Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Um, cheers me. So guys, we're going to talk about small bowel obstruction today. Um My name is Tarek. As we all know if you do have any questions at all throughout it, just let me know, just interrupt as we go along and we'll try and make it as engaging as possible. So I will ask questions. So we're gonna talk about, you, shut that door over there. So we're gonna talk about the definition and causes of small bowel obstruction, how it typically presents and the symptoms, how to examine a patient with small bowel obstruction, what investigations you might want to get. And we'll have some imaging examples that we'll go through, uh, how to identify complicated small bowel obstruction, ie ischemia or perforation. And then we'll go through the initial management of small bowel obstruction and then the decision management around whether a patient needs conservative or surgical management, the rule of gastrograph and, and the evidence for it. And then we'll have a look at some images of small bowel intraoperatively, uh, to guide our decision making about whether a patient needs a bowel resection or not. So, first of all, the definition of small bowel obstruction. Uh, it is a condition leading to the absence or abnormal progression and passage of intestinal content throughout the small bowel. And it can either be mechanical or functional and it's important to know which ones which and how they present clinically as surgeons were more interested in the mechanical small bowel obstruction. And these patients sometimes need operative intervention. And when you think of mechanical obstruction, it can either be a partial or subacute or they may still be opening their bowels or um so they may still be passing wind on the CT scan. They may not have evidence of a complete obstruction. So causes of mechanical obstruction, I've put an image in the top right corner to give you a clue. Who wants to start with causes of mechanical small bowel obstruction, adhesions. Yes. What causes adhesions? Jitter? Yes. What else? Yes. What else in? Yes and congenital. Of course, who's seen a diagnostic lap with a normal appendix? You, yeah. Have you seen any adhesions in the right leg fossa despite the normal appendix? Yeah. So they are congenital adhesions and congenital adhesions usually occur in the terminal ileum. And I think it's worth mentioning now, whilst we're talking about that, whilst we've got, when we've got congenital adhesions causing small bowel obstruction, you're faced with a difficult decision because they've got a virgin abdomen, a lot of the time if they've got adhesional obstruction. And what do you do in that case? And there's an element of surgical dogma there, which we can talk about later. So, yeah, first cause leading cause adhesions. That's 60 to 75% of all small bowel obstruction admissions. And it might be post surgical infective inflammatory or congenital, as we've all said, what's the second leading cause radiation? Pardon? Radiation of small bowel obstruction, hernias, hernias. Yes. Yeah. What types of hernias do you know if you have? Yeah. Um, ok. Yeah, we've got lots of hernias. Hernias are the leading cause of small bowel obstruction in a virgin abdomen. So, if you've got a patient with a virgin abdomen with small bowel obstruction, make sure you do a thorough clinical examination. And I've written here the importance of physical examination, exhumation, mark, exhumation, mark. Any other causes of small bowel obstruction, guys, polyps, tumors. Yes. What else? Um, yes. What else? I Crohn's disease. Yeah. Think systematic guys, we're talking about mechanical, right? Solely mechanical obstruction. We're not going to go. So, guys, initially, we give the definition of small bowel obstruction. We can either be mechanical or functional and our surgeons were more interested in mechanical obstruction, but we still look after patients with functional small bowel obstruction. Can we think of any other rare causes of small bowel obstruction or any cases that you've seen? Yes. A stricture which can be inflammatory infective. It might be due to ibd Crohn's. Yeah. Anything else? Just a second. Yes. And intussusception in adults is quite worrying, they don't necessarily need an operation immediately. We need to think. Is there a leading point? Is there an underlying counsel that might be in for that any other causes? I mean, there's such an extensive list here and of pressure from not the tumor of the small bowel but ex extreme of pressure from an ovarian tumor. Yeah. Yeah, 100%. And you can. Yes. And to lead on from that, you can think of them as intraluminal intramural or extramural. So anything outside the abdominal wall, like a ma, like a mass might be causing compression, it might be invading. Um, so I've written a few rare causes but this is by no means an extensive list. Foreign bodies typically occur in people with a history of psychiatric issues. If they've got learning disabilities, if they're old and frail and have swallowing difficulty and they might swallow the dentures, they might, I've stayed on. Yeah. Yeah. They most weird. Oh, did you have one? Yeah, it happens. Do you have for this, like injection? Like, you know, psychiatric patients, colonoscopy a, a very common thing. A common you said? Yeah. What was that? Batteries? And what's the weirdest thing you can find? I found once I found a gerbil. Yeah, but not from the, it went from the other passage and it's actually a pract called Gerling. I will tell you about it later. Ok. Yeah. What, what were you allergic to? A, what? Pickle lemon Nice. Nice. I think it was, I don't know where to go from here, but there, there are essentially a lot of causes of mechanical small bowel obstruction. And usually you can figure out what that cause is. If you take an extensive history and examination, even before you get to imaging, it's really important to know because it dictates your management in a way which will come on to. So, how does small bowel obstruction present? I've given you a clue with some pictures, including a bristal stool chart. You would like to start us off with symptoms. Yes. Correct. One out of four. Anything else? Yes. Central abdominal pain, usually crampy. Thank you. Um So yeah, so we've touched on some of the symptoms. So usually they get central intermittent colicky abdominal pain. If it's constant pain, then you need to start worrying how this patient developed an ischemia. Be is vomiting abdominal distension and then obstipation. Um