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Small Bowel Obstruction - Surgical Recall

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What is a SBO?
Small bowel obstruction
Mechanical obstruction of the passage of intraluminal contents
What are the signs/symptoms of SBO?
Abdominal discomfort
Cramping
Nausea/vomiting
Abdominal distention
High-pitched bowel sounds
What are the classic electrolyte/acid-base findings with proximal obstruction?
-Fluid level?
-Cl level?
-K level?
-Acid-base status?
Hypovolemic (from vomiting)
Hypochloremic (from vomiting)
Hypokalemia (from vomiting)
Alkalosis (from vomiting)
What must be ruled out on physical exam in pts with SBO?
Incarcerated hernia
--Also look for surgical scars
What major AXR findings are associated with SBO?
Distended loops of bowel with air-fluid levels on upright film
What is a complete SBO?
Complete obstruction of the lumen
--There will be no flatus or stool
Why can pts continue to have flatus/stool after a complete SBO?
The distal bowel still has some contents left over
What is the danger of complete SBO?
Risk of closed loop strangulation of the bowel
Why is closed loop strangulation of the bowel bad?
Risk of bowel ischemia and necrosis
What is partial SBO?
Incomplete SBO
--Some colon gas
What is the initial management of all pts with SBO?
NPO, NGT, IVF, Foley
What tests can differentiate partial from complete bowel obstruction?
CT with oral contrast, small bowel follow-through
What are the ABCs of SBO?
Adhesions
Bulge (hernias)
Cancers/tumors
What are other causes of SBO?
-GIVES BAD CRAMPS
Gallstone ileus
Intussusception
Volvulus
Extrinsic compression
SMA syndrome

Bezoars/Bowel wall hematomas
Abscess
Diverticulitis

Crohn's
Radiation
Annular pancreas
Meckel's diverticulum
Peritoneal adhesions
Strictures
What is SMA syndrome?
Duodenum gets compressed under the SMA as it branches off the aorta
What is the treatment of complete SBO?
Laparotomy and lysis of adhesions
What is the treatment of incomplete SBO?
Conservative therapy at first
--Close observation, NGT decompression
Intraoperatively, how can the level of obstruction be determined in pts with SBO?
Transition from dilated bowel proximal to decompressed bowel distal to obstruction
What is the most common indication for abdominal surgery in pts with Crohn's disease?
SBO
Can a pt have complete SBO and bowel movements and flatus?
Yes
--Bowel distal to obstruction can clear gas/stool
After a small bowel resection, why should the mesenteric defect always be closed
Prevent bowel wall hematoma
What is the #1 cause of SBO in adults (industrialized world)?
Adhesions from prior surgery
What is the #1 cause of SBO in the world?
Hernias
What is the #1 cause of SBO in kids?
Hernias
What are the signs of strangulated bowel in SBO?
Fever
Severe/continuous pain
Hematemesis
Shock
Gas in bowel wall/portal vein
Abdominal free air
Peritoneal signs
Acidosis (lactic acidosis)
What are the clinical parameters that will lower the threshold to operate on a partial SBO?
Increasing WBC
Fever
Tachycardia/tachypnea
Abdominal pain
What are absolute indications for operation on partial SBO?
Peritoneal signs
Free air on AXR
What classic saying is associated with complete SBO?
Never let the sun set or rise on complete SBO
What condition commonly mimics SBO?
Paralytic ileus
--Gas will be present in the colon on AXR
What is the differential diagnosis of paralytic ileus?
Post-op ileus
Electrolyte abnormalities (hypokalemia)
Medications (anticholinergics/narcotics)
Inflammatory intra-abdominal process
Sepsis/shock
Spine injury
Retroperitoneal hemorrhage
What tumor classically causes SBO due to mesenteric fibrosis?
Carcinoid tumor
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