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OBSTRUCTION
Leslie Kobayashi
Trauma Conference 2013
Overview
Background
Pathophysiology/Etiology
Diagnosis
Treatment
Outcomes
Small bowel obstruction
(SBO)
Mechanical obstruction of the small bowel
preventing free passage of intraluminal
material
May be due to:
Bowel wall inflammation, edema or tumor
Intraluminal obstruction (bezoar, gallstone,
foreign body)
Extrinsic compression (adhesion, hernia,
tumor, volvulus)
Background
Obstruction is the most common
small bowel pathology requiring
surgical consultation
Accounts for 20% of acute surgical
admissions
Costs $800 million annually
Background
Most common causes of SBO
Adhesive 60-75%
Malignancies 9-11%
Hernias 8-18%
IBD 5%
SBO in the virgin abdomen
Historically
Primary causes: hernia and volvulus
Currently
Primary causes: malignancy, IBD
Bleeding Inflammation
Capillaries &
Barmparas et al, J Gastrointest Surg Migration of Adhesion
2010 Fibroblasts
Pathophysiology
Postmortem study
Minor procedure: 51% had adhesions
Major procedure: 72% had adhesions
Multiple operations: 93% had adhesions
Age
Comorbid conditions
Prior surgery
Stepwise increase with number of prior
procedures
Surgical technique
Open technique associated with
significantly higher rates of SBO
Risk increased 2-8x’s
Procedure related risk
Total # of Adhesion-related
Surgery Technique
patients readmission
Open 266,695 1.4%
Appendectomy
Lap. 4,445 1.3%
Open 141 7.1%
Cholecystectomy
Lap. 7,103 0.2%
Open 121,058 9.5%
Colectomy
Lap. 930 4.3%
Ileal pouch-anal
Open 5,268 19.3%
anastomosis
Laparotomy for
Open 1,913 2.5%
Trauma
Gynecological Open 24,998 17.1%
procedures Lap. 773 0%
Barmparas et al, J Gastrointest Surg 2010
Trends over time?
↓risk of SBO with laparoscopy compared
to open
Laparoscopy rate ↑over time
Has this resulted in ↓rate of SBO?
No
Plain films
Benefits: rapid, repeatable, no
contrast required, patient does
not have to be supine for
prolonged time period, can be
done at bedside
Diagnosis:
Radiology findings
Findings:
Distended loops of bowel
Air-fluid levels
Step laddering of bowel
Lack of air in colon, rectum
Diagnosis:
Radiology findings
CT scans
Benefits: high sensitivity and
specificity (90%), gives information on
intra and extraluminal pathology,
highly sensitive for free air/fluid, can
identify transition zones, hernias, and
bowel ischemia
Diagnosis:
Radiology findings
Findings:
Dilated bowel
Transition zone from dilated to
collapsed
Passage of contrast material (partial)
or not (complete)
Bezoars, masses
Treatment
Treatment
Yes
OR
2: Ischemia
Strangulated
Physical signs Sensitivity Specificity PPV
(N=21)
Temp (°F) 99 ± 0.9 24 70 36
Pulse 104 ± 23 52 43 39
No bowel sounds 5/20 25 83 50
Peritonitis 6/21 29 97 86
2004
Plain films
Bowel wall edema, portal venous gas
No
Yes
Ischemia?
Fever, Tachycardia, Acidosis
Portal air, pneumatosis, ascites
mesenteric stranding
OR
Yes
OR
3: High grade, or closed loop
SBO
Patients with high grade SBO, or those with
closed loop obstruction should be strongly
considered for early operative management
Signs of high grade SBO
> 25mm
Air-fluid levels of
Air fluid width of differential height
25 mm or more in the same loop
Accuracy of plain X-ray to
diagnose a high grade SBO
Sensitivity 66-75%
No
Yes
Ischemia?
Fever, Tachycardia, Acidosis
Portal air, pneumatosis,
ascites mesenteric stranding
OR
No
Yes Closed loop or
high grade
SBO?
OR
Yes-OR
Summary: treatment
No
Yes
Ischemia?
Fever, Tachycardia, Acidosis
Portal air, pneumatosis,
ascites mesenteric stranding
OR
No
Yes Closed loop or
high grade
SBO?
OR
Yes-OR No-obs
Principles of NOM
Longer LOS
Increased incidence of bowel
necrosis and need for bowel resection
Increased mortality
Increased morbidity
NOM
Given risks of delay to surgery:
How long should NOM trial last?
Studies suggest 48hrs although can
be longer in pSBO
NIS data suggest delay of ≥4d
associated with 64% increase in
mortality and increased LOS
•50–100ml Gastrografin or
40ml Urografin administered
orally
•Abdominal plain radiographs
after 4 h, 8 h or 24 h to follow
contrast through the GI-tract
Water-Soluble Contrast (WSCA) –
Diagnostic and Therapeutic role
Conclusion
Water-soluble contrast was effective in predicting
the need for surgery in adhesive SBO (sensitivity
96%, specificity 98%)
In addition, it reduced the need for operation and
shortened hospital stay.
Outcomes
Outcomes
Mortality 3-8%