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Summary

This on-demand teaching session will cover large bowel obstruction and provide medical professionals with relevant insight in managing such cases. Led by graduate Dr. Samal Ammo AO of the University of Ghana Medical School and core surgical trainee, attendees will learn the epidemiology and pathophysiology of this condition, including common causes such as colorectal malignancies, ileus, and small hernias, as well as associated complications like sepsis. Discussion will also touch on principles of management, investigation, and photos to gain further understanding.
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Description

Dr Samuel Amo-Afful is a graduate of University of Ghana Medical School. He is presently a Core Surgical Trainee, passionate about medical education and research. He would be speaking to us on “Large Bowel Obstruction” from his wealth of experience working in reputable centres, including his present one, Dorset County Hospital.

Learning objectives

Learning Objectives: 1. Understand the causes and classification of large bowel obstruction 2. Be aware of the epidemiology of large bowel obstruction 3. Learn to identify the presentation of patients with large bowel obstruction 4. Become familiar with the pathophysiology of large bowel obstruction 5. Understand the principles and challenges of managing patients with large bowel obstruction
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The following transcript was generated automatically from the content and has not been checked or corrected manually.

And yeah. OK. So join in and see you later. OK. We expect more people to join in as we go on. So, um I'll just be reading your um description. So uh Dr Samal Ammo AO is a graduate of the University of Ghana um Medical School. He's currently core surgical trainee. He is presently core surgical trainee passionate about medical education and research, as evidenced by his presence here today. Um He will be speaking to us on large bowel obstruction from his wealth of experience which has been gathered from working in multiple reputable centers, including his present one Dorset County Hospital. Um So without wasting much more time, I would like to invite doctor Samuel Amar for because of your life down obstruction. OK. So a good evening to everyone and thank you mi and for your wonderful introduction and I'm very excited to join um everyone today to present um our series on intestinal bowel obstruction and for those of you who were able to join last week, and we started with a small bowel obstruction and we'll finish it up today with large bowel obstruction. Um So once again, um this is just uh an email address here. You can get in touch with me and we can, uh, discuss more about surgery. And if you have any further questions at the end of the topic, feel free to ignore me and I can learn from you and you can also learn something. So in way of our objectives today and we'll make a quick introduction. Look at the etiology of large bowel obstructions and talk briefly about the pathophysiology and the history of a patient presenting with bowel bowel obstruction and complications associated with large bowel um obstruction, how we generally manage these patients. And in terms of the principles of the management and investigating these patients, and then we'll look at some few images and then we will summarize it. So we saw this picture last week and we dealt with the small intestine. And today we're looking at the large intestine, um, large bowel obstruction, um can present as an acute or chronic um, obstruction. Um, unlike in small bowel obstruction, we saw last week, which usually present acutely, you could have a large bowel obstruction and that can take days and weeks and months, um to, to present. And it's important to always bear in mind that this patient can always present quite septic, especially if they are um, perforated or very dehydrated. And we learned from last week that the bowel is able to seek sequestrate a lot of fluid. And therefore you have a if, if you have an obstruction. This is um a text piece of fluid sheets that is reasonable. Yeah, so sorry to interrupt. We are not able to see the slides as they move on. So if you please share um share the screen, not the window, please. So sorry, the slides are not moving. Ok. Yeah, so sorry to interrupt you. Ok. Are they moving now? Um Let me see. Not yet. It was moving at first but it's not moving now. Maybe if you share the entire window instead of, I mean, if you share the entire screen, not just the window. OK. Yeah. Thank you. So sorry to interrupt your presentation. So OK, we can see your screen on large bowel obstructions. OK. OK. Yes, it's moving now. All right. Learning objective. Yeah. Yeah. Yeah, please go ahead. Yeah, apologies. Um So I um by way of introduction again, so these patients can come in septic or very dehydrated. Um unlike in small bowel obstructions when we saw last week, the, the most common cause was adhesions and in terms of large bowel obstruction, the most common cause are usually