Accounting, Bookkeeping, payroll and tax

Small-Bowel Obstruction

Special Promotions: 2 months free for bookkeeping and/or payroll service are on now. 3 years Business and Personal income tax filings FREE for residents in any 50 state are also included now! 2 Accounts Left Only, Click Any Where Here! 2 months FREE, Limited Time Offers Only, FOR Either Bookkeeping and/or Payroll Services!

Day(s)

:

Hour(s)

:

Minute(s)

:

Second(s)

FANTASTIC Useful WAYS to spend less one great REOCCURRING |

Accounting Department

Delightful! Great working day and thank you for your explore check out. There are huge TERRIFIC Helpful means to help save substantial amounts of tax and your current monthly bills on items you are already spending monthly. I will share with you a great deal more than the followings you find and more of these are coming. Guaranntee EFFECTIVE & HIGH SAVINGS monthly for you. I will give you particulars include recommendations illustrations and percentages % as well. Throughout this particular blog post, anyone read this likewise will certainly identify from administrator even more favours as well as allows available for you additional in proper everyday life with obvious examples concerning the correct way to put into play with regard to this correct successful high expense cost savings give good results. It all is a strong top core reason for assisting you actually; and also certainly coming from that years, everyone all of need to advance to twice or even considerably more than 65 several years average of years. I ACTUALLY expectation an individual recognise what is definitely called such as typically the abode. Finally, for Longevity, what if they can double like 150 ages instead of 65 as average? It will be normal? Some more important points are happiness stages are true dreams and are not visible or realized; hungry feeling of one is a good sight of my discovery even though none of these in this article are my medical advise; several areas of yourself likely are undeveloped; healing foods are not constant and experienced show mostly are not what they are. | Great additional profound helps from HeavenFARReach Admin.

Small-Bowel Obstruction

No Results

processing….

Small-bowel obstruction (SBO) is caused by a variety of pathologic processes. The most common cause of SBO in developed countries is intra-abdominal adhesions, accounting for approximately 65% to 75% of cases, followed by hernias, Crohn disease, malignancy, and volvulus.^[1] In contrast, SBO in developing countries is primary caused by hernias (30-40%), adhesions (about 30%), and tuberculosis (about 10%), along with malignancy, Crohn disease, volvulus, and parasitic infections.^[2]The general trend in developing countries is an increased incidence of SBO from adhesions, with a higher incidence of laparotomies. See the image below.

See Can’t-Miss Gastrointestinal Diagnoses, a Critical Images slideshow, to help diagnose the potentially life-threatening conditions that present with gastrointestinal symptoms.

Symptoms of SBO can be characterized as either partial or complete versus simple or strangulated. The classic symptoms of nausea, vomiting, abdominal pain, and constipation are rarely present in all cases of SBO. Abdominal pain associated with SBO is often described as crampy and intermittent. Without treatment, the abdominal pain can increase as a result of bowel perforation and ischemia. Therefore, having a clinical suspicion for the condition is paramount to early identification and intervention. Furthermore, the clinical presentation of the patients varies and no one clinical symptom on its own identifies the majority of patients with SBO. Some studies have suggested that the absence of passage of flatus and/or feces and vomiting are the most common presenting symptoms, with abdominal discomfort/distention the most frequent physical examination findings.^[3]Other studies have shown that abdominal pain is present in the majority of patients found to have SBO.

Some signs and symptoms associated with SBO include the following:

Nausea/vomiting (60-80%): The vomitus can often be bilious in nature

Constipation/absence of flatus (80-90%): Typically a later finding of SBO

Abdominal distention (60%)

Fever and tachycardia: Late findings and may be associated with strangulation

Some risk factors associated with SBO include the following:

Previous abdominal or pelvic surgery, previous radiation therapy, or both: May be part of the patient’s medical history

History of malignancy: Particularly ovarian and colonic malignancy

Inflammatory bowel disease

See Presentation for more detail.

