Case 3

Paul a 43 year old male present to ER complaining of of intermittent abdominal pain for 2 days duration. The pain was associated with projectile bilious vomiting and abdomen distention with inability to pass stool.

There was no pervious attacks4 years ago the patient had appendectomy

On Examination:Insp.: distended abdomen+ Mcburny ScarPalp.: Generalized Abdomen tenderness + no cough impulsesPercussion: tympanic with no shifting dullnessAuscultation: hypoactive bowel soundsDRE: Empty Rectum

Small bowel obstruction

ImagingFor most patients, we obtain plain radiographs to quickly confirm a diagnosis of bowel obstruction and, provided the films do not have findings that indicate the need for immediate intervention, we use computed tomography (CT) of the abdomen to further characterize the nature, severity, and potential etiologies of the obstruction.

X- Ray

Dilated loops of bowel with air-fluid levels

Erect Supine

CT ScanCT of the abdomen is more useful than plain radiographs for identifying the specific site and severity of obstruction (partial vs complete) ; determining the etiology by identifying hernias, masses, or inflammatory changes; and for identifying complications (ischemia, necrosis, perforation)

CT Scan

(A)

(B)

Similar to the findings on plain abdominal radiography, a diagnosis of bowel obstruction on abdominal CT can be made by the findings of dilated proximal bowel with distal collapsed bowel, and air-fluid levels

Management1- Admission.2- Fluid therapy3- Gastrointestinal decompression

2- Fluid TherebyIn general, all patients with mechanical bowel obstruction should be made nil per os (NPO) to limit bowel distensionPatients with bowel obstruction can have severe volume depletion, metabolic acidosis or alkalosis, and electrolyte abnormalities.

adequate intravenous (IV) access in the form of two large-bore peripheral lines should be obtained for fluid resuscitation.Aggressive potassium repletion may be needed, but it is important to be certain the patient does not have acute kidney injury (acute renal failure) from severe dehydration, in which case potassium supplementation should be given cautiously until renal function can be improved.

Gastrointestinal decompression

By a nasogastric tube decompression of the distended stomach improves patient comfort and also minimizes the passage of swallowed air, which can worsen distensionThe drainage from nasogastric tubes placed for gastrointestinal decompression should be documented to help judge the progression or resolution of obstruction and the need for supplemental intravenous fluid. Fluid and electrolyte replacement for nasogastric losses depends upon the volume and nature of the loss.

assessment of the need for surgical exploration

All patients suspected of having complicated bowel obstruction (complete obstruction, closed-loop obstruction, bowel ischemia, necrosis, or perforation) based upon clinical and radiologic examination should be taken to the operating room for abdominal exploration

NONOPERATIVE MANAGEMENT

Nonoperative management with nasogastric suction and intravenous fluids can be successful in patients with partial small bowel obstruction. This approach requires frequent reassessments of the patient to ensure that there are no developing complications.Many patients can safely undergo initial nonoperative management, but clinical evaluation must first exclude complicated obstructionoverall successful in 65 to 80 percent of patients.patients with small bowel obstruction (without indications for immediate surgical exploration) should be observed for no longer than 12 to 24 hours after which time, if no improvement is seen, the patient should be explored.

Serial monitoring .. (Outcome)

Frequent clinical reassessments of the patient are necessary to ensure that complications are not developing

- Resolution of small bowel obstruction: accompanied by a decrease in abdominal distension, the passage of flatus and/or stool per rectum, and a decrease in the volume of nasogastric tube output. - Complication: Complicated bowl obstructionRenal failure

Case 4

Bert is a 63 Year old male a known case of peptic ulcer disease. delivered to ER by his wife. the patient was complaining of Abdominal pain for 6 h duration the pain was diffuse and constant, aggrvated by movment and respiration.The pain was associated with Fever (38.1) , anorexia , malaise

On Examination: by inspection you noticed He takes shallow fast breaths. On palpation there was generalized rigidity and tenderness. on percussion it was dull. Reduced bowl sounds on auscultation.

Peritonitis/ caused by perforated viscous

ImagingPatients who meet the criteria for secondary bacterial peritonitis should undergo emergency plain and upright abdominal films and a computed tomographic scan of the abdomen.

X-Ray : Erect: Subdiphramtic GasSupine: dilated loops in paralytic ileusCT scan: used to identify the cause of peritonitis ( Diverticulitis , pancertitis) and influence management decision

X- Ray

CT scan

CT scan of the abdomen with free air (star) and air in bowel wall (arrow)

Management- Admission- IV FluidBroad- spectrum AB: that cover ( aerobic and anaerobic) : most common bacteria : E.Coli , Bacteroids , KlebsiellaAnalgesiaEmergent Laparotomy: peritoneal lavage and drainage.

Prognosis and outcomeMortality Rate is 10% .. (B&L)Complications:- Bacteremia- Shock- Systemic inflammatory response syndrome- Death

To Sum UpIntestinal obstruction commonly caused by adhesions , hernia, neoplasm The management of I.O is by NPO , IV , NGComplicated I.O ex, necrosis/perforation : SurgeryPeritonitis commonly caused by perforated viscousPatient with Secondary peritonitis (surgical peritonitis) should do Erect/Supine X-Ray and a CT scan.Treatment By : Peritoneal lavage

Homo Naledi

100,000 years old

Thank you