malignancies. Yes. Sorry, sorry, sorry to interrupt. Um I think you're using the presenters mode. So we are seeing two slides in two slides at a time if you don't mind making it um a presentation mode. We are saying two slides at the same time we should be seen one. OK, I get you. Thank you. OK. I think that's better now. This is just one now. Yeah, perfect. Ok. Yeah, thank you. Sorry. And I decided to do it on, on, on the hos from the hospital and the computer is playing. So forgive. Um So, so unlike small bowel obstruction, which is usually adhesions, um colorectal mal malignancies or cancers are the most common cause of large bowel obstructions. Um 40% of all the patients with colorectal cancers or with large bowel obstructions presenting with co colorectal cancers may come in as an acute emergencies. So large bowel obstructions, like I said earlier, could be acute or chronic. Um, and four out of 10, um, these patients will come out will come to the A ne as acute emergencies. Um, in terms of epidemiology, it's usually seen around the fifth decade and there's a 6% lifetime risk of having a large bowel obstruction. So, what are the causes of large bowel obstruction? We have um, colorectal cancers, uh ulus and the most common ulus are usually the sca ulus, whether it's torsion or twisting of the sco around this m or the sigmoid volo and this um are flexible points of transition in the large bowel. Um, some other benign causes are strictures and you could have strictures from um diverticulitis or diverticular disease or strictures from inflammatory bowel disease processes. And quite rare and not very common is having um, a left inguinal hernia where the uh intestinal content of the hernia is the sigmoid colon. And this is because the sigmoid colon is um, has a very, is very flexible and mobile and therefore could be caught up in um uh an inguinal hem. But this is quite rare. The most common cause once again is the color of cancers and usually the benign causes are Volos and strictures. There are times where you meet intussusception, um, polyps that are leading into an interception causing large bowel obstructions, but these are also rare or having pelvic malignancies from gynecological um, malignancies also leading to large bowel obstruction in, in way of pathophysiology. Um, some large bowel obstructions usually present as close loop obstructions. Er, and what I mean by closed loop obstruction is that you have a, a pros and a distal and um, um, obstruction. So there is a point of distal end which probably may be a stricture of the cancer and there is another point of distal, um, occlusion. And the reason why this is quite common as a, um, in large bowel obstruction is because of a competent Illa valve. So, the Illa valve acts as a one way valve allowing contents, the contents to transmit between the small bowel into the large bowel, preventing backflow of um, uh, large, uh, large bowel content. If the, uh, illa valve is incompetent, then you could have the distention, um, continue on into the small bowel. But with the competent UC valve, you're likely to have what we call a closed loop obstruct obstruction. And the problem with closed loop obstruction is that it leads to vascular compromise. It leads to vascular compromise. There is continuous distension of the bo of, of the bowel. It causes venous um, obstruction, eventually causes arterial compromise. And then this will lead to bowel necrosis. And that point of weaknesses will lead to perfusion of the bowel. And that is the point where we are very concerned. And because the contents of the large bowel is mainly PSIS and this will cause a car peritonitis patient to be very unwell and septic. The other thing about closed loop obstruction is that because of the bowel distension and the ischemia, um, it leads to loss of gut immunity and therefore, there is translocation of the gut bacteria into systemic circulation and this leads to um septicemia. So your, your patient with a large bowel obstruction may be presenting with sepsis or would be very unwell with the bacteremia. And it's, it's important to bear this in mind. We must also, I appreciate that the sco is the most susceptible point of per and because it's, it's the point of transition between the small and the large bowel. And when you have, um, a distal obstruction that with the competent in the C five, then the point of um, so susceptible perforation becomes the sco. So how would the a patient with a small bowel with a large bowel obstruction present? And like we earlier indicated, um, patients can be coming in as an acute intestinal obstruction or a chronic intestinal obstruction or an acute on chronic um, intestinal obstruction. And, um, and I'm saying this because patient, unlike small bowel obstructions where they usually present with acute obstruction and in large bowel patients could be coming in with dates with days and months or weeks of, of alternating bowel habits and uh, abdominal distension, abdominal pain, abdominal vomiting. And the only reason why they probably presented to A&E is because there is an acute episode of what has been going on for