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 Obstruction
Signs & Symptoms
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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 Obstruction
Laboratory 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 Obstruction
Radiologic Evaluation
• Xrays: ? AFLs, ? Free Air, ? Distal Gas
• UGI / SBFT: Identify mechanical
obstruction
• Enteroclysis: Independent of gastric
emptying
• CT Scan: ? Free Air, ? Pneumatosis, ?
Small Bowel Obstruction
Etiologies
• Adhesions
• Malignancy
• External or Internal Hernia
• Volvulus
• Crohn’s Disease
• Intra-abdominal Abscess
Small Bowel Obstruction
Etiologies (Cont.)
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Radiation Stricture
Foreign Body
Gallstone Ileus
Meckel’s Diverticulum
Intramural Hematoma
Mesenteric Ischemia
Intussusception
Intestinal Ileus
Etiologies
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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 Obstruction
Partial vs. Total
• Why Not Just Wait??
– Potential for Closed Loop Obstruction
– Risk of Ischemia / Perforation (4-6
hrs)
Small Bowel Obstruction
Treatment
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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 Obstruction
Special 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 Obstruction
Diagnosis
• 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 Obstruction
Etiologies
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Colon Cancer
Diverticulitis
Extrinsic Cancer
Fecal Impaction
Intussusception
Volvulus
Incarcerated Hernias
Large Bowel Obstruction
Colon 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 Obstruction
Treatment
• 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?
Esophagus
Small
Intestine
Stomach
Large
Intestine
(Colon)
Rectum
Appendix
• 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
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