And if they're still passing wind, then it might be that they've got an eso obstruction. I put, oh, I put an arrow in there because there is, if you like an order of events that happen in small bowel obstruction, whilst nothing is ever quite like a textbook, it is pretty much a small bowel obstruction. So usually they get the pain followed by the bo machine, followed by the distension, followed by the observation. But there are some caveats to that and that comes down to where the point of obstruction is, or the transition point. So, if you've got a proximal obstruction, ie let's say proximal or jeal, you're probably gonna get more pain and vomiting, but less the, the, the distension because is that point of, um, obstruction or your small bowel is collapsed. So you don't get any distension whilst, if you've got a distal obstruction, say a cecal mass which causing a night obstruction of the ICV, you'll be very distended and you may not get vomiting at least in the initial phase unless the, the disease is a bit more progressed. And the other caveat to that is if you've got a, um, closed loop obstruction or you've got, well, medical student, what is your name? Anna? Hi. And do you know what a closed lip obstruction is? It's ok if you don't. Um, no, no, no. Nope Jin Jitter. What is occlusive obstruction? Post obstruction is when enough. Uh, it's like blockage from both. So, so to prevent blockage from? Yeah. Yeah. So it can twist on itself in the sense of it. So, if you think about just say a standard small bowel obstruction, you've got one transition point, the ball. If you think of the bow like a pipe, anything distal to that transition point is going to be collapsed, anything proximal to it, it's going to be dilated, it's going to fill with fluid and then eventually you're going to vomit. If you've got a close loop obstruction, you've got at least two transition points, you've got one dis one proximally and then that loop of ball in between is going to distend. But then this, that's gonna remain collapse. And at least initially, you're not gonna get the fluid come back up through the more proximal small bowel. Um I think I've put in some images which we'll come on to later. Uh uh Not necessarily. Um You can get it with adhesions. It's more common. If you've got a volvulus or twist in the small part, you get two transition points. Um But it's again important to think about that when you're examining the patient taking a history, if, if, if you think they do have obstruction, but they're not vomiting, it might be, oh, they've got a really distal obstruction. If they're really distended or if they don't have much distension, then it might be, they've got a close bit obstruction, the caveat with uh they want to set up the labs closely. Uh No, no, go ahead. It's not actually in my slides, but it's so you, you, you know, we usually see the lactate if it's increased. You suspect there is some element of ischemia. So you suspect there might be ischemic bowel if you have a close loop obstruction because what is lactate is something intra cellular that goes extracellularly because of the anaerobic metabolism. So, if you have a closed loop obstruction, the outflow from that is blocked. So the lactate is trapped in the skin bowel and it doesn't go to the ST, so you want to see theoretically, um, an increase of the lactate. At least not initially. But, yeah, it's a very valid point. So, if we move on to examination, um, let's start with Emma, you've got a patient with small bowel obstruction. What are you looking out for when you're examining a patient? Um, yeah, dehydrate. Yeah. Yeah. Absolutely. You more closely, Um, the ab ab, mhm. Um, like pain, like. Mhm. Look for s, yeah. Yeah. Brilliant. Really good. You can, you can pass to a friend, by the way. Don't feel like you need to keep going. Anything else you might find on the examination? Yeah. Yeah. I don't actually, but I should, uh, yeah. Anything else is that what is in? Yeah. Absolutely. And always check for blood because if they're vomiting excessively, you know, they might have it for them. They might do and if they've got ischemia they might have blood in the vomit as well. Um, so, yeah, that's a really good point. She had anything else that you would be looking for on examination? Mhm. Think of your causes of small bowel obstruction. Uh, did you say previous incision? Yeah, that's, that's really important. Yeah. Um, hernias. Yes. Um, uh, you know, like adjuncts. Like, so, like any bedside adjuncts. Gastros. Too much. Yeah. Very good. So, I've written a list here. I mean, any patient who comes into the hospital by Ed. You should initially do an ABC D assessment. Of course. First of all, as MS look for signs of dehydration, these patients tend to be profoundly dehydrated. They are vomiting excessively, they get a lot of face loss as well. Um It's important to be able to accurately assess someone's hydration status. So you want to look peripherally for their cap refill, whether they're cold, peripherally or warm. Have they got a strong or weak radial pulse or the tachycardic skin turner? I've never assessed for, but it's worth considering and dry mucous membranes. Um And if they've got a catheter, it says what color it is and what's actually coming out fever, fever is not typically associated with small bowel obstruction. I have put a question mark behind it because patients can get an aspiration pneumonia as a result of the vomiting. Um And if they do have an element of ischemia, then they may have a fever as well or if they've perforated also, if they've got IBD or an inflammatory process going on, they may also have fever. So it's worth noting if they do, but it's not very typical of small bowel obstruction in the early stages. Uh Abdominal examination, I think I've put an asterix there because abdominal examination is arguably the most important aspect. It's way more important than CT and this is really where you're going to make your decision. Does this patient need an operation immediately or do they not. Um and realistically, a lot of these patients come in overnight and you have to find the registrar consultant and you need to be able to read an abdomen like a textbook or a short children's story. That's it. So have a look, look for any distension. Are they really tense or are they quite soft and lax? That's important because when you come down the line to see, examining the patient, you want to know are the measures that you put in place. Are they helping to resolve the obstruction or are they