weeks or there is, um, there is an acute um onset. The patient did not go through a chronic procedure but had a sudden acute, um, 40% of people presenting with that acute presentation unlike um, small bowel obstructions where we said abdominal pain was very classic and you have this classic uh colicy abdominal pain. You do not necessarily see much of abdominal pain in large bowel obstruction. And this is because the small bowel is very mobile, unlike the large bowel, which is fixed and plastic, uh, r peritoneal and therefore peratis activity is very limited. So they have a bit of pain, but you don't have that severe classic uh colicy abdominal pain in small bowel obstruction. So they may complain of some abdominal discomfort. But the major concern is an abdominal distension. They have usually huge, um, um, bellies, abdominal distension. They may talk about the history of um, where they've noticed that their bowel habits have changed where they have intermittent moments of constipation with overflow di diarrhea, or some few moments of diarrhea, they might, may come with weight loss, weight, bleeding pr which may present with symptoms of anemia, which may present with melena or fresh bleed and they may come in with absolute absolute constipation and then, um, vomiting which is not quite frequent in, um, patient with large bowel obstruction Because if they have inco incompetent, unless they have an incompetent in lua valve, that is where you have um, enlarged bowel content, transmitting into the small bowel and then having um fecal vomiting in your history. It's important to ask, especially about family history of um colorectal cancers and prior history of diverticular diseases or inflammatory bowel disease because we earlier on uh mentioned that benign strictures can also be a cause of um large bowel obstruction patient with large bowel obstructions are not quite frequent. These patients are usually elderly patient with multiple comorbidities with family history of cancers. Some of them are bedbound or bedridden. And therefore the per static activity in the large bowel is usually decreased, having an increased chance of time causing severe constipations, aligning the bo and the bowels to, to rotate and twist among his cell. And therefore most, most often the classical presentation of patient with Volos is that elderly patient who is in a social care home or a nursing home constipated for, for weeks or days and, er, er, immobile, er, and then present with a huge abdominal distension, um, abdominal discomfort, um, and then sometimes with the bleeding pr or, or absolute constipation in these patients. Um, it's important to bear in mind that this patient may be come in with a last bowel obstruction. So by way of examination, we would do a head to toe examination, examining the patient completely like we do for any other patient, chest examination, but we will do a focus abdominal examination and what would be glaring and obvious, maybe and maybe dark gross abdominal distention and you will palpate over, over the abdominal quadrants. And there might not be so much tenderness, but usually, um you might find some tenderness if the patient is perforated or per Peric or in cases where sometimes there is an impending perforation and usually the points of impending imp around the s or the sigmoid. And you may find tenderness around these areas or if the patient has a background, um developing history of recurrent divertic colitis, you may find that tenderness over the region. So it's important to, to, to bear in mind when you are palpating for these patients. And um when you are palpitating of a patient with f cross abdominal distension, you have to be careful not to push too down to, to, to perforate the seco of the bowel, you may do apr and it would be evidence that the there is no uh fess or the rectum is empty. So we would investigate this patient generally by doing uh baseline blas we do a full blood count, we do a UN E A full blood count and MLS, we'll do LFTs do a clotting profile. We'll do everything to make this patient optimize and ready for surgery. And also um this if these blasts will help us uh know whether this patient is septic and this patient is not septic and also help with surgical planning. Um in the in, in the long time, uh our diagnostic images or diagnostic investigations would be our image radiological imaging. We have abdominal estray. And last week, we said abdominal x-ray w were diagnostic in about 60 to 80% in small bowel um obstructions and most centers will not first line do abdominal x-ray and large bowels. Abdominal xu are also not clearly important. They are very sensitive, especially in Volos um but not, not very helpful in and large bowel obstructions. And we explained last week that it is because you need to know the transition point of the obstruction. You need to know what the the etiology of the bowel obstruction is. And ct scans are better place to, to give you um enough about what might be the cause. What might be the transition point, whether there's a perfusion, whether there's ischemia and and help eventually with the surgical