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Small Bowel Obstruction Tarak ChouariLearning objectives • Definition and causes • Presentation and symptoms • Examination • Investigations – imaging • Complicated Small bowel obstruction - ischaemia/perforation • Initial Management of SBO • Conservative versus Surgical management • Gastrograffin evidence • When to resect bowel – intra-operativelyDefinition • SBO is a condition leading to the absence or abnormal progression and passage of intestinal content through the small bowel MECHANICAL FUNCTIONAL Partial/Subacute CompleteMechanical causes of SBO 1. Adhesions (60-75% of SBO admissions). • Post-surgical • Infective/inflammatory • Congenital 2. Hernia • The most common cause in the virgin abdomen – the importance of physical examination!! • Eg. Inguinal, femoral, incisional, internal, parastomal 3. Rarer aetiology eg. Foreign body, gallstone ileus, neoplasm (primary SB or secondary/metastatic), Crohn's stricture, intussusception, haematoma, TB/Parasitic infection Think of these as intraluminal, intramural and extramural.Presentation and Symptoms PROXIMAL DISTALExamination • ABCDE rd • Signs of dehydration from vomiting and 3 space loss • Fever? • Abdominal examination*: Look: Distension/scars/hernias (abdominal/groin), beware of the still patient Feel: Peritonism/hernias Listen: Bowel sounds DRE – Collapse rectum, rectal masses, blood – ischaemia/inflammatory, peritoneal shelfingInvestigations Sensitivity: 79-83% Specificity: 67-83% AXR NORMAL IN 20% AXR of PATIENTS WITH SBO IH, et al. Challenges in diagnosinggh World J Gastroenterol. 2013;19: 7489– 93. Investigations ü Definitive diagnosis of Sensitivity: mechanical SBO 95% ü Diagnosis of underlying aetiology Specificity: ü Identify location i.e. 96% transition point ü Severity i.e. complete Mallo RD, Salem L, Lalani T, et al. versus incomplete ischemia and complete obstruction in ü Identify complications – CT small bowel obstruction: a systematic 2005;9:690–4.trointest Surg. ischaemia, necrosis, perforation ü Identify features which may dictate if patient will settle or notSpot diagnosis on CTSpot diagnosis on CTSpot diagnosis on CTSpot diagnosis on CT Ischemia on CT • Ischemia is notoriously difficult to predict on CT alone: Sensitivity varies ; 15-100% 1,2,3 • Yet important to predict – associated with 25% mortality in SBO versus 2% without ischemia .1 1. Zalcman M, Sy M, Donckier V, Closset J, Gansbeke DV. Helical CT signs in the diagnosis of intestinal ischemia in small-bowel obstruction. AJR Am J Roentgenol2000;175(6):1601–1607 3. Sheedy SP, Earnest F IV, Fletcher JG, Fidler JL, Hoskin TL. CT of small-bowel ischemia associated with obstruction in emergency department patients: diagnostic performance evaluation. Radiology2006;241(3):729–73697;205(2):519–522Assessing for ischemia Constant severe pain as opposed to colicky. Clinical and Pain out of proportio biochemical signs correctly predictfindings Clinical Evolving abdominal sides findings (Hx of cases o lynism and Ex) Tachycardia/hypotension/ new fever 1Metabolic acido isn D, Svanes K, et al. Early operation Imaging Biochemical small conservative management of patients with 20.bowel obstruction? Eur J Surg. 2002;168:475–81. Previously 2. Takeuchi K, Tsuzuki Y, Ando T, et al. Clinical studies 2004;70:40–4.uc cytosisbowel obstruction. Am Surg. discussed and CRPInitial management • NBM • Intravenous fluids / resuscitation • Analgesia /anti-emetics • NG tube to decompress SB – aid with symptoms, prevent aspiration, help resolve obstruction, facilitates measuring of fluid losses & guides IVF, monitor if resolving. • Fluid balance • Stool chart • Urinary catheter • +-Abx • G&S • PPI • (NELA) to aid any operative decision makingReassess response through serial clinical assessment & decide on operative versus conservative management +- GGOperative vs conservative management ? Indications for exploratory surgery: • Complicated SBO i.e. closed loop obstruction, bowel ischaemia, necrosis or perforation • Aetiology eg. Hernias, Gallstone ileus, small bowel volvulus, closed loop obstruction, managed )y1(studies show a high failure rate and high mortality rate if not operatively • Failure of non operative management in 72 hours - can potentially extend conservative management to 5 days* • ?Virgin abdomen mortality and morbidity .2anagement beyond 5 days is associated with increased 1. 