Vomiting, Diarrhea & Constipation

Mark J. Koruda, MD

Professor of Surgery

Case 1

• A 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 & Symptoms

• Intermittent, Crampy Abdominal Pain

• Nausea / Emesis

• Distension

• Obstipation

• Peristaltic Rushes on Auscultation

• Focal Tenderness

• Diffuse Peritonitis

Case 1

• What findings should be looked for on physical exam?

• Distended

• No peritoneal signs

Case 1

• What laboratory tests should be ordered?

Small Bowel ObstructionLaboratory Evaluation

• May see hypochloremic, hypokalemic

metabolic alkalosis if having frequent

emesis (proximal obstruction).

• May see evidence of contraction alkalosis

– Increased H/H, BUN.

• WBC usually normal early.

Case 1

• What laboratory tests should be ordered?

• What diagnostic tests should be ordered?

Small Bowel ObstructionRadiologic Evaluation

• Xrays: ? AFLs, ? Free Air, ? Distal Gas

• UGI / SBFT: Identify mechanical obstruction

• Enteroclysis: Independent of gastric emptying

• CT Scan: ? Free Air, ? Pneumatosis, ? Tumor

Small Bowel ObstructionEtiologies

• Adhesions

• Malignancy

• External or Internal Hernia

• Volvulus

• Crohn’s Disease

• Intra-abdominal Abscess

Small Bowel ObstructionEtiologies (Cont.)

• Radiation Stricture

• Foreign Body

• Gallstone Ileus

• Meckel’s Diverticulum

• Intramural Hematoma

• Mesenteric Ischemia

• Intussusception

Intestinal IleusEtiologies

• Postoperative State• Sepsis• Electrolyte Imbalance• Drugs• Ureteral and Biliary Colic• Retroperitoneal Hemorrhage• Spinal Cord Injury• Myocardial Infarction• Pneumonia

Case 1

• What is the initial management plan?

Small Bowel ObstructionPartial vs. Total

• Why Not Just Wait??

– Potential for Closed Loop Obstruction

– Risk of Ischemia / Perforation (4-6

hrs)

Small Bowel ObstructionTreatment

• Correct intravascular volume deficit

• NGT vs. Miller-Abbott or Cantor Tubes

• Serial Exams

• Operation if no improvement or if signs of complete (closed loop) obstruction or incarceration.

• Evaluation of Bowel Viability

Small Bowel ObstructionSpecial Cases

• Early Postoperative SBO– <1% risk in first month– Must be considered after 7 days of

“ileus” since adhesions become dense in 2-3 weeks.

• Recurrent SBO (5-15%)

• Malignant Obstruction

• Radiation Fibrosis

Case 2

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

• Key Points in History?

Large Bowel ObstructionDiagnosis

• Crampy Pain• Onset may be acute or insidious• Distension (50-60% have competent ileo-cecal

valve and develop severe distension)• Xrays: 12-14 cm cecum, perforation risk• Contrast enema: Obstruction vs Oglive’s• Consider rigid sigmoidoscopy to r/o and treat

sigmoid volvulus

Case 2

• Physical Exam

• What further tests are indicated

Case 2

• Differential Diagnosis

– Colonic Obstruction• Malignant• Benign

– Colonic Dysfunction

Large Bowel Obstruction

Large Bowel ObstructionEtiologies

• Colon Cancer

• Diverticulitis

• Extrinsic Cancer

• Fecal Impaction

• Intussusception

• Volvulus

• Incarcerated Hernias

Large Bowel ObstructionColon Cancer

• 20% of colon cancers present with

obstruction

• Left-sided lesions are more prone to

obstruct (more narrow lumen, more

solid fecal stream)

Large Bowel ObstructionTreatment

• IVF• NGT• Operation

– Emergently if signs of peritonitis / perforation– Prep bowel if possible

• Is an ostomy necessary?– Right vs. Left-sided Lesions– Traditional vs. Newer Attitudes

Large Bowel Dysfunction

• Inflammation

• Colonic Inertia

• Etc

Oglive’s Syndrome(Colonic Pseudo-

Obstruction)

• May mimic mechanical obstruction• Associated Conditions• Treatment:

– Rectal tube / enemas /exams (work in most)

– Colonoscopic decompression (80-90% eff.)– Surgery (Cecostomy vs. Resection) -

cecum >12 cm or peritoneal signs

Case 3• A 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 Crohn’s Disease?

• Crohn’s disease (CD) is an inflammatory bowel disorder that may affect any part of the gastro-intestinal (GI) tract

• The inflammation penetrates the lining of the GI tract and often causes ulcers to form

SmallIntestine

LargeIntestine(Colon)

Appendix

Esophagus

Stomach

Rectum

Case 3

• Key Points in History

Case 3

• Key Points in History – Crohn’s disease– Previous surgical history– No Crohn’s Rx– Chronic symptoms– Weight loss– No fevers– Crampy pain

Case 3

• Physical Exam

• Diagnostic Studies?

• Differential Dx

Crohn’s Disease

Crohn’s Disease

Crohn’s Disease

• Medical vs Surgical Management

Case 4

• 22yo 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 4

• 22yo 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– Diarrhea– Bleeding

Case 4

• Physical Exam

• Diagnostic Studies?

Ulcerative Colitis