planning. And uh abdominal ultrasounds can also be done as a noninvasive first line. Um, and it's been shown that it's very sensitive, especially for large bowel compared to, um, small bowel obstructions. So large bowel obstruction, you could have specificity and sensitivity around 90 to 96% which is abdominal ultrasound. Um, um, good diagnostic will be going in for your CT aboral abnormal pelvis. But if we are clearly dealing with a large bowel and, um, it's a, it's a, it's a cancer or malignancy we are dealing with, then you would, would need to consider doing a staging um CT which would be a CT chest abdomen and pelvis. MRI um is, it's not really 1st, 1st line but in patients with large bowel obstruction, especially in pregnant women and in Children where you are careful about x-ray radiation, you may consider MRI. I put colonoscopy as, as an investigation and, and as we go on in our discussion would appreciate the role of colon colonoscopy and colonoscopy can help um more or less as a investigation to as a diagnostic tool and also as a therapeutic tool um in large bowel obstruction. And I'll talk more about it as we, we go ahead and basically, when we start using colonoscopy, especially in investigating patients with large bowel. Um One of the key things to, to put in mind is that the in insufflation gas is actually not at the insufficient gas we actually use is usually carbon thiazide to avoid um per in the bowel. And um and and this is because carbon diazide is absorbed by the intraluminal and colon uh about 150 times faster than you would do for a so to prevent um perforation, these patients are carefully done by um by surgeons um in, in them with carbon diazide. And this gives a very good view of what could be the cause. It could also help us biopsy if there's a stricture or a cancer. And we could also do therapeutic maneuvers like putting in um erectile tube or derotating a sigmoid vol. And we see some of it when we go through the principles of management. So we've seen the classic history of a patient presenting with a large bowel obstruction. Um We still have the triad of abdominal discomfort, abdominal distension and constipation. But we, we say plus or minus vomiting depending on how competent the UC valve is. And we have seen how our ex ami findings are and how we will proceed to investigate these patients starting with a baseline plans and also moving on to um initial diagnostic uh modalities and also um confirmatory diagnostic modalities. But one of the things to appreciate before we discuss management is the principles of management is to, is to bear in mind that patient presenting usually may come in with complications and sometimes unlike small bowel obstructions where pain will pain and vomiting, we will usually bring them in patients in large bowel obstructions may take days and weeks to present. And therefore, you must always bear in mind that this patient may only be presented because they have a complication because they, they might have been tolerating whatever has been going on for weeks and months, um, until the time of complications. And, um, I must remind us again that sepsis is a very, an important concern in large bowel obstruction, perforation. It changes the surgical planning, it changes a lot about, about how this patient will be treated. And therefore, if this patient is very protonic, you have to consider perforation and, and um other complication is bowel ischemia, necrosis and gangrene. And these patients are very dehydrated with electrolyte abnormalities and eventually, um this can lead to death. So we would move on to discuss what are the principles of management and the principles of management begins 1st, 1st, save the patient and by way of saving the patient, I mean, totally resuscitate these patients. This patient have fluid which is not available to them. This patient might be septic and we need to start them on the antibiotics. We need to, to do uh a to e assessment. Get our bloods, keep them nose by mouth. Stick an NG tube tube, done, get some analgesia and anti antis if that's helpful, put them on fluids, keep a fluid shot, stick in a catheter, start the antibiotics and prepare them for surgery if um they would need one urgently. So what are the main principles of management when we talk about large bowel obstructions. And I think that when we're doing small bowel obstructions, it was very easy to, to, to tailor what the management modalities were. And if, if I, if I should remind you, we said adhesions, you could do conservative and surgical management. But in large bowel is a bit tricky because you are dealing with um a lot of uh malignancies and you need a lot of oncology input. So, so by and large, the management of large bowel obstruction involves a mo a multidisciplinary team. And this would involve um several team members including oncologist, pathologist, stomach care, nurses, cancer care, nurses, and dieticians and physiotherapy and all those things. So, you need a lot of surgical planning for this patient because most of these are oncolo oncological procedures and we need to properly teach this