not look for scars? As you, as said, look for any evidence of hernia. I think it's unforgivable if you don't diagnose a hernia on clinical examination, especially in a virgin abdomen. So really do need to be checked in the groins. Um and the abdomen thoroughly and be aware of the still patient. I put that in phone because I think any patient who's still and isn't moving has peritonitis until proven otherwise, uh always have a feel of the abdomen for any peritonitis. Again, this might suggest ischemia and that the patient needs an urgent operation. Um And again, feel for hernias, listen for tingling in both sides and always do a dre even if it is small bowel obstruction, they can still have a collapsed rectum and they might have some rectal masses which may allude to the actual underlying diagnosis of the obstruction, whether it's a metastatic disease or a rectal mass which is invading the small bowel and check for blood, which again, might suggest ischemia or an inflammatory process or a malignant process and assess for peritoneal shelling. Who knows what peritoneal shelling is? Yeah. Exactly. Yeah. Has anyone felt peritoneal shelling? I'm almost certain that patient on colorectal who's got the nephrostomy will have peritoneal shelf. Yeah. Uh, but it would not be appropriate to go and do a dre on her. But patients like that whenever they come in, you can initially get an idea if they don't have a diagnosed malignancy is something else going on. Do they have an ovarian cancer? Do they have a rectal cancer, etcetera, et cetera. So, investigations hands up who is doing an abdominal x-ray as the first investigation, we usually get Abdomal xray, xray done x-ray. Ok. Wants to do an Abdomal x-ray. So this slide is not going to be done well. Ok. So I don't think there's any value in x-ray. What's that? So, uh, this, where have you got? So I think if you had a degree of suspicion that they've got small bowel obstruction, you're gonna get a CT anyway. And whilst abdomal x-rays might show small bowel obstruction and it is the right thing to do in a way. Um, as in here you can see in this Abdo x-ray and there's a beautiful picture of small bowel obstruction. They've got central dilated loops of small bowel, um, with multiple fluid levels, but actually, the sensitivity and specificity of an abdominal x-ray is 79 to 83% and around 60 70 83 respectively. And abdominal x-rays can miss small bowel obstruction in 20% of patients. So, ultimately, you're gonna end up getting a CT, so do an abdominal x-ray. But I think if I'm going to get a CT and it's going to be done very soon. Do, do I just want to go straight for a CT CT? Yes. Uh So CT is much better, obviously, sensitivity, 95% specificity, 96%. And there's multiple advantages of an abdominal x-ray. So it can give you a definitive diagnosis of mechanical obstruction first place. It can give you an idea of the underlying etiology. It can also identify the location of the transition. And as we said before, distal proximal obstructions um can be quite different and also in terms of how they present. So if you've got a really proximal obstruction, the main symptoms are going to be vomiting. So you might get metabolic alkalis hypokalemia. Um and hypokalemia and they tend to have more electrolyte dimensions than distal obstruction. So, um it is worth noting. It can also tell you the severity whether it's a complete obstruction or incomplete. How do we, how can we tell if there's a complete obstruction or incomplete obstruction on a CT? Um, if the, the bowel and distance has collapsed. Yeah, it is complete obstruction. Yeah. Yeah, absolutely. Um And you can identify complications if there's any evidence of ischemia necrosis or perforation. I've got some examples coming up that I'll show you of these. Uh and you can also identify features that might suggest is this patient gonna settle or are they not? Do they have a high grade obstruction or not? So, spot diagnosis, what is the sign of put in to make it a bit more obvious? Hm. Uh No. Speak up. It's OK if you don't know, I don't know, we can go through it. So it's, it's the sign. So what is that sign in the small bottle? Think about nature. Remember medicine? The old medicine was describe in things. Uh So this is, well, that's a bit of contrast but this is what normal small peri bar will look like. This is very different. So, does anyone know what this is? It's um visualization of the small bowel. Have, have we heard of that before? Pardon? Related to ni uh no, there's a sign here at the lower the a the lower one, right? Yeah. Yeah. No, this is not right there right there. You see big, yeah. Pick up a big sign and you'll see the bowel loop will be coming in this way and then it will be prolapsed. Yeah. Yeah. No, no, I was talking about the fecal. I'm not sure if this is a fall or whether that's some fluid around the wall of the bowel, but either way. Yeah. It's an important point to make. Um And fecal either suggests like a, a chronic element to an obstruction or that there's quite, um, quite an acute, high grade obstruction and it occurs due to overgrowth of bacteria. Um, and stasis. Now, who's, uh if we look at the image on the left, do you want to talk through what you can see? I appreciate. It's one slide. So it's difficult to interpret. But if you can just tell us what you can see, they've got 22 against the part, it's likely to be obstructed. I can see the Yeah, I collapsed. Yeah. Uh I'm not sure what the a respond to. So I think it's a part of the large part that's collapsed. OK. O guys, I organized this for everybody. Thank you. I said some technical difficulties. More important. 