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Gastrointestinal Problems

The Acute Abdomen

Bowel Obstruction

Bowel Cancer

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The Acute Abdomen

• Acute onset of abdominal pain

• Many different causes

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Causes of Acute Abdominal Pain

– Abdo penetrating trauma

– Bowel obstruction with perforation or necrosis

– Acute ischaemic bowel– Appendicitis– Pelvic inflammatory

disease– Inflammatory bowel

conditions (Chron’s, ulcerative colitis)

- Gastroenteritis

- Peptic Ulcer- Ruptured ectopic

pregnancy- Ruptured ovarian cyst- Cholecystitis- Ruptured abdominal

aneurysm

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The Acute Abdomen

• Signs & Symptoms– Pain: most common presenting symptom– Abdominal tenderness– Nausea/Vomiting– Diarrhoea– Constipation– Flatulence– General unwell/fatigue– Fever– Increased abdominal girth (distension)

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The Acute Abdomen

• Diagnostic– Complete history– Physical examination (including rectal & pelvic exam)– Blood tests (FBC, U&E’s,)– Urinalysis– Abdominal x-ray– ECG– Pregnancy test– Abdominal USS + - CT scan

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Bowel Obstruction

• Occurs when intestinal contents cannot pass through the GI tract

• Obstruction maybe partial or complete

• Causes classified as mechanical or non-mechanical

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Bowel Obstruction

• Mechanical Obstruction– Account for 90% of all bowel obstructions– Affects the lumen of the bowel– Caused by an occlusion of the lumen– Most occur in the small intestine– Mainly caused by adhesions, hernias or

neoplasms– Carcinoma is the most common cause of

large bowel obstruction

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Bowel Obstruction

• Non-Mechanical Obstruction– May result from neuromuscular or vascular disorders Related to peristalsis Paralytic ileus (lack of intestinal peristalsis) is the

most common• Occurs after surgery • Electrolyte abnormalities• Spinal fractures

– Vascular obstructions• Due to interference to blood supply to a portion of intestines

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Pathophysiology of Bowel Obstruction

Normally 6-8 L of fluid enters small bowel daily Approx 75% of intestinal gas is swallowed air Bacterial metabolism produces methane &

hydrogen gases Fluid, gas & intestinal contents accumulate

proximal to the intestinal obstruction This causes distention, reduces the absorption

of fluids & stimulates intestinal secretions

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Pathophysiology (cont.)

The increase in fluid increases the pressure in

the lumen Increased pressure leads to increase capillary

permeability & extravasion of fluids electrolytes

peritoneal cavity Oedema, congestion & necrosis from impaired

blood supply can occur Retention of fluid in the intestine & peritoneal

cavity can lead to severe hypovolaemia & shock

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Bowel Obstruction

• Signs & Symptoms– Vary depending on the location of the obstruction– Nausea/Vomiting– Abdominal pain

• Small bowel: colicky, cramp-like & intermittent• Large bowel: low grade cramp

– Abdominal distension (greater in large bowel)– Bowel Sounds

• Rapid, high-pitched tinkling• Absent

– Inability to pass flatus– Constipation

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Bowel Obstruction

• Treatment of Bowel Obstruction– Aim to decompress the intestine

• Removal of gas & fluid• Use of nasogastric &/or intestinal tubes

– Maintain fluid & electrolyte balance• 6-8L fluid rich in sodium, potassium & chloride moves

through the bowel each day• Normally most of it is reabsorbed• Retention of fluid in intestine & peritoneal cavity• Dehydration & electrolyte imbalances occur rapidly in small

bowel obstruction

– Surgeryl

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Bowel Cancer

Colorectal cancer One of the most common types of cancer

in NZ Diagnosed & treated early survival rate of

5 years + is approx 50% Often undetected in early stages as

asymptomatic Prevention & early screening

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Bowel Cancer

Cause• Exact cause unknown• Risk factors include

- History of intestinal polyps, inflammatory bowel disease- Hereditary disposition- Aged 50+- Obesity, sedentary lifestyle- Diet high in animal fat- Smoking

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Bowel Cancer

• Signs & symptoms Vary with anatomic location of the tumour Initially may be asymptomatic Fatigue Weakness Loss of appetite Weight loss Blood in stool

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Bowel Cancer

• Ascending colon & caecum tumours Abdominal pain R) lower quandrant Iron deficiency anaemia Occult blood in stool Palpable mass Weakness Weight loss Tumours may be large before causing

changes in bowel habit

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Bowel Cancer

• Transverse colon tumours Including the R) & L) flexures Occult blood in the stool Constipation Altered frequency bowel movements Abdominal fullness Cramp adominal pain

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Bowel Cancer

• Descending colon Bright red rectal bleeding Ribbon shaped stools Colicky abdominal pain Alternating constipation & diarrhoea Nausea/vomiting These tumours may be ulcerative & infiltrate

the bowel

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Bowel Cancer

• Sigmoid colon & rectum Dull or aching pain in sacrum or rectum Feeling of rectal fullness Bright red blood from rectum Narrow stools Tenesmus (painful, ineffective straining to

empty bowel ) Anaemia

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Bowel Cancer

• Diagnostic Studies– History & physical examination– Rectal examination (PR)– Sigmoidoscopy– Colonoscopy – Barium enema– Faecal occult blood specimen– Blood tests (FBC’s, U&E’s, LFT’s)– Abdominal x-ray

• Show presence of gas & fluid in intestines– CXR– Abdominal USS/CT

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Bowel Cancer

• Diagnostic– History & physical examination– Rectal examination (PR)– Sigmoidoscopy– Colonoscopy– Barium enema– Faecal occult blood specimen– Blood tests (FBC’s & U&E's, LFT’s)– CXR– Abdo USS

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Bowel Cancer

• Duke’s modified classification & prognosis– Duke’s A

• Confined to the bowel wall• 72% survive 5yrs

– Duke’s B• Extended through bowel wall• 56% survive 5yrs

– Duke’s C• Regional lymph node involvement• 35% survive 5yrs

– Duke’s D• Distant metastases• 0% survive 5yrs

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Bowel Cancer

• Treatment– Surgery: first line – Type depends on the location & extent of

tumour– R) Hemicolectomy: tumours of the caecum &

ascending colon– L) Hemicolectomy: tumours of the descending

& sigmoid colon– Transverse colectomy: middle or L)

transverse colon

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Bowel Cancer

• Surgery– Anterior resection: proximal & mid rectal

tumours– Anterior-posterior resection: advanced

disease– Abdominoperineal resection: malignant

tumours of the lower sigmoid colon, rectum & anus. Too low for anastomosis