patient to provide um curative procedures as much as possible. So, the principle management involve conservative versus surgical versus endoscopic um procedures and the modality of treatment will usually depend on where the tumor is sighted. So, um, you, you won't be sticking, um, um, a scoop all the way down to the sco when there is a large bowel obstruction because your chances of Perin it is high. But if you had a, a left-sided obstruction, um uh or tumor, you, you could do something endoscopically. Um, and, and, um, also depending on the, whether the there is perforation or there's no perforation, depending on the general wellbeing of the patient. The frailty, the comorbidity of this patient, is this patient septic or not septic? Um is, is the patient having um a confirmed um tumor diagnosis. So all these are all these uh uh factors that would bear in mind. Do we know uh prior history of this patient recurrent um divertic colitis or recurrent inflammatory bowel disease or had this patient developed um um a malignant stricture? So these things are questions to bear in mind. Um Before we we plan out and definitive procedures for for surgery. And the primary goal is always to try and get resection with permanent anastomosis. And most of the time these are not achievable. So what these patients are offered are usually, are we going to offer them decompressive procedures that and that is, are we going to just do a different functioning or a diversion stor for this patient, make them comfortable, make the the bowels and intestinal content move into a stoor and then uh properly stage this patient probably probably diagnose this patient and then move on to to a definitive procedure. So most of the management in a large bowel are more of a stage approach. So, if a patient presented with large bowel obstruction, acutely, um there's risk of perforation on the CT or on the imaging or patient was septic or was very unwell with it, a patient was fit for anesthesia or fit for surgery. It's a question about whether we could do something endos endoscopically to reduce the, the, the obstruction or whether we could do a minimal surgery, we could go into surgery and do, um, a, a stoma, a colostomy and then come out of surgery to plan properly. Or we could have a confirmatory diagnosis right at the, whether pre op or intra op and perform a, a primary resection in anastomosis. So, the modalities are very different when we come into bow um, last bowel obstruction as compared to small bowel obstructions, sometimes these patients that so, so unfit for surgeries and sometimes they are managed conservatively. So for example, patients may have a sigmoid perforation and these perforations may be contained and they can be observed um if they're not very septic or if they're not very unwell with it to avoid anesthesia. So, one of the things that we do is in patients with sigmoid volo. So what in patients with sigmoid volu, what happens is that you have, you have the option of going to theater to perform, to, to perform a sigmoid colectomy. If it's a, you think it's a benign diverticular stricture causing the so sorry, um That, that is a sigmoid um um um stricture. But if you're dealing with a sigmoid ulus, what what you have is you, you can go to s to s to surgery detox or de rotate the volo, perform a fixation of the sigmoid to the retroperitoneal wall or excise the sigmoid and do a, a primary anastomosis of, of the, uh, of the rectum to, to the left colon or what you can do is you can avoid surgery entirely by performing, um, an agent colonoscopy. And as colonoscopy, we would, you would put in a tube, um, the colonoscope, um, have a good look at the, the, the bowel and when we look at the good look at the, of, of the sigmoid, we're looking at seeing whether the sigmoid is viable. And what, what, what we mean by it, the sigmoid is viable is, is the sigmoid necrotic is the tissue necrotic. Because if the tissue is necrotic, then your risk of perfusion is high, then there's no point doing um putting in a erectile tube, de um de rotating the, the uh sigmoid and leaving the patient. So in that case, it will be worth exploring this patient in theater to perform a sigmoid colectomy because this patient is likely to be free anyway. And we need immediate surgery. If we put in the scope and the sigmoid is viable, it's not necrotic, it's not ischemic. Then what we can do is that you can do, rotate it by putting in um um uh AAA tube or erectile tube and decompress the sigmoid. And in that, so it helps de rotate and resolve the, the, the vo in that case, you have converted something which are, which would have been emergency or an immediate surgery to something more of like an elective agent or, or a palliative procedure. So there are times where patient get going into recurrent sigmoid voles and they are unfit for surgery and they have a tube left, left in to decompress the sigmoid and, and it tip to their legs and this helps resolve the voles from time to time. So it's, it's, it's important to consider whether we are doing a conservative surgical endoscopy. And like, like I said, that, that what