Small bowel obstruction and Intestinal Fistulas

Small Bowel ObstructionJosé Luis Cortés Sánchez

Brunicardi, F. C. (2015). Schwartz's Principles of Surgery. 10 Ed. McGrawHill Ed


Epidemiology Most frequently encountered surgical disorder

of the small intestine Anatomic relationship to intestinal wall: 1.- Intraluminal: 2.- Intramural 3.- Extrinsic

Intraabdominal adhesions related to prior abdominal surgery account for up to 75% of cases

300,000 patients are estimated to undergo surgery to treat them annually

From 1988 to 2007 there was no decrease in this rate

Ongoing problems with this “old” disease



Other causes: Hernias, malignant, Chron’s

Few are due to primary bowel tumors

Congenital usually become evident during childhood, but sometimes are not

i.e. Intestinal malrotation, mid-gut volvolus (without history)

Superior mesentric artery Sx. (rare etiology)


PathophysiologyGas and fluid acumulate

Intestinal activity increases Pain and diarrhea

Swallowed air and produced

Swallowed liquids and GI secretions Bowel distends IM/ IL pressure rises

Motility is eventually reduced

Luminal flora changes

If IM pressure high enough perfusion is impaired ischemia - necrosis

Strangulated bowel obstructionBrunicardi, F. C. (2015). Schwartz's Principles of Surgery. 10 Ed. McGrawHill Ed


Partial

Allows passage of some fluid and gas

Event progression occur more slowly

Less likely to become strangulated

Closed-loop

Particularly dangerous E.g. volvolus Rapid rise in luminal

pressure Rapid progression to

strangulation


Clinical presentation Colicky abdominal pain, nausea, vomiting,

obstipation More vomiting w/proximal than distal Feculent? bacterial overgrowth (more

established) Continuos passage of flattus/stool >6-12

hours= Partial

Signs Abdominal distention (more if distal) Initially hyperactive bowel sounds then

minimal Lab:

Intravascular volume depletion Hemoconcentration Electrolyte abnormalities Mild leukocytosis


Strangulated Abd. pain disproportionate to degree of abd

findings -suggestive of intestinal ischemia

Tachycardia, Localized abd tenderness Fever Marked leukocytosis Acidosis

Alert!

Prompt early surgical intervention!


Diagnosis 1.-Distinguishing mechanical obstruction from

ileus 2.-Determine the etiology 3.-Discriminate partial from complete 4.-Discriminate simple from strangulated


History Prior abd operations Abd disorders (cancer, IBD) Meticulous search for hernias(inguinal, femoral) Dx.- confirmed by radiographic exams



Abdominal series Rx of the abdomen patient in supine Abdomen w/patient upright Rx of the chest w/patient in upright

Most specific triad:-Dilated small bowel loops (>3 cm in diameter)-Air-fluid levels on upright-Paucity of air in colon

S= 70-80%E= lowDDX.-

Ileus, colonic obstruction

FN= proximal; fluid but no gas Closed-loop

Despite these limitations, abdominal radiographs remain an important study in patients with suspected small bowel obstruction because of their wide- spread availability and low cost


CT scan Discrete transition zonew/dilation of proximal Decompression of distally Contrast that doesn’t pass beyond transition Colon with little gas or fluid

S= 80-90%E= 70-90%

-CT may also provide evidence of closed-loop/strangulation--Closed-loop U-/C-shaped bowel+ radial messenteric vessels in torsion point

-StrangulationThickening of bowel wall, pneumatosis intestinalis, portal venous gas, mesenteric hazinessPoor uptake of IV contrast

CT also reveals the etiology


Appearance of contrast in colon w(24hrs) is predictive of non-surgical resolution