Laboratory tests

The following are adjunctive laboratory tests used in the evaluation of SBO:

Serum chemistries: Rarely abnormal early in the disease unless due to vomiting or dehydration

BUN/creatinine levels: May be elevated in dehydration due to vomiting

CBC count: Elevation can be associated with complications

Serum lactate levels: Elevation is suggestive of dehydration or tissue hypoperfusion

Urinalysis

Type and crossmatch

PT, PTT, and INR measurements

Laboratory tests to exclude biliary or hepatic disease are also needed. They include the following:

Phosphate level

Creatine kinase level

Liver panel: AST, ALT, ALP, and bilirubin levels

Imaging tests

Obtain plain radiographs first for patients in whom SBO is suspected. Although not sensitive, upright abdominal films may help substantiate the diagnosis if the presence of air-fluid levels or a paucity of gas is observed. Note that supine films may obscure the detection of air-fluid levels.^[4]

Multislice CT has been show to be a particularly effective imaging tool for evaluating patients suspected of having SBO, with a sensitivity of over 95%.^[5]CT imaging is also capable of detecting complications of SBO not visualized on plain films, including ischemia, perforation, mesenteric edema, and pneumatosis.

Ultrasonography is less costly and invasive than CT scanning and may reliably exclude SBO in as many as 89% of patients; specificity is reportedly 100%. It may be a useful alternative imaging modality in children and pregnant women.

Enteroclysis is another valuable diagnostic test in detecting the presence of obstruction and in differentiating partial from complete blockages. This study is useful when plain radiographic findings are normal in the presence of clinical signs of SBO or when plain radiographic findings are nonspecific. However, CT imaging has superseded enteroclysis due to the increased availability of CT scanners as well as owing to the procedure’s increased risk of perforation and aspiration.

See Workup for more detail.

Management

Nonoperative treatment

Nonoperative treatment for several types of SBO are as follows:

Malignant tumor – Obstruction by tumor is usually caused by metastasis; initial treatment should be nonoperative (surgical resection is recommended when feasible)

Inflammatory bowel disease – To reduce the inflammatory process, treatment generally is nonoperative in combination with high-dose steroids; consider parenteral treatment for prolonged periods of bowel rest, and undertake surgical treatment, bowel resection, and/or stricturoplasty if nonoperative treatment fails.

Intra-abdominal abscess – CT scan ̶ guided drainage is usually sufficient to relieve obstruction

Radiation enteritis – If obstruction follows radiation therapy acutely, nonoperative treatment accompanied by steroids is usually sufficient; if the obstruction is a chronic sequela of radiation therapy, surgical treatment is indicated

Incarcerated hernia – Initially use manual reduction and observation; advise elective hernia repair as soon as possible after reduction

Acute postoperative obstruction – This is difficult to diagnose because symptoms are often attributed to incisional pain and postoperative ileus; treatment should be nonoperative

Adhesions – Decreasing intraoperative trauma to the peritoneal surfaces can prevent adhesion formation

Surgical care

A strangulated obstruction is a surgical emergency. In patients with a complete small-bowel obstruction (SBO), the risk of strangulation is high and early surgical intervention is warranted. Laparoscopy has been shown to be safe and effective in selected cases of SBO.^{[6, 7]}

See Treatment and Medication for more detail.

In the United States, 15 of every 100 admissions for abominal pain are due to small-bowel obstruction (SBO), with 300,000 admissions annually.^[8] An SBO is caused by a variety of pathologic processes. The leading cause of SBO in industrialized countries is postoperative adhesions (65-75%), followed by malignancy, Crohn disease, and hernias, although some studies have reported Crohn disease as a greater etiologic factor than neoplasia. Surgeries most closely associated with SBO are appendectomy, colorectal surgery, and gynecologic and upper gastrointestinal (GI) procedures (see the image below). (See Etiology.)

One study from Canada reported a higher frequency of SBO after colorectal surgery, followed by gynecologic surgery, hernia repair, and appendectomy. Lower abdominal and pelvic surgeries lead to obstruction more often than upper GI surgeries. (See Etiology.)

SBOs can be partial or complete, simple (ie, nonstrangulated) or strangulated. Strangulated obstructions are surgical emergencies. If not diagnosed and properly treated, vascular compromise leads to bowel ischemia and further morbidity and mortality. Differentiating the characteristics and etiologies of obstruction is critical to proper patient treatment because as many as 40% of patients have strangulated obstructions. SBO accounts for 20% of all acute surgical admissions. (See Presentation, Workup, and Treatment.)

Small-bowel obstruction (SBO) leads to proximal dilatation of the intestine due to accumulation of gastrointestinal (GI) secretions and swallowed air. Bowel dilatation stimulates cell secretory activity, resulting in more fluid accumulation. This, in turn, leads to increased peristalsis above and below the obstruction, with frequent loose stools and flatus early in its course.