you are dealing with will inform what modality you'd want to do where the site of the obstruction will also inform the modality. If you have a patient with s volo, it's very difficult to get a colonoscopy all the way down to the sco in, in a very distended bowel. Your risk of Perin is high. So this patient would usually need open up surgery and de rotate the, the the sco um there are different modalities to, to manage them. If the patient is fit and can tolerate an extended procedure, you can go ahead and do a right hemi um decompress the, just decompress the CCO and fix the sico with the scope. Um There are more other less invasive procedures like a sequences toy which can be done under ultrasound or or radiological imaging. And these are also ways of dealing with sometimes um this patient. The other way to also consider this patient is also considering a palliative self expanding metallic ST and this is something that in recent times have become, um, um, a choice of managing this patient, um, compared to performing a diversion, colostomy. So the patient comes in, he has a large bowel obstruction at the point of presentation. We may not be too sure whether this is cancer, whether it's me, whether it's, it's, it has metastasized to other parts of the body and whether we have time and fitness of the patient to tolerate a full procedure. So what we would do is that most surgeons will go for a diversion, colostomy, dilate the Feiss come in for it. Well, stage plan, um MD discussion or what to do in recent times, what, what's come up is that there are these self expanding metallic stents. So what, what you can do is that instead of doing an open up or laro um laparoscopic surgery to, to do a dilation, you do a colonoscopy, take your biopsies and, and stick in a stent and, and you, you, the, the benefit of the stent is you avoid having um, um, a major anesthesia. You avoid having a, a colostomy uh for the patient to deal with and all its complications and all it or, or, or things that can come with it. But the problem with these things is that these things can migrate, these stents can perforate and sometimes, um I mean, and research hasn't really mentioned any benefit of the stent, especially in the long term um oncologic oncological care of these patients. So it's important to, to bear in mind when we have these patients with small bowel obstructions is quite, pretty straightforward and there's a lot you can do. Um, right for the patient from, from the beginning or with last bowel obstructions, it usually requires senior input. It usually requiring, um, patience and role planning for these patients. So we, we've already seen this. So what are some of the differential diagnosis of small bowel obstruction and, and of large bowel obstruction or obviously small bowel obstruction is a differential diagnosis. And then one of the important differential which always, we always have to bear in mind is colonic pseudo obstruction or the ogv syndrome. Um, so this is more of like a ma it also presents acutely and you would have an acute dilatation of the colon just the same way you would have in um uh mechanical large bowel obstruction. But in the colonic uh colonic pseudo obstruction, there is no mechanical obstruction and usually these patients are severely unwell. And when you do imaging for this patient, you will see large bowel distention and this patient can also be managed quite similar, but because there is no mechanical obstruction, usually we, we do watchful waiting, we try to treat any reversible causes. So, if the patient is very unwell with um, electrolyte disturbances, um, any shock cardiovascular issues or any other things that are treatable, um, diabetes or renal failure and all those anything that could be contributing to this form of pseudo obstruction, we try to correct them. There is um documented evidence that using treatment, um, medications like neostigmine is also very helpful. But the problem with neostigmine is that you require ecg monitoring of this patient because it can cause severe bradycardia and, and cardiac um um issues and collapse of this patient. And therefore this patient has to be well. But it's important to bear in mind that when you have this a patient with large bowel obstruction in the severely unwell patient, you have to think that this may not be mechanical obstruction. This may be colonic pseudo obstruction and they, they may do well with conservative management. So before we, before we end, and we take some questions, um I just put some images at the end. Um II, I could not find so much interesting cases to try and tease ourselves today. But um I just want to ask the image on the far left if you can see the arrow and it shows the an abdominal x-ray showing ac volo. So this is quite typical of what you will see in a cus. And this is another presentation of C ulus on abdominal x-ray. And you see a bit of a reverse of the image or the presentation in sigmoid volo. And this is what we call the co co appearance on abdominal ay in um sigmoid phus. I, I put this slide up to, to make you aware of most, most of the times your, your get