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Specialists Without Borders

Seminar in Surgery
Rwanda, September 2010

Differentiating Large Bowel


Obstruction from
Small Bowel Obstruction
David Birks FRACS
September 2010
Darwin

Brisbane

Perth
Sydney
Adelaide
Canberra

Melbourne
Victoria
Hobart
Differentiating large bowel obstruction
from small bowel obstruction
Objectives
• Physiology & anatomy of small/large bowel
• Causes of bowel obstruction
• Symptoms & signs
• Investigations (plain xray)
• Complications
• Management – conservative & operative
Functions of intestine
• Small intestine – absorption of fluid, food,
vitamins

• Large intestine – absorption of water & Na


- converts 1000-2000ml into
200ml semisolid faeces
Fluid replacement - GI loss
• Type Na K Cl HCO3

Gastric 100 10 100

Bile 140 5 80 40

Pancreas 140 5 80 100

Small Bowel 90 10 90 30
Fluid replacement - GI loss
• Type Volume
(litres)
Gastric 2.0
Bile 1.0
Pancreas 1.0
Small bowel 3.5

Total 7.5
Causes of small bowel obstruction
• adhesions (previous operation)
• external hernia
• small bowel volvulus (primary)
• neoplasms
• miscellaneous
Causes of large bowel obstruction
• carcinoma of colon
• volvulus (sigmoid)
• diverticular disease
• miscellaneous
Symptoms of bowel obstruction
• abdominal pain
• vomiting
• distension
• constipation (no flatus)
High small bowel obstruction
• frequent, profuse vomiting
• central abdo pain
• minimal distension
Lower small bowel obstruction
• colic pain
• moderate vomiting ( may be faeculent)
• moderate distension
Large bowel obstruction
• abdominal distension
• constipation
• lower abdo pain ( may be minimal)
• minimal vomiting
Physical Examination
• abdo scars
• external hernia
• signs strangulation (tenderness, fever, mass)
Investigations
• Plain Xray – supine
- erect
- chest
• Hb, WCC, Urea & Electrolytes
Further investigations
• CT abdomen
• contrast study (via NG )
Plain x ray SBO
• dilated loops with gas
• centrally placed
• transverse lines (circular folds)
Plain x ray LBO
• dilated bowel with gas (caecum)
• peripheral
• haustra (not lines across bowel)
• may have cut-off point
SBO
Supine

LBO
Prone

Carcinoma of Sigmoid – LBO –


Decompressed into SB
Complications of bowel obstruction
• fluid & electrolyte loss - small bowel
• aspiration – small bowel
• respiratory restriction– large bowel
• strangulation – small bowel
• caecal perforation – large bowel (competent
Ileo-caecal valve)
Management of bowel obstruction
• nil orally
• IV fluid & electrolyte replacement
• NasoGastric drainage (small bowel)
Operation for bowel obstruction
• external hernia (SBO) – emergency
• signs of strangulation – emergency
• SBO not settling – within 24-48 hr
• LBO due to carcinoma - soon
Non-operative treatment of bowel
obstruction
• sigmoid volvulus – decompress via
sigmoidoscope
• post-operative SBO
• intussusception in infants (2/12 – 2 yr)
• previous operations for SBO
• radiation
• abdominal carcinomatosis
Operation - SBO
• midline incision
look for ileo-caecal valve
• treat cause
• external hernia – incision over hernia
- if gangrene convert to midline
Operation - LBO
• midline and resect bowel pathology
+/- anastomosis
+/- stoma
• if left sided obstruction – transverse
colostomy through right upper trans incision
Summary of bowel obstruction
• Physiology & anatomy of small/large bowel
• Causes of bowel obstruction
• Symptoms & signs
• Investigations (plain xray)
• Complications
• Management – conservative & operative
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