– History –
1. Is it obstruction or not?
- Cardinal features: N\V, abdominal pain, distension, decreased flatus, constipation\obstipation
2. What’s the likely level of obstruction?
|Cramping pain (periumbilical)
Early vomiting (may be bilious)
May still have bowel movement\passing flatus distal to obstruction
|Cramping pain (lower abdomen)
Late\absent vomiting (may be fecal)
3. What’s the probable cause:
- Fecal impaction, gallstone ileus, foreign body, bezoar, worm ball (Ascaris)
- Neoplasm (benign\malignant), intussusception, inflammatory, ischemia
- Adhesions, hernia, volvulus\malrotation, intra-abdominal tumors (ovarian masses, mesenteric cysts, pancreatic cysts, GIST), tumor cell deposits in mesentery, annular pancreas, intra-abdominal abscess or hematoma
4. Partial or complete?
- Still passing stool\flatus -> partial obstruction
- No bowel movement > 24 hrs \ obstipation -> complete obstruction
5, Simple or complicated?
- No peritoneal signs = simple obstruction
- Peritoneal signs, ischemia, gangrene, perforation = complicated obstruction
6. Any systemic manifestations caused by the obstruction?
- Dehydration, electrolyte disturbances, hemodynamic instability, renal impairment
Important points in PMHx:
- Diseases: malignancy, atherosclerotic ds, prev MI\stroke, arrhythmia, IBD, diverticulitis, chronic biliary colic, hx of hernia
- Review medications
- Previous abdominal operations
– Physical Exam –
- Vital signs: hemodynamic stability (tachycardic, hypotensive), fever
- Abdominal exam:
- Inspection: scars, distention, obv masses, hernia
- Palpation: tenderness, guarding, masses, hernia
- Percussion: tympanic
- Bowel sounds: hyperactive -> hypoactive\absent
- PR exam:
- Empty rectal vault?
- Fecal impaction?
- Pelvic masses?
- + FOBT -> strangulation, ca, inflammation
– Investigations –
- CBC: leukocytosis, hgb\hct (high if dehydrated, low if anemic)
- Electrolytes: hypokalemia
- Renal function: BUN, Cr (high if dehydrated)
- Plain films: initial
- Barium: for LBO
- CT: for SBO
– Management –
- If partial, simple obstruction -> conservative therapy:
- IV hydration
- Correct electrolyte imbalances
- NGT decompression
- Foley’s cath to monitor output
- If not improving or worsening of partial obstruction w\ conservative therapy, signs of peritonitis, hemodynamic instability -> OR