out of Jae K would be go inside the patient. They have a sigmoid pous or they have a dive stricture or they have uh an IBD stricture or they have a sigmoid tumor. And uh you, you resect. Do you do a minimal rectal sigmoid resection? Do an N colostomy? Get a heart man pouch come back months or weeks afterwards and then do a reversal of the heart man to, to, to correct this patient. What happens is that these things also buy time. So one of the, the reasons in large bowel obstruction is that you, you, you have to consider that your patient may need chemotherapy, um either new adjuvant chemotherapy or adjuvant chemotherapy. And therefore you do what is minimally best for the patient at the time being, which may be stenting or stoma or colonoscopy with, with tubing and, and I rotating the volo and that may be just enough. And then we come to discuss staging planning for this patient with, with, with the biopsies we have and um plan a definite procedure for this patient. So I, I did mention that sometimes um in large bowel obstructions, patient may be too unwell and to tolerate um any surgery or anything. And, and the point of sus susceptible perforation is usually the, the CCO and this can be done percutaneously and by ultrasound guided procedure and, and they, they they stick a, a tube down into the CCO and, and drain it out. And usually the cut off point is around um about 10 or 14 centimeters en margin of the sco which in the competent IC valve and patients can tolerate anesthesia or something and it is uh sometimes palliative stuff which is done. So this is how sometimes the procedure is done. So, um you, you may not have seen this before, but then um this can be patient lies on his left lateral side, um or or right lateral side. The the scope is put in the surgeon has a look and then insist a tube and this is a patient with the sigmoid Volos. So under colonoscopy, if you, they inserted the a tube decompress the the sigmoid and colon and then, and this will help, they rotate the vlo and surgical planning can follow up with the patient. And usually these patients will need um surgery within the same admission. And so we we we look at the AO FI images. So this is a CT images of large bowel obstruction. And in this patient, the difficulty was this patient had a history of recurrent diverticulitis. And if you look at this image, you could see some, some um diverticula in the sigmoid. And the, the fear was, was this a malignant stricture which had caused the large bowel obstruction or this was a benign stricture from the recurrent divertic colitis which has caused um the large bowel obstruction. So this patient um had a colonoscopy, had a biopsy and histology was negative for malignancy and had a full sigmoid colectomy with the primary anastomosis. Um I ha I must mention that sometimes you can have a acute divertic colitis with no stricture but can also present with light obstruction. And sometimes it's because there is a lot of inflamma inflammatory process going on and the inflammatory edema causes um, a bit of an obstruct obstructive, um, pathology. But most of these patients can be, can do well conservatively without, um, any surgery. And this is a patient with erectile tumor and extending into the sigmoid. Um, so trying just a way of wrapping up, we've seen small and large bowel obstruction and in our last, um, um, discussion and in way of symptomatology and small bowel differs from large bowel obstruction in way of pain where you have a mid, um, um, cyclical pain in small bowel obstruction as compared to lower and peripheral pains in large bowel obstruction. The pain is usually colicky and it can become constant unlike the dull, continuous pain in large bowel, um, obstruction, vomiting is very early, uh, and it's late in large bowel obstruction and sometimes, um, especially if you have a competent in c valve distention is usually mild and moderate, but you have severe distention. This is the classic thing you, you want to look out for in large bowel obstruction, constipation may be absent because there's so many loops of bowel with, with contents filled in small bowel obstruction as compared to large bowel obstruction where you have low or distal obstructions. So you have a lot of constipation or obstipation in these patients. So let me try and summarize what we've learned in these last two sessions in way of management. Um So we sit patient present with intestinal obstruction. It's not easy to just pinpoint to say it's large bowel, small bowel, but in way of history, examination and imaging, I mean, we, we said we move on to higher modalities like ct. So ultrasound and brain abdominal x-rays will not be necessary. And if you're in a, you're in a good facility, but we did mention that most of the causes of small bowel obstruction were adhesions in our last presentation. And we said that the second most common cause for abdominal hernia. So patient comes in with intestinal obstruction. You are asking yourself, does the patient the, does the patient have abdominal wall hernia? If the answer is yes, the question is, is it reducible or it's not reducible? If