25. So I get her something. Sign up. Yeah. What's the pain? Can you put me back to the other side? No, no. Let's let everyone get their food first and then we can continue. Oh, can I can you for uh appetizer is fine. OK. OK. Thank you. Thanks very much. Thank you. Ok. So let's uh right come. OK. I'm looking as well. Oh Right. Uh On the I get Yeah. All right. So as s was seen here, we can see some dilated lupus of small bile with their level in them. Um And down here this other arrow is pointing towards some collapsed loops of small bowels. So we can appreciate the, um, the, uh, transition point. It's probably going to be somewhere near the pelvis. There's also a bit of fluid surrounding these, these bowel loops, which is never a good sign. Um, and then on the right hand side panels, what can you see? There's a big arrow pointing towards something. Yeah. So this is the LA women, the, so probably a hernia. Is that correct? It, it is a hernia. Yeah. Uh, it's a left inguinal hernia, um, which is at, at least incarcerated. Yeah, we don't know if it's stimulated. Uh Yeah. So, um, yeah. Yeah. And anything else. And also there is swelling of the above the wall. So, I mean, yeah. So here, here we've got some dilated loops of small bowel. Here we've got contrast and a small bowel loop and then distal to that, this bow is a bit collapsed and there's no contrast in there. And you can appreciate pinching of the bowel wall here. Now, in terms of what type of hernia it is, it's really difficult to appreciate one slide. Um, but if you look at the, at the femur, this is way further back than where the inguinal ligament is, isn't it? And it's certainly not a femoral hernia, but it's something more medial and it's an obturator hernia. Yeah. But that's sorry, that was a bit tricky and a bit unfair. Um, but yeah, it's just nice to see that because it's quite rare that we see that in clinical practice. Uh Any questions about that? I, um, I've never actually seen an obturator hernia repair before. Um Mister G. I think ultimately, it depends on the surgeon's experience and skill set. No, I think, to be honest, I, I'd try, um, a, well, I wouldn't try laparoscopic repair but I think a laparoscopic repair would be more feasible and sensible in the right hand. Um I think an open approach is the ideal way to manage these. No. So next, another ct spot diagnosis and it comes back to what I was explaining earlier about certain types of obstruction. Uh Does, does anyone know what type of obstruction? Yes. Exactly. Um, and this could be quite easily appreciated here with I fi so here we've got a long segment of collapse, small bowel relative to this short segment of collapse, small bowel. And then you've got this loop which is uh distended and fluid filled. And so is this the proximal side or is this the proximal side of the point of obstruction on? Exactly. And why? Pan because there is pre stoic dilation? Yeah. And all the distal sides all collapsed. Um So whilst I said to you before, you don't typically get vomiting with fluid live obstruction. You don't initially. But as fluid builds up this, the proximal bowels all going to get distended, fluid filled, but eventually you will get vomiting. Um, and we've got a picture. Get an appreciation of what it might look like. Any questions? Oh, ok. So another spot diagnosis. Uh, do you wanna talk us through these scans? So, this is showing me, uh, what I think is we try correct is, um, perforation of the gallbladder with a stone in the small bowel causing obstruction. That's what a point on the leg. There's a stone there. Yeah. Anyway, um, and what, what is triad just for everyone in the room? So we gallstone, um, bowel caused by, uh, so the triad is obstruction on imaging. Mhm. Um, there's also. Mhm. I. Mhm. Good. Yes. Yeah. So we need those three features for regular sign, pneum, mobil dilated loops and small bowel and opacity in keeping with the gallstone. Um, and that's quite patho of gallstone. Ele, its. Can everyone appreciate what Jade is referring to? Yeah. I mean, the a are pretty obvious, aren't they? But I'm not sure if that's actually a perforation or if that's just gas in the actual gallbladder. Um, and they've obviously got a connection somewhere between the bowel and the, and the gallbladder. And the only way to manage this is operatively, please do. Yeah. Yeah, you still, the KK will be, can you see that stone? It's a big wound. So most probably it's a single stone in the gallbladder. Go check on the gallbladder again and you will find the gallbladder empty. So you can't see any further stones, at least big ones which is the one has already communicated and got into the bowels and caused the obstruction. Excellent. Um, and a, a Charles, how, how would you manage this patient in terms of, do they operatively? What would you want to do? Um, typically it would be um, an enterotomy and extraction of the stone and prepare the enterotomy in the same set. Yeah. Um, I don't think in most cases, um, gold or will, will respond to conservative manage. Yeah. Yeah, that, that would probably be the la enterotomy extraction. So, and how are you making your incision? And where are you making it? And how are you closing it? Um It would be a midline incision. Uh I mean, sorry, the enterotomy. Well, it could be on the ant Mesenteric product. Yeah. Ant Mesenteric border. You want to li the gallstone back um and then make your incision, you make it um a along the Tumin incision, then you close it transversely. Yeah. And reflex. Same way that you do like a pesty, things like that and just maintain the patency of the, of the lumen of the bowel. And then what do you do with the gallbladder and that sitting? Would you remove it? Would you leave it? Would you call a friend? Yeah. Who, who do you want to call? Um But would you, would you deal with that in the first set? My or would you leave it alone and come back another day if need be. Same thing. Same set. Fair enough. Yeah. So I know what the, the idea would be that you have noun communication. The gall bladder is draining. So, um, it wouldn't be a trouble idea if you leave it. Well, I, I would say first of all, if, uh, it is because of cysto, they did not fistula or it is just a, a small stone, a small stone that stayed in the CBD became large and then passed. Uh, if it is a cor the did fis, I will not do it in the same time, maybe I will do it because it drained, as I said, and you should, it, it depends what kind, what is the real cause of this stone to be there? Uh, yeah, but in terms of fistula or it, it is just a stone in terms of frequency, which is the most common cause like I trust like fistula or a big stone that past, which is more the cause more commonly, I'm asking, I, I don't know the, the percentage but, uh, usually it happens to, uh, old patients that they had several stones and they develop something like that. Uh, and then, yeah, yeah. So most common is the consist of media fistula and the surgery like do relieve the obstruction, do the obstruction and close as I OK, and tackle the main problem if possible. Uh, depending on the, uh, expertise available at your center. Uh, so if you have a H PB, you H PB Center, so you're in the ideal place. So get the everything at one place. Uh or if you have a background of the P experience and you can deal this such a problem. Otherwise some people tend to like deal with the acute thing now, but refer to HPV Center as the