Vomiting occurs if the level of obstruction is proximal. Increasing small-bowel distention leads to increased intraluminal pressures. This can cause compression of mucosal lymphatics, leading to bowel wall lymphedema. With even higher intraluminal hydrostatic pressures, increased hydrostatic pressure in the capillary beds results in massive third spacing of fluid, electrolytes, and proteins into the intestinal lumen. The fluid loss and dehydration that ensue may be severe and contribute to increased morbidity and mortality.

Strangulated SBOs are most commonly associated with adhesions and occur when a loop of distended bowel twists on its mesenteric pedicle. The arterial occlusion leads to bowel ischemia and necrosis. If left untreated, this progresses to perforation, peritonitis, and death.

Bacteria in the gut proliferate proximal to the obstruction. Microvascular changes in the bowel wall allow translocation to the mesenteric lymph nodes. This is associated with an increase in the incidence of bacteremia due to Escherichia coli, but the clinical significance is unclear.

The most common cause of small-bowel obstruction (SBO) in developed countries is intra-abdominal adhesions, accounting for approximately 65% to 75% of cases.^[1]Postoperative adhesions can be the cause of acute obstruction within 4 weeks of surgery or of chronic obstruction decades later. The incidence of SBO parallels the increasing number of laparotomies performed in developing countries.

Prevention of SBO may be essentially limited to decreasing the risk of adhesion formation by decreasing the number of intra-abdominal procedures (ie, laparotomies) and resultant scar formation. In a study by Van Der Wal et al, the incidence of chronic abdominal symptoms was significantly reduced after the use of a hyaluronic acid ̶ carboxymethylcellulose membrane (Seprafilm). However, Seprafilm placement did not provide protection against SBO.^[9]

Following adhesions, the most common causes of SBO in developed regions are hernias (incarcerated groin hernias) (10-20%), malignancy (10-20%), inflammatory bowel disease (5%), volvulus (3%), and miscellaneous causes (2%).^[1] The causes of SBO in pediatric patients include congenital atresia, pyloric stenosis, and intussusception.

In contrast, SBO in developing countries is primarily caused by hernias (30-40%), adhesions (about 30%), and tuberculosis (about 10%), along with malignancy, Crohn disease, volvulus, and parasitic infections.^[2]

With proper diagnosis and treatment of the obstruction, prognosis in small-bowel obstruction (SBO) is good. Complete obstructions treated successfully nonoperatively have a higher incidence of recurrence than do those treated surgically.

Morbidity and mortality are dependent on the early recognition and correct diagnosis of obstruction. If untreated, strangulated obstructions cause death in 100% of patients. If surgery is performed within 36 hours, the mortality rate decreases to 8%. The mortality rate is 25% if the surgery is postponed beyond 36 hours in these patients.

Some factors associated with death and postoperative complications include age, comorbidity, and treatment delay. According to one Norwegian group, morbidity and mortality from SBO decreased from 1961 to 1995; the mortality was reported to be about 5%.^[10]

Complications of SBO also depend on the severity of the condition, the patient’s age, the presence of comorbities and, often, the duration of symptoms/signs, and include the following:

Sepsis: Due to translocation of intestinal bacteria from tissue breakdown

Intra-abdominal abscess

Wound dehiscence

Aspiration

Short-bowel syndrome (as a result of multiple surgeries)

Disability and death (secondary to delayed treatment)

Cardiac and pulmonary complications may result from procedures and hospitalization, neurologic complications, thrombosis/embolism, major hemorrhage, incision infection or rupture, and abdominal abscess or fistula formation. They include the following^{[3, 10]}:

Pneumonia: Including aspiration, ventilator associated, and/or hospital acquired

Bowel ischemia/perforation

Peritonitis

Acute kidney injury/acute renal failure

Surgical complications

Menzies D, Ellis H. Intestinal obstruction from adhesions–how big is the problem?. Ann R Coll Surg Engl. 1990 Jan. 72 (1):60-3. [Medline].

Hasnain SQ, Ahmed M. Intestinal obstruction in adults at the Aga Khan University Hospital. J Pak Med Assoc. 1994 Jun. 44 (6):143-5. [Medline].

