Small Bowel Obstruction

  • – Impairment to the aboral passage of intestinal contents can result from
  •            • Mechanical obstruction of the bowel
  •            • Failure of normal intestinal motility in the absence of an obstructing lesion (ileus)

 

  •                               SMALL BOWEL OBSTRUCTION

 

  • Causes:
    • – Intra-abdominal adhesions following laparotomy: this accounts for approximately 60% to 85% of all cases

 

 

  • Clinical Features: History:
  • Physical Examination:

 

 

  •                                Investigations: CBC:
    • – Simple obstruction: Slight leucocytosis + Hemoconcentraion
    • – Strangulated obstruction: Significant neutrophilia + immature WBC forms

    Blood Biohemistry:

    • – Increased BUN
    • – Increased serum creatinine
    • – Abnormalities of serum sodium, potassium, and chloride concentrations
    • – Metabolic acidosis due to severe volume depletion with or without intestinal ischemia

  •  

 

 

  •                                Medical Management of SBO:
    • – Restoration of intravascular volume by isotonic fluid
    • – Correction of serum electrolyte abnormalities as rapidly as possible
    • – Metabolic acidosis should be treated by restoration of normal intravascular volume
    • – NG tube should be placed to
    •                       • Decompress the stomach
    •                       • Minimize further intestinal distention
    •                       • Reduce the risk of aspiration
    • – Patients who are to undergo laparotomy should receive broad-spectrum antibiotics directed toward Gram negative aerobes and anaerobes. Ertapenem is used because of its prolonged duration (24 hr) of clinical effectiveness, thus reducing the need for repeated dosing in long surgical cases
    •      •In the absence of clinical evidence to suggest strangulated obstruction or an incarcerated hernia, 64% to 73% of patients with partial SBO can be managed successfully with fluid and electrolyte resuscitation and NG aspiration
    • – Most patients who can be successfully managed nonoperatively have substantial improvement within the first 48 hours of treatment
    • – Patients whose SBO is most likely to resolve without operation may be identified by the appearance of oral contrast within the cecum on abdominal films within 4 to 24 hours of administration                        

                                                 Surgical Management of SBO:

    • – Adhesive SBO : Division of the obstructing adhesions and resecting any gangrenous bowel
    • – All adhesions are usually not divided, as they will reform after surgery is completed.
    •             • In the absence of frankly necrotic intestine : Viability should be assessed several minutes after release of the obstruction. Return of normal color and peristalsis and return of arterial pulsation in the vasa recta suggest that the involved segment is viable
    • – SBO due to a hernia : Surgical repair of the hernia
    • – SBO due to a primary malignancy: Area of obstruction usually resected, with either an anastomosis or proximal stoma, depending on the quality of the bowel proximal to the obstruction.
    • – SBO due to metastatic disease: Either resecting the site of obstruction or by bypassing the obstructe segment of bowel

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