U UK policy to get it done at the HPV Center because of the difficulty dealing with the HPV at the. So academically, what would be the, I think it depends and it depends on who the consultant is and their expertise and their comfort levels because you have consultants who aren't as comfortable dealing with those types of fistulas and that complex anatomy like Mr G is and in that case, it's better to leave it alone. You, you also just have to move, it's completely right. But the other thing you just add is if there is no gallstone left in the gallbladder, then what is the value of doing an operation at that point? And the risk of, of causing a catastrophic event when and if they're usually frail old comorbid patients who get these, yeah, and minimizing the length of their operation and get them off the table is ideal because all comorbid patients and most of them get off the table, but it's the recovery and the rehabilitation afterwards, which is the challenging bit. Uh you'll be putting your patient at a high risk of developing a recurrent cholangitis and we all know that. So that's why uh like I recommended that you deal with this problem. Yeah, straight away. But as we said, like, depend on how the patient physically are you going to do a damage control? Go. Um Do you have the expertise on both? Because each kind of con it's a tiny one, but you have a big effect on how we do it because the you and, but just one more thing for Mr CS, the answer is to leave that alone. Um But there's obviously a lot of nuances to anything with any clinical decision in medical or surgery that goes beyond a multiple choice question. But um that's the mrcs questions. Deal with the obstruction, leave the, leave the right or quad out, look hauls. Yeah. Can we move on? So, um CT is good for ischemia but it's not ideal and it can be difficult to predict. Um And as we were saying before being able to establish that the patient has ischemia or not, is ultimately the most important decision when it comes to whether this patient needs an urgent exploratory laparotomy or whether we can hold tight and manage them conservatively and see how they go. Um And I mean, the sensitivity for CT in terms of predicting ischemia is very variable depending on what study you rate. It's anywhere between 15 and 100%. Um But as I said, it's super important to be able to predict ischemia. Um, and there is a bit of an art to it, but I think ultimately, ischemia is associated with a 25% mortality and small bowel obstruction, uh, versus 2% of ischemia. So, it's really important to get it right. And if you're not sure, call friends, um, don't take the weight of that decision overnight whenever you're tired. Um, and it's not always quite clear. So, ct findings of ischemia, there's a long list of potential findings that you might find on the CT. I don't think any given one finding is it gives you a definitive diagnosis of ischemia, but it's more collective finding of them or constellation of findings in addition to the clinical and biochemical findings that you get from the patient. So bar thickening greater than three millimeters, mesenteric Edem fluid in the Masry or peritoneal cavity, abnormal wall enhancement occlusion of the mesenteric vessels or engorged mesenteric vessels. You can get a whirl sign or closed loop obstruction as we said before or volvulus, pneumatosis, meso venous gas and portal venous gas are all suggestive of ischemia. And we've got some more CT images that will go through and we can identify the signs of ischemia on them. You have things especially in the last few. Yeah, things hematosis is and these are sort of if you like a progression of ischemia from the early findings of the findings. So first image, what does that CT show again there sys that make it and obvious to where the point of interest is. Yes, pneumatosis. Can everybody appreciate that? It can be quite difficult. No, it's ok if you can. Yeah. Oh, sorry. Um, so here, so these are loops of small bowel and you can see there's gas here and it's within the wall of the small bowel and it's also on the non dependent part. I, and it's not where you would expect gas to be. The gas should be filled into the top and, and within, within the lumen of the actual ball, there's no gas, it's all on the periphery and you in here, you can appreciate that. And so that suggests pneumatosis. So there's gas within the bar wall which shoots that it probably has quite progressive ischemia. The next one. What can you say? Yeah. Yeah. Sorry. These are quite small images. Yeah. Um I would say is they mesenteric way? Yeah. Yeah, 100%. Yeah. And so so there's congestion so mess obviously, uh diverge, they don't converge. So they're coming out like this and you can see almost there might be a bit of a pinching point here, but these veins are all quite dilated and prominent compared to elsewhere on the mesentery. Uh And there's also some mistiness of this mesentery. So if you look at that, let's say over here, this is pretty dark, isn't it? I see. It's a bit fuzzy. And so that suggested that there's edema there and those vessels are EOR which again, it's another size potentially of venous congestion and impending ischemia or venous ischemia. Uh This scan here shows a whirl sign. Can we all appreciate that? Yeah. Uh And what does this scan show portal venous gas? It's quite traumatic and prominent and I mean, it's quite hard to miss. Um, but I mean, that's almost like a death sentence if a patient has extensive port venous gas like that. So as I said before, when we're assessing for ischemia, we need to think not only about the imaging but put that imaging in the context of your clinical findings in terms of the history and the examination as well as about chemical findings. Um and we've already spoken about what findings you might pick up on the imaging. But when it comes to the clinical findings, constant severe pain as opposed to colicky pain suggests that a patient has a more progressive obstruction and impending ischemia or ischemia or peritonitis and pain out of proportion. With the examination findings. Again, might suggest ischemia and evolving abdominal signs or peronism. It's important to not only assess these patients whenever they come in, but seriously assess them over time and see if something progressing are they're not responding to the measures that we've put in place. And then obviously, patients will have tachycardia hypertension and new fevers. From a biochemical point of view, they might have metabolic acidosis and their