Case 3

Paul a 43 year old male present to ER

complaining of of intermittent
abdominal pain for 2 days duration. The
pain was associated with projectile
bilious vomiting and abdomen
distention with inability to pass stool.
There was no pervious attacks
4 years ago the patient had
appendectomy

On Examination:
Insp.: distended abdomen+
Mcburny Scar
Palp.: Generalized Abdomen
tenderness + no cough
impulses
Percussion: tympanic with
no shifting dullness
Auscultation: hypoactive
bowel sounds
DRE: Empty Rectum

Small bowel obstruction

Imaging
For most patients, we obtain plain
radiographs to quickly confirm a diagnosis
of bowel obstruction and, provided the
films do not have findings that indicate the
need for immediate intervention, we use
computed tomography (CT) of the
abdomen to further characterize the
nature, severity, and potential etiologies of
the obstruction.

Supine

X- Ray

Erect

Dilated loops of bowel

with air-fluid levels

CT Scan
CT of the abdomen is more useful than
plain radiographs for identifying the
specific site and severity of
obstruction (partial vs complete) ;
determining the etiology by identifying
hernias, masses, or inflammatory
changes; and for identifying
complications (ischemia, necrosis,
perforation)

CT Scan

(A)

Similar to the findings on plain

abdominal radiography, a
diagnosis of bowel obstruction
on abdominal CT can be made
by the findings of dilated
proximal bowel with distal

(B)

Management
1- Admission.
2- Fluid therapy
3- Gastrointestinal decompression

2- Fluid Thereby
In general, all patients with mechanical bowel
obstruction should be made nil per os (NPO) to
limit bowel distension
Patients with bowel obstruction can have severe
volume depletion, metabolic acidosis or
alkalosis, and electrolyte abnormalities.
adequate intravenous (IV) access in the form
of two large-bore peripheral lines should be
obtained for fluid resuscitation.
Aggressive potassium repletion may be
needed, but it is important to be certain the
patient does not have acute kidney injury (acute
renal failure) from severe dehydration, in which
case potassium supplementation should be given
cautiously until renal function can be improved.

Gastrointestinal
decompression
By a nasogastric tube
decompression of the distended stomach
improves patient comfort and also
minimizes the passage of swallowed air,
which can worsen distension
The drainage from nasogastric tubes
placed for gastrointestinal decompression
should be documented to help judge the
progression or resolution of obstruction and
the need for supplemental intravenous
fluid. Fluid and electrolyte replacement for
nasogastric losses depends upon the
volume and nature of the loss.

assessment of the need

for surgical exploration
All patients suspected of having
complicated bowel obstruction (complete
obstruction, closed-loop obstruction, bowel
ischemia, necrosis, or perforation) based
upon clinical and radiologic examination
should be taken to the operating room for
abdominal exploration

NONOPERATIVE
MANAGEMENT
Nonoperative management with nasogastric suction and
intravenous fluids can be successful in patients with partial
small bowel obstruction. This approach requires frequent
reassessments of the patient to ensure that there are no
developing complications.
Many patients can safely undergo initial nonoperative
management, but clinical evaluation must first exclude
complicated obstruction
overall successful in 65 to 80 percent of patients.
patients with small bowel obstruction (without indications for
immediate surgical exploration) should be observed for no
longer than 12 to 24 hours after which time, if no
improvement is seen, the patient should be explored.

Serial monitoring ..
(Outcome)
Frequent clinical reassessments of the
patient are necessary to ensure that
complications are not developing
- Resolution of small bowel
obstruction: accompanied by a decrease
in abdominal distension, the passage of
flatus and/or stool per rectum, and a
decrease in the volume of nasogastric tube
output.
- Complication: Complicated bowl
obstruction
Renal failure

Case 4

Bert is a 63 Year old male a known case of peptic

ulcer disease. delivered to ER by his wife. the patient
was complaining of Abdominal pain for 6 h duration
the pain was diffuse and constant, aggrvated by
movment and respiration.
The pain was associated with Fever (38.1) ,
anorexia , malaise
On Examination: by inspection you noticed He takes
shallow fast breaths. On palpation there was
generalized rigidity and tenderness. on percussion it
was dull. Reduced bowl sounds on auscultation.

Peritonitis/

caused by
perforated viscous

Imaging
Patients who meet the criteria for secondary
bacterial peritonitis should undergo
emergency plain and upright abdominal
films and a computed tomographic scan of
the abdomen.
X-Ray :
Erect: Subdiphramtic Gas
Supine: dilated loops in paralytic ileus
CT scan: used to identify the cause of
peritonitis ( Diverticulitis , pancertitis) and
influence management decision

X- Ray

CT scan

T scan of the abdomen with free air (star) and air in bowel wall (

Management
- Admission
- IV Fluid
Broad- spectrum AB: that cover ( aerobic
and anaerobic) : most common bacteria :
E.Coli , Bacteroids , Klebsiella
Analgesia
Emergent Laparotomy: peritoneal
lavage and drainage.

Prognosis and outcome

Mortality Rate is 10% .. (B&L)
Complications:
- Bacteremia
- Shock
- Systemic inflammatory response
syndrome
- Death

To Sum Up
Intestinal obstruction commonly caused by
adhesions , hernia, neoplasm
The management of I.O is by NPO , IV , NG
Complicated I.O ex, necrosis/perforation :
Surgery
Peritonitis commonly caused by perforated
viscous
Patient with Secondary peritonitis (surgical
peritonitis) should do Erect/Supine X-Ray and a
CT scan.
Treatment By : Peritoneal lavage

Homo Naledi

100,000 years old

Thank you