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Vomiting, Diarrhea & ConstipationMark J. Koruda, MDProfessor of Surgery
AssumptionsStudents understand the anatomy, embryology and physiology of the gastrointestinal tract.
Case 1A 54-year-old woman presents with a two day history of crampy abdominal pain followed by episodes of bilious emesis.
Important Items in the History?
Previously hysterectomy for treatment of cervical cancer.
Small Bowel Obstruction
Small Bowel ObstructionSigns & SymptomsIntermittent, Crampy Abdominal PainNausea / EmesisDistensionObstipationPeristaltic Rushes on AuscultationFocal TendernessDiffuse Peritonitis
Case 1What findings should be looked for on physical exam?
Distended
No peritoneal signs
Case 1What laboratory tests should be ordered?
Small Bowel ObstructionLaboratory EvaluationMay see hypochloremic, hypokalemic metabolic alkalosis if having frequent emesis (proximal obstruction).May see evidence of contraction alkalosisIncreased H/H, BUN.WBC usually normal early.
Case 1What laboratory tests should be ordered?
What diagnostic tests should be ordered?
Small Bowel ObstructionRadiologic EvaluationXrays: ? AFLs, ? Free Air, ? Distal GasUGI / SBFT: Identify mechanical obstructionEnteroclysis: Independent of gastric emptyingCT Scan: ? Free Air, ? Pneumatosis, ? Tumor
Small Bowel ObstructionEtiologiesAdhesionsMalignancyExternal or Internal HerniaVolvulusCrohns DiseaseIntra-abdominal Abscess
Small Bowel ObstructionEtiologies (Cont.)Radiation StrictureForeign BodyGallstone IleusMeckels DiverticulumIntramural HematomaMesenteric IschemiaIntussusception
Intestinal IleusEtiologiesPostoperative StateSepsisElectrolyte ImbalanceDrugsUreteral and Biliary ColicRetroperitoneal HemorrhageSpinal Cord InjuryMyocardial InfarctionPneumonia
Case 1What is the initial management plan?
Small Bowel ObstructionPartial vs. TotalWhy Not Just Wait??
Potential for Closed Loop ObstructionRisk of Ischemia / Perforation (4-6 hrs)
Small Bowel ObstructionTreatmentCorrect intravascular volume deficitNGT vs. Miller-Abbott or Cantor TubesSerial ExamsOperation if no improvement or if signs of complete (closed loop) obstruction or incarceration.Evaluation of Bowel Viability
Case 2A 72-year-old man presents with a two month history of gradually increasing constipation.
Key Points in History?
Large Bowel ObstructionDiagnosisCrampy PainOnset may be acute or insidiousDistension (50-60% have competent ileo-cecal valve and develop severe distension)Xrays: 12-14 cm cecum, perforation riskContrast enema: Obstruction vs OglivesConsider rigid sigmoidoscopy to r/o and treat sigmoid volvulus
Case 2Physical Exam
What further tests are indicated
Case 2Differential Diagnosis
Colonic ObstructionMalignantBenign
Colonic Dysfunction
Large Bowel Obstruction
Large Bowel ObstructionEtiologiesColon CancerDiverticulitisExtrinsic CancerFecal ImpactionIntussusceptionVolvulusIncarcerated Hernias
Large Bowel ObstructionColon Cancer20% of colon cancers present with obstructionLeft-sided lesions are more prone to obstruct (more narrow lumen, more solid fecal stream)
Large Bowel ObstructionTreatmentIVFNGTOperationEmergently if signs of peritonitis / perforationPrep bowel if possibleIs an ostomy necessary?Right vs. Left-sided LesionsTraditional vs. Newer Attitudes
right colon - can reanastamosetransverse colon - extended right hemileft colon3 stage (ostomy, resection, takedown)2 stage (resect with protecting ostomy, takedown)1 stage (resect, anastamose with or without colonic lavage)leak rate 5%1 stage (resect whole colon and do an ileoproctostomy to avoid fecal loading)
Large Bowel DysfunctionInflammationColonic InertiaEtc
Oglives Syndrome(Colonic Pseudo-Obstruction)May mimic mechanical obstructionAssociated ConditionsTreatment: Rectal tube / enemas /exams (work in most)Colonoscopic decompression (80-90% eff.)Surgery (Cecostomy vs. Resection) - cecum >12 cm or peritoneal signs
Associated Conditions:AmyloidosisBlunt traumaCardiopulmonary BypassC-sectionChemotherapyDermatofibrosisDiabetesElectrolyte abnormalitiesHypothyroidismMedications (anticholinergics, ganglionic blockers, narcotics, phenothiazines, tricyclic antidepressants)Ortho or Neurologic ProceduresRenal FailureRenalTransplantationSclerodermaDementia / StrokeSLE
Case 3A 54-yo Caucasian male with history of ileocolonic Crohn's disease, s/p ileocolectomy in 1979, who has not been on any Rx for CD. Presents to the UNC ER complaining of crampy abdominal pain that began at 8 hrs earlier located in the right lower and left lower quadrant. He also had nausea and vomiting as well as decreasing flatus associated. The patient stated his last BM was on the day of admission. He stated that the pain feels like his previous obstructions. Occurring every couple of months, recently increasing in frequency. No fevers. About 10 lb weight loss.
Key Points in History
What Is Crohns Disease?Crohns disease (CD) is an inflammatory bowel disorder that may affect any part of the gastro-intestinal (GI) tractThe inflammation penetrates the lining of the GI tract and often causes ulcers to form
SmallIntestineLargeIntestine(Colon)AppendixEsophagusStomachRectum
Case 3
Key Points in History
Case 3
Key Points in History Crohns diseasePrevious surgical historyNo Crohns RxChronic symptomsWeight lossNo feversCrampy pain
Case 3Physical Exam
Diagnostic Studies?
Differential Dx
Crohns Disease
Crohns Disease
Crohns DiseaseMedical vs Surgical Management
Case 422yo UNC student presents with 3 mos of increasing bloody diarrhea, going to the bathroom 15-20x/day. It rules my life!
Key Points in History
Case 422yo UNC student presents with 3 mos of increasing bloody diarrhea, going to the bathroom 15-20x/day. It rules my life!
Key Points in HistoryDiarrheaBleeding
Case 4Physical Exam
Diagnostic Studies?
Ulcerative Colitis
right colon - can reanastamosetransverse colon - extended right hemileft colon3 stage (ostomy, resection, takedown)2 stage (resect with protecting ostomy, takedown)1 stage (resect, anastamose with or without colonic lavage)leak rate 5%1 stage (resect whole colon and do an ileoproctostomy to avoid fecal loading)Associated Conditions:AmyloidosisBlunt traumaCardiopulmonary BypassC-sectionChemotherapyDermatofibrosisDiabetesElectrolyte abnormalitiesHypothyroidismMedications (anticholinergics, ganglionic blockers, narcotics, phenothiazines, tricyclic antidepressants)Ortho or Neurologic ProceduresRenal FailureRenalTransplantationSclerodermaDementia / StrokeSLE