Reduce overall length of hospitalization

S= 50% , for low-grade or partial

Small bowel series/ Enteroclysis can be helpful


Therapy Marked depletion of IV volume –> fluid resuscitation is integral

to treatment Central venous o pulmonary artery catheter assist fluid

management (CVS or severe) Antibiotics? No data to support it

Isotonic fluid IV + Bladder catheter

NG tube to evacuate stomach. Not jejunum nor ileum

Decreases nausea, vomiting, distention, aspiration

“the sun should never rise and set on a complete bowel obstruction.”



nonoperative aproaches

R/O closed-loop ; neither intestinal ischemia

Observe closely and undergo serial exams

Early surgical intervention

Minimize the risk for strangulation

Morbimortality

Signs and lab tests and imaging don’t distinct between them

Goal? operate before onset of ischemiaA period of observation and NG decompression, provided no tachycardia, tenderness or WBC increases

Conservative therapy 1. Partial small bowel obstruction

2. Obstruction occurring in the early postoperative

3. Intestinal obstruction due to Crohn’s disease

4. Carcinomatosis

Strangulation is unlikely to occur. Succesful in 65-81% Of these 5-15% don’t improve at 48 hrs

Patients with partial obstruction thath do not improve at 48h should undergo surgery!0

-Occur in 0.7% patients undergoing laparotomy.

-Pelvic surgery, especially colorectal procedures, have the greatest

risk.

-Should be considered if

-symptoms of intestinal obstruction occur after the initial

return -Function fails to return within the expected 3 to 5 days after

-25-33% of patients with

-Even in cases in which the obstruction is related to recurrent malignancy,

palliative resection or bypass can be performed.

-Patients with obvious carcinomatosis pose a difficult challenge, given their

limited prognosis.

May be best achieved by a bypass procedureBrunicardi, F. C. (2015). Schwartz's Principles of Surgery. 10 Ed. McGrawHill Ed


Adhesions lysed Tumors resected Hernias reduced and repaired.

The affected intestine should be examined, and nonviable bowel resected.

If the patient is hemodynamically stable, short lengths of bowel of questionable viability should be resected

Bowel of uncertain viability should be left intact and the patient re-explored in 24 to 48 hours in a “second- look” operation.

Criteria suggesting viability:

-normal color,-peristalsis, -marginal arterial pulsation

Operative procedure varies according to the etiology

Laparascopic procedure have a quicker recovery, less complications, and lower costs.

Distended loops of bowel can interfere with adequate visualization, early cases likely due to a single adhesion

Conversion rate to open surgery is between 17% and 33%

Outcomes Prognosis is related to the etiology Less than 20% of conservative patients will have a

readmission over the subsequent 5 years The perioperative mortality rate associated with

surgery for nonstrangulating small bowel obstruction is less than 5%,

Mortality rates associated with surgery for strangulating obstruction range from 8% to 25%.



Prevention

Good surgical technique, careful handling of tissue, and minimal use and exposure of peritoneum to foreign bodies form the cornerstone of adhesion prevention.

Colorectal or pelvic surgery, hospital readmission rates of greater than 30% over the subsequent 10 years

.

These measures alone are often inadequate.

Open surgery is associated with a 4x increase in risk of small bowel obstruction within 5 years of the index procedure

Seprafilm

INTESTINAL FISTULAS

fistula abnormal communication between two

epithelialized surfaces. internal fistula .- between two parts of the GI

tract or adjacent organs external fistula involves the skin or another

external surface epithelium. Over 80% of enterocutaneous fistulas represent

iatrogenic complications that occur as the result of enterotomies or intestinal anastomotic dehiscences.

Spontaneously without antecedent iatrogenic injury are Crohn’s disease or cancer. low-output fistulas

Entero- cutaneous fistulas that drain less than 200 mL of fluid per

day

high-output fistulas. those that drain more than 500 mL

of fluid per day

Pathophysiology Low-resistance enteroenteric bypass

malabsorption Enterovesicular Recurrent UTI’s Drainage from enterocutaneous irritates skin

excoriation Loss of enteric luminal contents (high-output)

dehydration, electrolyte abnormalities, malnutrition

Fistulas have the potential to close spontaneously, but:

Clinical

Presentation

Fever Leukocytosis prolonged ileus abdominal tenderness, wound infection

evident between the 5th-10th postoperative days.

initi

al si

gns.

