Intestinal Obstruction: Small and Large Bowel
General surgeons are commonly asked to manage patients presenting to the emergency department with an intestinal obstruction. Management is dependent on the patient's history and the location of the obstruction. Small bowel obstruction is most commonly du
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Joseph A. Posluszny Jr. and Fred A. Luchette
Case Presentation A 76 year old male presented to the emergency room with 3 days of intermittent lower abdominal pain and nausea. He had not vomited but had not eaten or drank liquids in the past day. He was passing gas until 24 h ago. He has a past medical history of coronary artery disease requiring a coronary artery bypass, atrial fibrillation for which he was anticoagulated with warfarin and benign prostatic hypertrophy. He has a past surgical history of a right colectomy with primary anastomosis 10 years ago. He has never had a bowel obstruction. He was afebrile, heart rate was 85 and blood pressure was 130/80. On exam, he was not in any distress, his mucous membranes were dry, his abdomen was slightly distended with a midline scar and minimally tender. There was no evidence of ventral or inguinal hernias. Lab studies revealed a WBC count of 10, no
J.A. Posluszny Jr. (*) Surgery, Loyola University Stritch School of Medicine, Maywood, IL, USA Edward Hines Jr. Veterans Administration Medical Center, Maywood, IL, USA e-mail: [email protected] F.A. Luchette Department of Surgery, Stritch School of Medicine, Loyola University of Chicago, Chicago, IL, USA VA Affairs, Surgical Service Lines, Edward Hines Jr., Veterans Administration Medical Center, Maywood, IL, USA
bands, hematocrit of 50, creatinine of 1.3 (baseline 1.0), lactate 1.2 and INR of 2.0. A CT scan of the abdomen and pelvis (below) showed dilated, fluid filled small bowel with a tapering in the RLQ, a stool filled colon and was without pneumatosis, portal venous gas or significant mesenteric edema (Fig. 80.1). Question How do you manage a patient with a small bowel obstruction? Answer Since this patient had no signs of intestinal ischemia (fever, leukocytosis, tachycardia unresponsive to fluids, peritonitis), intestinal perforation (no pneumoperitoneum), a closed loop obstruction or hernia defect and had a history of prior abdominal surgery suggesting an etiology of adhesive small bowel disease, he was initially managed non-operatively with IVF resuscitation, NPO and nasogastric (NG) tube decompression. The NG tube initially evacuated 1.5 L of gastric and bilious fluid. Over the course of the next 3 days, the NG tube output remained elevated but was more gastric in nature. He remained with only minimal abdominal tenderness but he was not passing gas per rectum or having bowel movements. As a result, laparotomy with lysis of adhesions was recommended for treatment of persistent small bowel obstruction and performed on hospital day 4. During the laparotomy, a combination of extensive moderate and dense adhesions was identified that twisted the bowel in a partially
© Springer International Publishing Switzerland 2017 R.C. Hyzy (ed.), Evidence-Based Critical Care, DOI 10.1007/978-3-319-43341-7_80
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J.A. Posluszny Jr. and F.A. Luchette
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Fig. 80.1 CT scan images of small bowel obstruction. (a) Representative axial section of CT scan of the abdomen and pelvis with PO and IV contrast
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