Large Bowel

Clinical
History
1) Obtain history of bowel movements,
flatus, constipation (i.e., no gas or
bowel movement), and symptoms
► Major complaints include
abdominal distention
nausea
vomiting and
crampy abdominal pain
Large Bowel
Clinical
History
Abrupt onset of symptoms makes an acute
obstructive event (e.g.: cecal or sigmoid
volvulus) a more likely diagnosis
Large Bowel
Clinical (History)
History of chronic constipation, long-term
cathartic (laxative) use, and straining at stools
implies:
diverticulitis or
carcinoma

Change in caliber of stools strongly suggests

carcinoma

When associated with weight loss, likelihood of

carcinoma increases
Clinical (History)
2) Colonic lesion development history
Right-sided colonic lesions can grow quite large
before obstruction occurs because of the:
large capacity of the right colon and
soft stool consistency

Sigmoid colon and rectal tumors cause colonic

obstruction much earlier in their development
because:
the colon is narrower and
the stool is harder in that area
Large Bowel
Clinical
History
3) Obstruction secondary to intussusception
Patients may describe:
intermittent
crampy abdominal pain
that is colicky and relieved by assuming fetal
position

Weight loss and fatigue are common

Large Bowel
Clinical
History
4) pneumaturia
mucinuria or
fecaluria
may occur when fistulization of the
sigmoid colon to the bladder occurs
Physical Examination
Large bowel
Abdominal distention may be significant in
patients with a large-bowel obstruction

Bowel sounds may be normal early on but

usually become quiet

Abdomen is hyperresonant to percussion

Physical Examination
Large bowel
Palpation of the abdomen reveals
tenderness
fever
severe tenderness and
abdominal rigidity

►They are findings that suggest peritonitis secondary to

perforation
Physical Examination
Large bowel
Remember
Sigmoid diverticulitis and a perforated
sigmoid secondary to carcinoma are clinically
difficult to differentiate

Patients may have guaiac-positive stool if

carcinoma is the etiology
Physical Examination
Large bowel
Remember
Rectal or
lower sigmoidal mass
may be palpated on rectal examination

A mass or fullness may be appreciated if a tumor is present in the cecum

 Differential Diagnosis
Large bowel
Abdominal Pain in Elderly Persons
Constipation
Diverticular Disease
Obstruction, Small Bowel
Lab Studies
Large bowel
Obtain a blood sample for:
a CBC
electrolyte levels
prothrombin time (PT)
blood type and crossmatch
Emergency Department Care
Initial therapy includes:
1) gastric decompression
(Insert a nasogastric tube if the patient has
been vomiting)

2) volume resuscitation

3) appropriate preoperative antibiotics

4) timely surgical consultation

Imaging Studies
Large bowel
Obtain an upright chest radiograph and flat and
upright abdominal radiographs

Chest radiographs demonstrate free air if

perforation has occurred
Abdominal radiographs may be diagnostic of:
sigmoid or
cecal volvulus
air-fluid levels ►► sign that suggests colonic
obstruction
Imaging Studies
Illustration
Imaging Studies
Large bowel
The absence of free air does not exclude
perforation (this finding may be absent in half
of all perforations)

Additional contrast studies may include:

* an enema with water soluble contrast(e.g:
gastrographin:

* CT examination
 Imaging Studies
Large bowel
Contrast studies that reveal a column of
contrast ending in a "bird’s beak" are
suggestive of colonic volvulus
 INTESTINAL OBSTRUCTION

Pediatrics, Intussusception
Background
Intussusception is the telescoping or prolapse
of one portion of the bowel into an
immediately adjacent segment

Contrast enema can reduce the

intussusception in approximately 75% of
cases
 INTESTINAL OBSTRUCTION

Pediatrics, Intussusception
Pathophysiology
Intussusception most commonly occurs at the
terminal ileum (i.e., ileocolic)

The telescoping proximal portion of bowel (i.e.,

intussusceptum) invaginates into the adjacent distal
bowel (i.e., intussuscipiens)
Pediatrics, Intussusception
Pathophysiology
The mesentery of the intussusceptum is
compressed, and the ensuing swelling of the
bowel wall quickly leads to obstruction

Venous engorgement and ischemia of the

intestinal mucosa cause bleeding and an
outpouring of mucous, which results in the
classic description of red "currant jelly" stool

Most cases (90%) are idiopathic

Pediatrics, Intussusception
Mortality/Morbidity
Most patients recover if treated within 24 hours

Mortality with treatment is 1-3%

If left untreated, this condition is uniformly fatal

in 2-5 days

Recurrence is observed in 3-11% of cases

Most recurrences involve intussusceptions that
were reduced with contrast enema
 INTESTINAL OBSTRUCTION

Sex
Overall, the male-to-female ratio is
approximately 3:1

With advancing age, gender difference

becomes marked

in patients older than 4 years, the male-to-

female ratio is 8:1
Age
Intussusception is most common in infants
aged 3-12 months
Pediatrics, Intussusception
Clinical Examination
History
The typical presentation is a previously healthy
infant boy aged 6-12 months with sudden onset
of colicky abdominal pain with vomiting

Paroxysms of pain occur 10-20 minutes apart

Initially, loose or watery stools are present

concurrent with vomiting and
within 12-24 hours, blood or mucous is passed
rectally
 INTESTINAL OBSTRUCTION
Pediatrics, Intussusception
Clinical Examination
History
Early in the course, the patient appears completely
well between the episodes of abdominal pain

Lethargy may dominate the initial presentation, however,

lethargy usually occurs later in the process

The classic triad of colicky abdominal pain, vomiting,

and red currant jelly stools occurs in only 21% of cases
 INTESTINAL OBSTRUCTION

Pediatrics, Intussusception
Physical Examination
Usually, the abdomen is soft and nontender early, but it
eventually becomes distended and tender

A vertically oriented mass may be palpable in the right upper

quadrant
 INTESTINAL OBSTRUCTION

Pediatrics, Intussusception
Physical Examination
Currant jelly stools are observed in only 50% of cases

Most patients (75%) without obviously bloody stools have

stools that test positive for occult blood

Fever is a late finding and is suggestive of enteric sepsis

Thanks