CURRENT Essentials of Critical Care.pdf

Chapter 11 Gastrointestinal Disease 175■■■Small-Bowel ObstructionEssentials of Diagnosis• Intermittent or colicky abdominal pain with crescendo-decrescendopattern; insidious onset with progressive abdominalbloating, constipation, or obstipation• Vomiting progressively feculent as illness progresses• Poorly localized crampy pain at site of involvement; progressesdistally over course of illness• Distended, tender abdomen; may have peritoneal signs and abdominalwall hernias• Peristaltic “rushes” are auscultatory hallmark; may occur alongwith gurgles and high-pitched tinkles• Volume and electrolyte depletion common• Radiographs demonstrate ladderlike pattern of dilated smallbowel loops and air-fluid levels; “thumbprinting” and gas inbowel wall suggest bowel necrosis• CT should be considered if plain films nondiagnostic• Etiologies: adhesions from previous surgeries, malignancies,hernias through the abdominal wall, volvulus, foreign bodies,inflammatory bowel disease, radiation therapy• Complications: aspiration pneumonia, strangulation, perforation,peritonitis, bacteremia, sepsisDifferential Diagnosis• Adynamic ileus • Pancreatitis• Large bowel obstruction • Cystic fibrosis• Mesenteric vascular occlusion • Appendicitis• Ischemic enteritis • Large bowel obstruction• Inflammatory bowel diseaseTreatment• Replete fluids and electrolytes with isotonic fluids• Nasogastric suctioning to decompress bowel• Serial abdominal examinations and radiographic studies• Broad-spectrum antibiotics if strangulation or perforation suspected• Consider surgical intervention early; indications include strangulation,failure of conservative therapy■ PearlA strangulated obstruction should be suspected in the presence of earlyappearance of shock, gross hematemesis, and marked leukocytosis.ReferenceWilson MS et al: A review of the management of small bowel obstruction.Ann R Coll Surg Engl 1999;81:320. [PMID: 10645174]