Iatrogenic enterocutaneous fistulas

The diagnosis is obvious when drainage of enteric material occurs.

These fistulas are often associated with intraabdominal abscesses.

Diagnosis CT scanning following the

administration of enteral contrastMost useful initial test?

Leakage of contrast material from the intestinal lumen can be observed. Intraabdominal abscesses should be sought and drained percutaneously. -Small bowel series or

enteroclysis examination can be obtained to demonstrate the fistula’s site of origin in the bowel.

-Useful to R/O the presence of intestinal obstruction distal to the site of origin.

If the anatomy of the fistula is not clear on CT scanning?

A fistulogram,

Therapy 1. Stabilization.

Fluid and electrolyte resuscitation is begun. Nutrition is provided, usually through the parenteral route initially.

Sepsis is controlled with antibiotics and drainage of abscesses. The skin is protected from the fistula effluent with ostomy appliances

or fistula drains. 2. Investigation. The anatomy of the fistula is defined

3. Decision. Tx options considered, and timeline for conservative

4. Definitive management. surgical procedure 5. Rehabilitation.

Objective is to increase the probability of spotaneous closure.

Nutrition and time are the key components of this approach.

Most patients will require TPN

however, a trial of oral or enteral nutrition should be attempted in patients with low-output fistulas originating from the distal intestine.

Octreotide is a useful adjunct, particularly in patients with high-output fistulas; -reduces the volume of fistula output thereby facilitating fluid and electrolyte management.

Timing of Surgical Intervention.

2 to 3 months of conservative therapy before considering surgical intervention.

surgical intervention after this time period is associated with better outcomes and lower morbidity

90% of fistulas that are going to close do so within 5 weeks

fails to resolve during this period ?

fistula tract, together with the segment of intestine from which it originates, should be resected.

Simple closure of the opening in the intestine from which the fistula originates is associated with high recurrence rates.

Outcomes

“FRIEND” Foreign body within the fistula tract Radiation enteritis Infection/Inflammation at the fistula origin Epithelialization of the fistula tract Neoplasm at the fistula origin Distal obstruction of the intestine

Over 50% of intestinal fistulas close spontaneously.

153 cases of enterocutaneous

fistulas Majority were found to originate from the small bowel Patients having undergone 5 or + previous surgeries. 30-day mortality of approximately 4% 1-year mortality of 15%. Morbidity was over 80%. First surgical repair attempt was successful 70% of

cases

Some patients requiring up to three attempts at surgical repair.

closure of the abdominal fascia as an important factor in reducing rates of refistulization and postoperative mortality.Owen RM, Love TP, Perez SD, et al. Definitive surgical treatment of enterocutaneous fistula: outcomes of a 23-year experi- ence. Arch

Surg. 2012;15:1.

A 43-year-old woman comes to the emergency department with a 3-day history of abdominal distention, nausea, and vomiting. She also reports decreased urine output over the last 24 hours. She has a history of total abdominal hysterectomy 5 years ago for benign disease. She does not take any medications. Her pulse is 110 beats/minute. Her abdomen is distended and there is mild diffuse tenderness. Bowel sounds are hyperactive. The rest of her exam is normal. Serum electrolytes are sodium—140, chloride—90, bicarbonate—32, and potassium—4.0. Which of the following is the most appropriate initial intravenous fluid to administer to this patient?

A.-D5 1⁄2 normal saline with 40 mEq KCl/L B. Lactated Ringer’s solutionC. Normal salineD. Colloidal starch solutionE. 5% albumin in normal saline

Small bowel obstruction and Intestinal Fistulas

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Transcript of Small bowel obstruction and Intestinal Fistulas