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Tehran Medical SchoolSina HospitalMahmoud Najafi
GOO, SBO, LBO
Gastric outlet obstructionEtiologyo Benigno Malignant
GOO
PUDGastric polypsIngestion of
causticsPancratitisGastric TBGastric vulvulusGastric Bezoars
pyloric stenosisBouveret
syndromeCrohn's disease congenital
duodenal webs
Benign causes of GOO
Pancreatic cancerDistal gastric cancer Ampullary cancerDuodenal cancerCholangiocarcinomasMetastases
Malignant causes of GOO
Nausea and VomitingAnorexiaEarly satietyBloating or Epigastric fullnessIndigestionEpigastric painWeight loss
Clinical Presentation
Tympanitic mass in the epigastric area
Volume depletion
Clinical Presentation
GastroparesisIntestinal obstruction
Differential diagnosis
Clinical featuresPhysical examinationLaboratory tests Radiologic testsEndoscopy
Diagnosis
Electrolyte abnormalitiesHypokalemic hypochloremic
metabolic alkalosisAnemiaElevated serum gastrin levels Serum tumor markers
Laboratory findings
Plain AXRContrast studies CT scan
Radiologic tests
Chronic pancreatitis: calcifications in the pancreas (X-ray of abdomen)
Gastric Volvulus (Pediatric)
Figure 4 : Gastric volvulus. Plain film shows a large, air-filled structure with an unusual configuration in the left upper quadrant. Absence of gas distal to the stomach suggests gastric outlet obstruction.
Barium meal studies were suggestive of deformed and spastic duodenum
Gastric outlet obstruction caused by Crohn's disease. There is tapered narrowing of the distal antrum due to Crohn's disease involving the stomach.
Gastric outlet obstruction caused by an annular carcinoma of the antrum. There is irregular narrowing of the distal antrum (arrow) with proximal dilatation of the stomach.
Abdominal CT in a patient with gastric outlet obstruction due to peptic ulcer disease showing a distended and fluid filled stomach
Endoscopy
Medical TherapyoHydrationocorrection of electrolyte
abnormalitiesoNG tubeoParenteral PPI
• Surgical Therapy
Treatment
the most frequently encountered surgical disorder of the small intestine
80% all mechanical intestinal obstruction
It has a wide range of etiologies
SBO (Small Bowel Obstruction)
Intraluminal (e.g., foreign bodies, gallstones, or meconium)
Intramural (e.g., tumors, Crohn's disease–associated inflammatory strictures)
Extrinsic (e.g., adhesions, hernias, or carcinomatosis)
Etiologies
Most Common Causeso Intra-abdominal adhesions (75%)
• Less prevalent etiologiesoherniasoCrohn's diseaseoCanceroCongenital abnormalities
Etiologies
Accumulation of gas and fluidIncreases of intestinal activityocolicky pain
Distendion of bowelRises of intraluminal and intramural pressures
Pathophysiology
Simple obstructionopartialoComplete
Strangulated obstructionClosed loop obstruction (e.g., with
volvulus)
Kinds of SBO
Symptomso colicky abdominal paino Nauseao vomitingo Obstipation
• Signsoabdominal distentionoBowel sounds may be hyperactive
Clinical Presentation
Reflect intravascular volume depletion
Consist of hemoconcentration and electrolyte abnormalities
Mild leukocytosis
Laboratory findings
TachycardiaLocalized abdominal tendernessFeverMarked leukocytosisAcidosisPositive stool blood test
Features of strangulated obstruction
Distinguish mechanical obstruction from ileus
Determine the etiology of the obstruction
Discriminate partial from complete obstruction
Discriminate simple from strangulating obstruction
Diagnosis
functional obstructionSame symptoms and signsPostoperative ileusmotility returning to normal after laparotomyo small intestinal 24 hoursoGastric 48 hours o colonic 3 to 5 days
Ileus
Historyo prior abdominal operationso presence of abdominal disorders
Examinationo search for hernias
Diagnosis
Triado dilated small bowel loops (>3 cm in
diameter)o air-fluid levels seen on upright filmso a paucity of air in the colon
Sensitivity 70 to 80% Specificity is low
Radiographic Examination
80 to 90% sensitive 70 to 90% specificdiscrete transition zoneo dilation of bowel proximallyo decompression of bowel distally
Computed tomography (CT)
Fluid resuscitationMonitor urine outputBroad-spectrum antibioticsNG tubeExpeditious surgery
Therapy
NG decompression & fluid resuscitation
Partial small bowel obstructionObstruction occurring in the early postoperative period
Intestinal obstruction due to Crohn's disease
Carcinomatosis
Conservative Therapy
Perioperative mortality:For Nonstrangulating Less than
5%For strangulating 8 to 25%
Prognoses
20% all mechanical intestinal obstruction
The etiology of LBO is age dependent
LBO (Large-bowel obstruction)
colon cancer 60% DiverticulitisVolvulus
CecalSigmoid
Etiologies
Chronic weight lossMelanotyc bloody stoolChange of caliber of stoolColonic lesion development history
o Right side Late obstruction
o Left side Early obstruction
History of Cancer
Recurent LLQ pain over yearso Diverticulitis
Abrupt onset of symptomso Vulvulus
History
Colonic distentionAbdominal painAnorexiaFeculent vomitingDehydration Electrolyte disturbances
Pathophysiology
Symptomso colicky abdominal paino Nauseao vomitingo Obstipation
Clinical Presentation
SBOo More severeo Shorter intervalo Shorter duration
LBOo Less severeo Longer intervalo Longer duration
Colicky Abdominal Pain
GOOo Food particles
SBOo Billous
LBOo Fecaloid
Vomiting
SBOo Less Distention
LBOo More Distension
Abdominal Distension
Acute Colonic pseudo-obstruction
colon becomes massively dilated in the absence of mechanical obstruction
occurs in hospitalized patientsassociated with the use of narcotics, bedrest, and comorbid disease
Ogilvie syndrome (ACPO)
by diminished or, in later stages, absent bowel sounds
The abdomen is distendedThe abdomen may be tender
Ph/Ex
Reflect intravascular volume depletion
Consist of hemoconcentration and electrolyte abnormalities
Mild leukocytosis
Laboratory findings
AXRdemonstrates dilation of the small
and/or large bowel air fluid levels
barium enema CT scan
Imaging Studies
Large-bowel obstruction. Gastrografin study in a patient with obstipation reveals colonic obstruction at the rectosigmoid level.
Large-bowel obstruction. Contrast study of patient with cecal volvulus. The column of contrast ends in a "bird's beak" at the level of the volvulus.
MedicalSurgical
Therapy
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