X ray : Dilated small and large bowel Management Drip and suck Electrolyte imbalance correction Correction of the cause Neostigmine

Pseudo obstruction (Ogilvie’s Syndrome):

Pseudo obstruction (Ogilvie’s Syndrome) Causes DM, Myxoedema, Parkinsonism, Scleroderma Symptoms and signs Abdominal discomfort and distension/Constipation Distended and silent abdomen Investigation X ray abdomen, Gastrograffin enema, Colonoscopy Treatment Colonoscopic decompression/Flatus tube Cisapride Tube caecostomy

Pseudo obstruction:

Pseudo obstruction

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