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

Ray Erect Dilated loops of bowel with air-fluid levels .Supine X.

masses. perforation) . or inflammatory changes. necrosis. and for identifying complications (ischemia.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.

a diagnosis of bowel obstruction on abdominal CT can be made by the findings of dilated proximal bowel with distal (B) .CT Scan (A) Similar to the findings on plain abdominal radiography.

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

adequate intravenous (IV) access in the form of two large-bore peripheral lines should be obtained for fluid resuscitation. . 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. but it is important to be certain the patient does not have acute kidney injury (acute renal failure) from severe dehydration. metabolic acidosis or alkalosis.2.Fluid Thereby In general. in which case potassium supplementation should be given cautiously until renal function can be improved. Aggressive potassium repletion may be needed. and electrolyte abnormalities.

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.

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

This approach requires frequent reassessments of the patient to ensure that there are no developing complications.NONOPERATIVE MANAGEMENT Nonoperative management with nasogastric suction and intravenous fluids can be successful in patients with partial small bowel obstruction. if no improvement is seen. but clinical evaluation must first exclude complicated obstruction overall successful in 65 to 80 percent of patients. . Many patients can safely undergo initial nonoperative management. 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. the patient should be explored.

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

Case 4 .

aggrvated by movment and respiration. . malaise On Examination: by inspection you noticed He takes shallow fast breaths. delivered to ER by his wife. anorexia . On palpation there was generalized rigidity and tenderness. The pain was associated with Fever (38. the patient was complaining of Abdominal pain for 6 h duration the pain was diffuse and constant.Bert is a 63 Year old male a known case of peptic ulcer disease. on percussion it was dull.1) . 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. pancertitis) and influence management decision . X-Ray : Erect: Subdiphramtic Gas Supine: dilated loops in paralytic ileus CT scan: used to identify the cause of peritonitis ( Diverticulitis .

Ray .X.

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

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

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

O is by NPO . neoplasm The management of I. Treatment By : Peritoneal lavage . 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.O ex. hernia.To Sum Up Intestinal obstruction commonly caused by adhesions . IV . NG Complicated I.

Homo Naledi 100.000 years old .

Thank you .