Grand Round Case
Presentation
Sub Acute Obstruction
Causes of SBO
Adhesions (70%) – usually from previous surgery but
TB infection can cause them
Hernia (20%)
Pressure from extrinsic structures (eg. tumour)
Gallstones
Inflammatory bowel disease
Intussusception (especially in young children – it can kill
quickly so beware!)
Volvulus
Gynaecological causes in women
20% of all Surgical admissions
Small Bowel Obstruction
Adhesions – what do they look like?
Initial Management of ?SBO
Full history including details of past surgery
Full abdominal exam including PR
Don’t forget hernial orifices (or end up in court)!
Imaging (CXR, AXR, CT, barium) & all bloods
Conservative management unless:
Perforation (imaging) and/or overt peritonism
Irreducible hernia
Palpable mass
Conservative Management
NBM, NG tube and close observations
Patient must have adequate resuscitation before
surgery: IV fluids & monitor urine output
Imaging studies: CXR, AXR, CT & barium
studies
Closely monitor patient bowel habits!! A SBO
can rapidly change from incomplete to complete
Be ready for any deterioration: pain, distension,
peritonism, dehydration, sepsis or absolute
constipation
Small bowel obstruction: AXR
Dilated loops of small
bowel
Central position
Valvulae conniventes
Distal collapse
Barium studies show
location of obstruction
?Absolute indication
for surgery
Take home points: SBO
Common surgical emergency
Good history, good examination,
appropriate investigations
Conservative management?
Close monitoring for deterioration
Repeat imaging
Peritonism or sepsis = surgery!
TB: Profs Prophecy
Suspect TB in any foreign national with:
Mediastinal/hilar lymphadenopathy
Persistent cervical lymphadenopathy
Pleural effusion
Monoarthritis
Chronic discharging sinus
Small bowel obstruction (7% of all Indian SBO’s!)
50% of TB presentations are extra-pulmonary!
TB is a notifiable disease: need to trace all
contacts for assessment and prophylactic
therapy
References
Wysocki A. Pozniczek M. Kulawik J. Krzywon J. Peritoneal adhesions as
cause of small bowel obstruction. Przeglad Lekarski. 60 Suppl 7:32-5, 2003.
Vijay K. Anindya C. Bhanu P. Mohan M. Rao PL. Adhesive small bowel
obstruction (ASBO) in children--role of conservative management. Medical
Journal of Malaysia. 60(1):81-4, 2005 Mar.
Fevang BT. Fevang J. Lie SA. Soreide O. Svanes K. Viste A. Long-term
prognosis after operation for adhesive small bowel obstruction. Annals of
Surgery. 240(2):193-201, 2004 Aug.
Ellis H. Adhesions: the early history. Historical Article. Hospital Medicine
(London). 65(6):328-9, 2004 Jun
Corfitsen MT. Hantho AF. Nilsson T. Conservative treatment of ileus caused
by adhesions, with a Miller-Abbott tube. Ugeskrift for Laeger. 146(18):13602, 1984 Apr 30.
Totikov VZ. Kalitsova MV. Amrillaeva VM. Diagnostic and treatment program
in acute adhesive obturative obstruction of the small bowel. Khirurgiia.
(2):38-43, 2006.
Thanks for listening!
Any Questions?