lactate might be up and they might develop worsening, leukocytosis and CRP. And I, I think these findings themselves, they're quite nonspecific and I can't reiterate enough how, um, it's the constellation of findings and putting them in context of the other findings which really get you to a diagnosis of ischemia because patients who are dehydrated and vomiting, they're going to have metabolic acidosis, their lactate will be up. If they've got an aspiration pneumonia, they're gonna have raised inflammatory markers. And again, from the dehydration, it might be tachycardia and hypertensive. So it's really thinking about things in a more abstract way as opposed to just um a, a strict definition if you like. And that's, I think the art of diagnosing ischemia, but again, clinical and biochemical signs on their own can predict ischemia in 40 to 50% of patients. Um So it is really a judgment call a lot of the time. Sometimes it's really obvious. Sometimes it's not. And we have had patients on the ward that have had a closed loop obstruction that we thought had ischemia, palliated them and they actually resolved and recovered like lots of risk. So it does happen. Um And as I said, we don't always get it right. So how do we initially manage small bowel obstruction G tube? Yeah. Yeah. And so, yeah. Anything else? No, by mouth. Yeah. Fluids, fluids. Yeah. Um Yeah. So what about that here? Little by mouth. IV, fluids and resuscitation, analgesia. Antics NG tube to decompress a small bowel, not only will an NG tube help with the patient's symptoms and prevent an aspiration. But it can also help to resolve the obstruction. If you think of the pathology that goes on the path of physiology behind a small bowel obstruction, you've got a transition point, you've got dilated small bowel that's fluid filled and it's causing pressure ischemia on the small bowel wall. It's preventing, um venous return and perfusion. And anything that you can do to minimize that pressure will help with the perfusion of the bowel and minimize the risk of them getting ischemia. So I think an NG tube is really helpful. It can help resolve ischemia and prevent it. Um progressing uh sorry, resolves small bowel obstruction, prevent it, progressing. And it also facilitates measuring of fluid losses and guides IV food resuscitation and you can monitor the patients resolving. So if on day two, day three, their NG aspects are still really, really high, then they're unlikely to resolve on their own by an intervention. Yeah. Um a practical thing. I mean, what will mention and will mention, I think you feel like you should cope and paste it and have it in your plan when you see somebody in. It's very helpful. Uh try to get the MG before they go to CT if you are sure they have obstruction uh because they might aspirate when the CT scan that's and chase. You need to do it or do it yourself because otherwise they may will leave the patient and most of the times you get them 10, 12 hours after and they have no energy, no anything, no fluid and the energy should be the first uh fluid balance on the stool chart. A urinary catheter to monitor urine output and the response to the resuscitative measures plus minus antibiotics. If you're worried about ischemia or an aspiration pneumonia and saves in case the patient needs an operation. A PPI can help to decrease secretions and the dissection of the small bowel. And, um, Anne, uh, I think even if you're not planning for an immediate intervention, anneal is useful just to guide how aggressive you're going to be with the management moving forward. Uh, and then always reassess the response. Uh Yes, sorry. So I recently done on the, uh, on bowel obstruction, which was made sense. Yeah. Remember you presented that I did. So apparently for is one of the recommendations that there is. There is. Yeah, that was just which I wasn't aware of. But no, no, that's a really good point. Um, I think we should be doing that on admission 100%. Uh, and as I said, always reassess the patient. So operative versus conservative management was a point that you guys wanted me to add in. Um, so first of all, what are the indications for doing surgery in the first place? We've sort of touched on them on the previous slides, um, shots to, well, if there's any sign of bowel or compromise, um, that's an indication, absolute indication for surgery that includes try and get it done. It includes a closed loop obstruction. Um, um, if so, that's, that's one of the things on the top of my head. Yeah. 100%. So, um, I've put a few indications in here. A lot of that we've covered so complicated bowel obstruction, ie closed loop ball ischemia, necrosis of perforation, dependent on the actual etiology of it. Hernias, gallstone, ileus, small bowel, volvulus, closed loop obstructions and malignancy. I mean, all studies show that they have a high failure rate and high mortality rate. So really operations are the only way forward in a patient who's fit to have one. And then if you are trialing conservative management, which is mainly for adhesional obstruction. If that's not settling within 72 hours, you should really um be considering an operation, but there is some evidence that you can extend that to five days um without increasing the mortality and morbidity. And then I've put a question mark with virgin abdomen. Um I get it. It's very much surgical dogma that anyone with a virgin abdomen and small bowel obstruction should have an operation. Um I don't know what the right answer is for that, whether they should or shouldn't. I think traditional teaching is, is that they should have an operation, but I think it comes down to a discussion with the patient and what the likely etiology is. If it's a congenital band and they're really opposed to having an operation, then you, you might want to hold fire and try and manage them conservatively. But I think either way they need to be, if you're not going to manage them surgically, they need to be appropriately followed up to make sure they don't have an underlying malignancy or anything else going on. Um But very much the traditional teaching is virgin abdomens should have an operation. Um Do you need anything to add to that vagin? What are your thoughts? Yeah. Um How to approach that? It's a different thing. It's a surgical approach. That's a different thing. But uh most of people like, yeah, as you said, yeah. So celiac facts on non operative management. So it is extremely rare that a subacute obstruction can cause ischemia. About 3 to 6% of patients with subacute