Markogiannakis H, Messaris E, Dardamanis D, Pararas N, Tzertzemelis D, Giannopoulos P, et al. Acute mechanical bowel obstruction: clinical presentation, etiology, management and outcome. World J Gastroenterol. 2007 Jan 21. 13 (3):432-7. [Medline].

Thompson WM, Kilani RK, Smith BB, Thomas J, Jaffe TA, Delong DM, et al. Accuracy of abdominal radiography in acute small-bowel obstruction: does reviewer experience matter?. AJR Am J Roentgenol. 2007 Mar. 188(3):W233-8. [Medline].

Paulson EK, Thompson WM. Review of small-bowel obstruction: the diagnosis and when to worry. Radiology. 2015 May. 275 (2):332-42. [Medline].

Zerey M, Sechrist CW, Kercher KW, Sing RF, Matthews BD, Heniford BT. The laparoscopic management of small-bowel obstruction. Am J Surg. 2007 Dec. 194(6):882-7; discussion 887-8. [Medline].

Khaikin M, Schneidereit N, Cera S, Sands D, Efron J, Weiss EG, et al. Laparoscopic vs. open surgery for acute adhesive small-bowel obstruction: patients’ outcome and cost-effectiveness. Surg Endosc. 2007 May. 21(5):742-6. [Medline].

Taylor MR, Lalani N. Adult small bowel obstruction. Acad Emerg Med. 2013 Jun. 20 (6):528-44. [Medline].

van der Wal JB, Iordens GI, Vrijland WW, van Veen RN, Lange J, Jeekel J. Adhesion prevention during laparotomy: long-term follow-up of a randomized clinical trial. Ann Surg. 2011 Jun. 253(6):1118-21. [Medline].

Fevang BT, Fevang J, Stangeland L, Soreide O, Svanes K, Viste A. Complications and death after surgical treatment of small bowel obstruction: A 35-year institutional experience. Ann Surg. 2000 Apr. 231(4):529-37. [Medline]. [Full Text].

Daneshmand S, Hedley CG, Stain SC. The utility and reliability of computed tomography scan in the diagnosis of small bowel obstruction. Am Surg. 1999 Oct. 65 (10):922-6. [Medline].

Lappas JC, Reyes BL, Maglinte DD. Abdominal radiography findings in small-bowel obstruction: relevance to triage for additional diagnostic imaging. AJR Am J Roentgenol. 2001 Jan. 176(1):167-74. [Medline].

Diaz JJ Jr, Bokhari F, Mowery NT, Acosta JA, Block EF, Bromberg WJ, et al. Guidelines for management of small bowel obstruction. J Trauma. 2008 Jun. 64(6):1651-64. [Medline].

Raptopoulos V, Schwartz RK, McNicholas MM, Movson J, Pearlman J, Joffe N. Multiplanar helical CT enterography in patients with Crohn’s disease. AJR Am J Roentgenol. 1997 Dec. 169(6):1545-50. [Medline].

Bodily KD, Fletcher JG, Solem CA, Johnson CD, Fidler JL, Barlow JM, et al. Crohn Disease: mural attenuation and thickness at contrast-enhanced CT Enterography–correlation with endoscopic and histologic findings of inflammation. Radiology. 2006 Feb. 238(2):505-16. [Medline].

Engin G. Computed tomography enteroclysis in the diagnosis of intestinal diseases. J Comput Assist Tomogr. 2008 Jan-Feb. 32(1):9-16. [Medline].

Rajesh A, Maglinte DD. Multislice CT enteroclysis: technique and clinical applications. Clin Radiol. 2006 Jan. 61(1):31-9. [Medline].

Gollub MJ. Multidetector computed tomography enteroclysis of patients with small bowel obstruction: a volume-rendered “surgical perspective”. J Comput Assist Tomogr. 2005 May-Jun. 29(3):401-7. [Medline].

Cappell MS, Batke M. Mechanical obstruction of the small bowel and colon. Med Clin North Am. 2008 May. 92(3):575-97, viii. [Medline].

Sheedy SP, Earnest F 4th, Fletcher JG, Fidler JL, Hoskin TL. CT of small-bowel ischemia associated with obstruction in emergency department patients: diagnostic performance evaluation. Radiology. 2006 Dec. 241(3):729-36. [Medline].