2014;149:383–92.inkerton C, Brasel KJ, et al. Palliative surgery for malignant bowel obstruction from car- cinomatosis: a systematic review. JAMA Surg. 2. Bauer J, Keeley B, Krieger B, et al. Adhesive small bowel obstruction: early operative versus observa- tional management. Am Surg. 2015;81:614–20.Salient facts on non-operative management • Extremely rare for subacute obstruction to result in ischaemia with non operative management (3-6% progress). But it can happen. 1 • Non-operative management is overall successful in 65-80% of patients within 2-5 days of admission 2 and (in appropriately selected patients – most studies specific to adhesional SBO). 1 Jeong WK, Lim SB, Choi HS, et al. Conservative management of adhesive small bowel obstructions in patients previously operated on for primary colorectal cancer. J Gastrointest Surg. 2008;12:926– 32. 2. Catena F, Di Saverio S, Coccolini F, et al. Adhesive small bowel adhesions obstruction: evolutions in diagnosis, management and prevention. World J Gastrointest Surg. 2016;8:222–31. 3. Choi HK, Chu KW, Law WL. Therapeutic value of gastrografin in adhesive small bowel obstruction after unsuccessful conservative treatment: a prospective randomized trial. Ann Surg. 2002;236:1–6.Gastrograffin & Evidence • Diagnostic, prognostic and therapeutic benefit Systematic review and meta-analysis: Ceresoli et al. Water-soluble contrast agent in adhesive small bowel obstruction: a systematic review and meta-analysis of diagnostic and therapeutic value. Am J Surg. 2016;211:1114–25. • Predicted resolution of SBO with a sensitivity 92% and specificity 93% • GG reduced need for surgery, decreased LoS and time to resolution of symptoms • No increased morbidity or mortality associated with GG Gastrografin challenge versus stan- dard treatment in adhesive small bowel obstruction. J Trauma Acute Care Surg. 2017;83:47–54. the Compared those with adhesional obstruction treated with and without GG: GG Group : Lower rate of operative exploration (21% vs 44%) Reduced LoS (4 vs 5 days) Multivariable regression models demonstrated GG was INDEPENDENTLY associated with successful non operative managementGastrograffin & Evidence Other contradictory evidence show no benefit: ASBO1 (Acute Small bowel obstruction study, prospective RCT ) – GG vs saline in adhesional SBO. -No difference in operative intervention or resection rates -No difference in LoS 1.intestine obstruction (ASIO): a prospective, randomized, controlled, clinical trial. World J Surg. 2008;32:2293–304.Gastrograffin • Water soluble hypertonic contrast solution How does it work? • Decreases bowel wall oedema • Stimulates bowel • When to give?Surgical Management Laparoscopic versus open surgery • Dependent on etiology of obstruction • Depending on the surgeon’s experience • Patient factors – extensive Hx of abdominal surgery/nature of previous surgeries i.e. meshes and timing of previous surgery abdominal Examination findings - distension/tense/space, CT - number of transition points, space patient physiology - able to tolerate time to carry out laparoscopy and physiological changes associated with it?When to resect small bowel? • What are intra-operative signs of ischaemia ? • Lack of peristalsis • Cold • Colour • Shiny appearance • Smell • Thrombosed mesentery • Lack of bleedingQuestions