obstruction will get subsequent ischemia, but it can happen. Um And it's important to continually reassess the patient and keep that in the back of your mind, irrespective of, of whether it's a full blown acute obstruction or subacute and then with non operative. Um I mean, these studies are for adhesion obstruction, with non operative management of adhesion obstruction. The success rate is anywhere between 65 and 80% which are quite good odds for a patient, I think. Um and is why we manage most of them conservatively in the first instance, in the absence of ischemia. Um but obviously, these studies are, they have very specific patient selection um where they don't have any evidence of ischemia. So, Gastrografin, Gastrografin can help with your diagnosis. You your, we touch on your prognosis and the therapeutic benefit. And so there, there's a systematic review in Metasis which was published in the American Journal of Surgery in 2016, um, which showed that it predicted the resolution of small bowel obstruction with good sensitivity and specificity. Um And it reduced the need for surgery, decreased length of stay and time to resolution of the symptoms or um, the function of the G I tract. And it didn't increase the morbidity or mortality associated with Gastrografin. The caveat of that is intraoperatively. Gastrografin can make bowel a bit more friable and fragile. Um There's also a multicenter prospective observational study which has found quite similar findings, um where they had a lower rate of operations and those treated with gastrograph and reduced length of stay albeit marginally. Um And the regression model showed that Gastrografin was independently associated with successful non operative management. So it is worth considering, but there is some contradictory evidence as well. There's this study here, the study which was an RC which compared given Gastrografin versus C line to patients with adhesional obstruction and they didn't show any benefit in terms of operative intervention or resection rates and no difference in length of stay. So I think the jury is very much still out there and we do manage patients with and it's relatively safe. Um, and whether it does, it doesn't help, it's, it's still out to the jury. No, it's, uh, it's a budget, a budget. Yeah. Ok. Well, this is certainly not a bucher and so it's so Gastrografin is a, a water soluble hypertonic contrast solution can do that. Does anyone know what, how, what the theoretic, what the theory is and how gastrograph it works. Well, it's cause water from the, in the bowel wall. Yeah, which causes a reduction in bowel wall swelling as well stimulates. Yeah. Also, yeah, the increase in internum pressure and also stimulates the bowel. Yeah, 100%. Uh And when to give it, uh when, when do we give Gastrografin? I think? Well, we give it an adhesion, obstruction, don't we? Um, and I guess the timing of it depends on what you, what your CT shows and how much is coming out of the NG tube. But if they've got really dilated, so if you've got really dilated small bowel and a CT with lots of fluid, then you want to get the tube in first aspirate as much as you can and give them a period of bowel rest to drain off as much fluid as possible because ultimately, you want the gast grain to pass to the point of, um, obstruction or the transition point Um, so I wouldn't give it overnight. I'd wait until the morning, let the consultant see the patient and then think about giving it anything else in terms of when you'd get that. Um, I think you're totally right. We need to, like, make a bowel empty to allow for it to add because if you are having full bowel trying to get the gast grain, so it will be number one diluted. Number two, you'll getting water more fluid into a fully distended bowel. So it making things difficult. So you need to have the bowels empty to draw the water out of this wool. So it makes things are help fluid. And are we done with this bit of gas or we have a not on Gastrografin? No? Ok. Uh, just to add as well, uh, there is a clear guidance from the Royal College of Surgeons that the Gastro Guin can be used as a modality for treatment of small bowel adhesion of small bowel obstruction. It's clear guidance, it's evidence based. And, uh, that's one of the things that we can argue with and I think that's nationally here with the new case. And there's another guidance from the Royal Society for emergency Medicine and surgery. Sorry. Yeah, about the uh, Gastro weapon as well, dealing with the small bowel obstruction and adhesion and it support use of the gastro as well. So we've got like national and international guidance regarding that to use it as therapeutic is not only uh what do you think about that? We are using it as a just uh do they argue that's not diagnostic or that's not therapeutic? If you say therapeutic, they will just like give you a hard time. So, yeah, but you can say the Royal College says, so don't get into that discussion because the, the e so I'm sorry to say that. Um and, but it, it needs to be discussed, it needs to be discussed at like a more within between both departments to set up a policy for that. In the meanwhile, we're using it as the policy as is a thin line because to make it therapeutic doesn't mean that you need to keep for like some of my colleagues are, you cannot have a basically with small bowel that you give one dose, then you give a second dose, you wait and then give a third dose. And within the week you give three or four doses without deciding to operate. OK. This is, this is uh dangerous. So there is a limit. Give gas breathing, you wait. If after 24 hours, the patient is not uh moving, then you need to operate. The other one which I have faced a couple of times recently that when we have prescribed a gastro, we need to make sure that we tell the N to stay. Otherwise you have two or three patients in Gastro, come up the wrong and it's just the thing is moved. You will never get another gastroin from the radiologist. It doesn't work in that fashion. Yeah. Should stay in the bowel, it should stay in the bo that's a technical thing about the those guidelines. Um, the guidelines are not super enthusiastic about the because there are guidelines and there are guidelines. Uh some guidelines are very robust methodologically. Usually the e and the guidelines, other ones are a bit more. Yeah, they read the recommendations very weekly but uh always scrutinizing in the guidelines. And I think we need more sub populations to study with clinical trials. So