Suri S, Gupta S, Sudhakar PJ, Venkataramu NK, Sood B, Wig JD. Comparative evaluation of plain films, ultrasound and CT in the diagnosis of intestinal obstruction. Acta Radiol. 1999 Jul. 40 (4):422-8. [Medline].

Kim JH, Ha HK, Sohn MJ, Shin BS, Lee YS, Chung SY, et al. Usefulness of MR imaging for diseases of the small intestine: comparison with CT. Korean J Radiol. 2000 Jan-Mar. 1(1):43-50. [Medline]. [Full Text].

Beall DP, Fortman BJ, Lawler BC, Regan F. Imaging bowel obstruction: a comparison between fast magnetic resonance imaging and helical computed tomography. Clin Radiol. 2002 Aug. 57(8):719-24. [Medline].

Regan F, Beall DP, Bohlman ME, Khazan R, Sufi A, Schaefer DC. Fast MR imaging and the detection of small-bowel obstruction. AJR Am J Roentgenol. 1998 Jun. 170(6):1465-9. [Medline].

Rubio EI, Blask AR, Badillo AT, Bulas DI. Prenatal magnetic resonance and ultrasonographic findings in small-bowel obstruction: imaging clues and postnatal outcomes. Pediatr Radiol. 2017 Jan 23. [Medline].

Jang TB, Schindler D, Kaji AH. Bedside ultrasonography for the detection of small bowel obstruction in the emergency department. Emerg Med J. 2011 Aug. 28(8):676-8. [Medline].

Di Saverio S, Coccolini F, Galati M, Smerieri N, Biffl WL, Ansaloni L, et al. Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2013 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group. World J Emerg Surg. 2013 Oct 10. 8(1):42. [Medline].

Scotte M, Mauvais F, Bubenheim M, et al. Use of water-soluble contrast medium (gastrografin) does not decrease the need for operative intervention nor the duration of hospital stay in uncomplicated acute adhesive small bowel obstruction? A multicenter, randomized, clinical trial (Adhesive Small Bowel Obstruction Study) and systematic review. Surgery. 2017 Jan 10. [Medline].

Cirocchi R, Abraha I, Farinella E, Montedori A, Sciannameo F. Laparoscopic versus open surgery in small bowel obstruction. Cochrane Database Syst Rev. 2010 Feb 17. CD007511. [Medline].

Wancata LM, Abdelsattar ZM, Suwanabol PA, Campbell DA Jr, Hendren S. Outcomes after surgery for benign and malignant small bowel obstruction. J Gastrointest Surg. 2017 Feb. 21 (2):363-71. [Medline].

Alhilli MM, El-Nashar SA, Garrett AT, Weaver AL, Famuyide AO. Use of Computed Tomography in the Diagnosis of Bowel Complications After Gynecologic Surgery. Obstet Gynecol. 2013 Nov 6. [Medline].

Henderson D. Postop CT Scans May Fail to Detect Bowel Obstruction. Medscape [serial online]. Available at http://www.medscape.com/viewarticle/814341. Accessed: November 18, 2013.

Fevang BT, Fevang JM, Soreide O, Svanes K, Viste A. Delay in operative treatment among patients with small bowel obstruction. Scand J Surg. 2003. 92 (2):131-7. [Medline].

Langer JC. Intestinal rotation abnormalities and midgut volvulus. Surg Clin North Am. 2017 Feb. 97 (1):147-59. [Medline].

Sokhandon F, Al-Katib S, Bahoura L, Copelan A, George D, Scola D. Multidetector CT enterography of focal small bowel lesions: a radiological-pathological correlation. Abdom Radiol (NY). 2016 Dec 20. [Medline].

Yang KH, Lee TB, Lee SH, Kim SH, Cho YH, Kim HY. Congenital adhesion band causing small bowel obstruction: What’s the difference in various age groups, pediatric and adult patients?. BMC Surg. 2016 Dec 7. 16 (1):79. [Medline].

Mityanand Ramnarine, MD, FACEP Assistant Professor of Emergency Medicine, Associate Chair, Department of Emergency Medicine, Program Director, Emergency/Internal Medicine/Critical Care, Hofstra Northwell School of Medicine at Hofstra University; Attending Physician, Department of Emergency Medicine, Long Island Jewish Medical Center

Mityanand Ramnarine, MD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, American College of Physicians, American Medical Association