Vomiting, Diarrhea & ConstipationMark J. Koruda, MDProfessor of Surgery

AssumptionsStudents understand the anatomy, embryology and physiology of the gastrointestinal tract.

Case 1A 54-year-old woman presents with a two day history of crampy abdominal pain followed by episodes of bilious emesis.

Important Items in the History?

Previously hysterectomy for treatment of cervical cancer.

Small Bowel Obstruction

Small Bowel ObstructionSigns & SymptomsIntermittent, Crampy Abdominal PainNausea / EmesisDistensionObstipationPeristaltic Rushes on AuscultationFocal TendernessDiffuse Peritonitis

Case 1What findings should be looked for on physical exam?

Distended

No peritoneal signs

Case 1What laboratory tests should be ordered?

Small Bowel ObstructionLaboratory EvaluationMay see hypochloremic, hypokalemic metabolic alkalosis if having frequent emesis (proximal obstruction).May see evidence of contraction alkalosisIncreased H/H, BUN.WBC usually normal early.

Case 1What laboratory tests should be ordered?

What diagnostic tests should be ordered?

Small Bowel ObstructionRadiologic EvaluationXrays: ? AFLs, ? Free Air, ? Distal GasUGI / SBFT: Identify mechanical obstructionEnteroclysis: Independent of gastric emptyingCT Scan: ? Free Air, ? Pneumatosis, ? Tumor

Small Bowel ObstructionEtiologiesAdhesionsMalignancyExternal or Internal HerniaVolvulusCrohns DiseaseIntra-abdominal Abscess

Small Bowel ObstructionEtiologies (Cont.)Radiation StrictureForeign BodyGallstone IleusMeckels DiverticulumIntramural HematomaMesenteric IschemiaIntussusception

Intestinal IleusEtiologiesPostoperative StateSepsisElectrolyte ImbalanceDrugsUreteral and Biliary ColicRetroperitoneal HemorrhageSpinal Cord InjuryMyocardial InfarctionPneumonia

Case 1What is the initial management plan?

Small Bowel ObstructionPartial vs. TotalWhy Not Just Wait??

Potential for Closed Loop ObstructionRisk of Ischemia / Perforation (4-6 hrs)

Small Bowel ObstructionTreatmentCorrect intravascular volume deficitNGT vs. Miller-Abbott or Cantor TubesSerial ExamsOperation if no improvement or if signs of complete (closed loop) obstruction or incarceration.Evaluation of Bowel Viability

Small Bowel ObstructionSpecial CasesEarly Postoperative SBO

Case 2A 72-year-old man presents with a two month history of gradually increasing constipation.

Key Points in History?

Large Bowel ObstructionDiagnosisCrampy PainOnset may be acute or insidiousDistension (50-60% have competent ileo-cecal valve and develop severe distension)Xrays: 12-14 cm cecum, perforation riskContrast enema: Obstruction vs OglivesConsider rigid sigmoidoscopy to r/o and treat sigmoid volvulus

Case 2Physical Exam

What further tests are indicated

Case 2Differential Diagnosis

Colonic ObstructionMalignantBenign

Colonic Dysfunction

Large Bowel Obstruction

Large Bowel ObstructionEtiologiesColon CancerDiverticulitisExtrinsic CancerFecal ImpactionIntussusceptionVolvulusIncarcerated Hernias

Large Bowel ObstructionColon Cancer20% of colon cancers present with obstructionLeft-sided lesions are more prone to obstruct (more narrow lumen, more solid fecal stream)

Large Bowel ObstructionTreatmentIVFNGTOperationEmergently if signs of peritonitis / perforationPrep bowel if possibleIs an ostomy necessary?Right vs. Left-sided LesionsTraditional vs. Newer Attitudes

right colon - can reanastamosetransverse colon - extended right hemileft colon3 stage (ostomy, resection, takedown)2 stage (resect with protecting ostomy, takedown)1 stage (resect, anastamose with or without colonic lavage)leak rate 5%1 stage (resect whole colon and do an ileoproctostomy to avoid fecal loading)

Large Bowel DysfunctionInflammationColonic InertiaEtc

Oglives Syndrome(Colonic Pseudo-Obstruction)May mimic mechanical obstructionAssociated ConditionsTreatment: Rectal tube / enemas /exams (work in most)Colonoscopic decompression (80-90% eff.)Surgery (Cecostomy vs. Resection) - cecum >12 cm or peritoneal signs

Associated Conditions:AmyloidosisBlunt traumaCardiopulmonary BypassC-sectionChemotherapyDermatofibrosisDiabetesElectrolyte abnormalitiesHypothyroidismMedications (anticholinergics, ganglionic blockers, narcotics, phenothiazines, tricyclic antidepressants)Ortho or Neurologic ProceduresRenal FailureRenalTransplantationSclerodermaDementia / StrokeSLE

Case 3A 54-yo Caucasian male with history of ileocolonic Crohn's disease, s/p ileocolectomy in 1979, who has not been on any Rx for CD. Presents to the UNC ER complaining of crampy abdominal pain that began at 8 hrs earlier located in the right lower and left lower quadrant. He also had nausea and vomiting as well as decreasing flatus associated. The patient stated his last BM was on the day of admission. He stated that the pain feels like his previous obstructions. Occurring every couple of months, recently increasing in frequency. No fevers. About 10 lb weight loss.

Key Points in History

What Is Crohns Disease?Crohns disease (CD) is an inflammatory bowel disorder that may affect any part of the gastro-intestinal (GI) tractThe inflammation penetrates the lining of the GI tract and often causes ulcers to form

SmallIntestineLargeIntestine(Colon)AppendixEsophagusStomachRectum

Case 3

Key Points in History

Case 3

Key Points in History Crohns diseasePrevious surgical historyNo Crohns RxChronic symptomsWeight lossNo feversCrampy pain

Case 3Physical Exam

Diagnostic Studies?

Differential Dx

Crohns Disease

Crohns Disease

Crohns DiseaseMedical vs Surgical Management

Case 422yo UNC student presents with 3 mos of increasing bloody diarrhea, going to the bathroom 15-20x/day. It rules my life!

Key Points in History

Case 422yo UNC student presents with 3 mos of increasing bloody diarrhea, going to the bathroom 15-20x/day. It rules my life!

Key Points in HistoryDiarrheaBleeding

Case 4Physical Exam

Diagnostic Studies?

Ulcerative Colitis

right colon - can reanastamosetransverse colon - extended right hemileft colon3 stage (ostomy, resection, takedown)2 stage (resect with protecting ostomy, takedown)1 stage (resect, anastamose with or without colonic lavage)leak rate 5%1 stage (resect whole colon and do an ileoproctostomy to avoid fecal loading)Associated Conditions:AmyloidosisBlunt traumaCardiopulmonary BypassC-sectionChemotherapyDermatofibrosisDiabetesElectrolyte abnormalitiesHypothyroidismMedications (anticholinergics, ganglionic blockers, narcotics, phenothiazines, tricyclic antidepressants)Ortho or Neurologic ProceduresRenal FailureRenalTransplantationSclerodermaDementia / StrokeSLE