we reach high level gu there's no doubt about that way to, to treat every patient, but uh it's deal with respect as well. So we have a guidance, we can argue on this support for us until we find a new guidance and that's why gu are anyway. Um But yeah, I, I think for the minute, the bottom line is if they've got adhesional obstruction, you, you should be child gastro um So surgical management, laparoscopic versus open surgery. And I was hoping these points wouldn't come up initially, so I could ask that they have. So, um I think that's a big decision about whether you're going to do the operation open or laparoscopic to begin with. I think it depends very much on the etiology of the underlying obstruction and the surgeon's experience and comfort levels with dealing with that etiology, laparoscopically you also need to think about patient factors. So, if they've got an extensive history of abdominal surgery, um, and the nature of those previous surgeries as well, have they got multiple meshes in? And how long ago was the surgery? For example, if they had surgery as a child, they don't tend to get as much adhesions as if they've had a lot of surgery later on in life. Um, and if they've had extensive surgery, then you may want to think twice about doing the operation laparoscopically because causing an enterotomy increases their morbidity and mortality by, by a large, a large amount. Um And when it comes to examination findings, if you've got a really tense distended abdomen with minimal space, often, if you just lift up the abdominal wall on the bedside, you'll be able to tell is there enough space here to do this operation and after safely or isn't there? And you can always, you can always check. I mean, you, you told me, you told me that. So, uh, and you can always review the CT scan, albeit bearing in mind that there's probably more space than there was on that CT because you will have decompressed them a bit by that point. Um, but it can give you an idea of how much space is in the abdomen, the number of transition points that you should expect and where they're located and whether they would be more easily managed through laparoscopic or open surgery. And then the last point is that you also need to think about the patient's physiology. Whenever you have laparoscopic surgery, it, it, it completely messes up your physiology and these patients are often dehydrated and so forth and they get decreased fa return hypertension, decreased cardiac output. Um, and if they're frail and crumbly, you might just want to go straight for an open operation as opposed to laparoscopically. Again. If they're really sick and, and have ischemia, you might not want to around with the laparoscopic operation. You just want to get them on and off the table as quick as possible. So, when to resect small bowel, this is my last slide. Sorry guys, I know it's, it's been over an hour now. Um, so what, what are the intraoperative findings that might suggest ischemia? There's a long list of them. There's seven that come to mind, I think seven or six. Just the bowel. Yeah. So color of the bowel. Yeah. And temperature of the bowel. Yeah. If it's cold, it's likely hypoperfused ischemic. Yeah. Uh, loss of, uh, peristalsis. Yeah. Lack of peristalsis. Bye bye. That. Pardon? Oh, yeah. Perforation. Absolutely. Yeah. Yeah. So anyone have any other suggestions on what I suggest is give you uh Well, yeah. Yeah. Um, but actual intraoperatively when you're looking at the bile? Mhm. Yeah. Maybe hemorrhagic fluid, anything you can feel no pulse. That's one of the Yeah. So, um, so as we said, so lack of peristalsis. Definitely. If the ball's cold, the color of it, if you look at this ball here on the right hand, the picture on top, on the right hand side, it's very shiny, isn't it? Um, compared to the left side, which I appreciate, it's still shiny but not as much. That's also a sign. Actually the smell of it. It usually smells like, um, it smells awful. Um, and you might have a thrombo mesentery. If you feel the mesentery, it might not be pulsating and there may be evidence of thrombosis there as well. And, um, there's often a lack of bleeding from the mesentery or from the cut end of the bowel. If you're not too sure whether this is ischemic and needs to be resected or not, you can always call a friend. The other option is to put the ball back into the abdomen, put in some hot water, leave it for 5, 10 minutes, go have, um, a cigarette or a beer or whatever it is you'd like to do in your spare time and then come back and have a look at it again and I think if it's still looking the way it's looking, you probably want to resect it. Any questions at that? Oh, you can second. Oh, I don't know. Doppler, Doppler. Yes. But would you like if it was a clear cut about like, yeah. Um, if you, she, once you open the before looking at the you know, it will linger on your hands despite the gloves for days. Exactly. So, um, and that's it guys. Has anybody got any questions? What the live to be? Who's on like 10 days? Yes. Check for this. No questions. No. You said when he goes bo say you said like a hernia, hernia, you said you would put the bowel back into the abdomen to see if it perks, up, up, up. Is that a, is that something that you, I thought like. So I'm not talking about. So if it's really ned or this is necrotic, this needs to go fine, but there's often this sort of gray area in between where you might have some venous congestion that looks a bit purply it's still in or what have you. Um in that case, it can be difficult to make a decision. Should you resect it or should you not? Um Because reception complicated, I mean, the, the bowel uh was inside the abdomen was outside because of the hernia. Ok. You go, you put it back in the normal environment that it should be OK. And uh if there's no perforation, even if it, if it looks, you need to take, you need to resect before putting back in the abdomen. The question we just go back to with the temperature is rising. So you need to have a good temperature to keep it warm because warm helps with the uh perfusion. And even some people tend to ask the anesthetist to get hyper oxygenate the patient, like 100% oxygen. Five minutes. One, you having warm packs, keeping things warm, having cigarettes? Do you have any extra time for me to say a few things with a small presentation or it's, or extra outside this, uh, we can close this and then if someone has some time. Yeah. Uh, we're not gonna t, it can if you want, I mean, I don't know because I, ok. Yeah.