it's not reducible and patient have intestinal obstruction, then you want to do an emergency surgery. You want to operate on this patient. If the hernia is reducible, then you want to plan an elective procedure for them and most likely within the same time of admission or if there's no theater space, these patients can be be booking for an agent procedure. The next question is there is no abdominal or there's no hernia. So we have ruled out a hernia, which we can clinically do except for the internal hernias, which we need a CT scan anyway. So there's no abdominal wall, external hernia. We, we go on ahead to do a CT scan. A CT scan comes back and see it's a small bowel obstruction or it comes back to say it's a large bowel obstruction. The next question to ask ourselves is if it's a small bowel obstruction, is it complicated or it's not complicated? Is it complicated? Means, is it ischemic? Is it perforated? Is it gangrene? Are we dealing with a patient with high lactic levels? Patient with CT scan finding of ischemia or perforation? If the answer is yes, there is no, I mean, obviously, surgical plan always has to take into perspective the patients wishes because patients can decline surgery and the fitness of the patient for the surgery and the benefits and risk um, modalities or, or assessment. So, uh, we are assuming that all things being equal. If there is complication, you will send this patient for emergency surgery. If there's no complication, then it's a question. Does this patient have adhesions? If the patient has additions we mentioned last week that you, we can do conservative management effective for 73 to 5 days. And if conservative managing management is successful, we will discharge this patient, the conservative management is not suc successful. This patient will come back to have an emergency surgery if the CT scan shows that it is not adhesions. But rather we are dealing with the small bowel cancers, which is usually not common or we are dealing with internal hernia. This patient will need surgery. There is no room for conservative management in these patients. Lastly, when we come to large bowel obstruction, it's still the same question about whether it's complicated or not complicated. If it's complicated, we will probably still go to surgery and, and do a, a diversion tumor and come out and do a stage planned, um, um, surgery, uh, with following chemo or possibly, um, a curative, um, procedure. If it's not complicated, then we are considering, can we achieve minimally invasive procedure by going endoscopically? Can we do? Um, can we, is it, is it a cancer? Can we do a scope when we do a scope? Are we looking at, at the cancer? We can take biopsies and put a stent if it's effective, we can con con do conservative management for this patient and bring them later again for an elective surgery. If it's ulus, can we do rotate the, the, um, the bowel endoscopically? If yes, we'll do it conservatively and do proceed with an elective plan. If endoscopy shows divers class stenosis, can we stent it or can we, um, treat them conservatively if it's, yes, then we, we do it conservatively and do a world stage plan. If the rotation fails in volo, we will end up doing an emergency surgery. If stenting fails, we end up doing emergency surgery. So this is in, in summary, what, what as a surgeon or what, what as a surgical sto or a house officer, this should be what be, should be going on in your head. And I remember when I was a, a surgical house officer, we had a, a AAA woman, she was a middleaged woman who had a colorectal cancer. And at the time, the surgeon felt that um we did not have definitive diagnosis and staging about the colorectal cancer. So it was best for the patient to go in to have colonoscopy and at colonoscopy. Um I'm not sure it wasn't at our facility, this was in in overseas. So the patient went to another facility for the colonoscopy and I'm not sure whether they in over insulated the the colon or whether they used a insulation. Um as we had already, as we've already discussed, it's best to do carbon dioxide insulation for this patient. But this patient almost perforated and was sent to us as an emergency for a colostomy. But it was, it was on, on fair discussion. It was a question about why did we send the patient first place, do a colonoscopy? We send the patient because at the time of presentation, patient was not in an acute intestinal obstruction. Patient had had a chronic of large bowel obstruction and, and was stable and therefore we could go in for, for a biopsy. The CT scan has shown that there was more of like a malignant stricture a around the left, the left sigmoid area. So we thought it was easier to do a scope and take some biopsies which would be more diagnostic than possibly just ac T diagnosis. What, what could the, um, the endoscopies have done, Um The endoscopies at the time if it was killed, probably could have put in a metallic stent um uh and take the biopsy, but po possibly we never, we never know what happened and this was not possible and the patient was, was rushing. So, so this is just, is just to see that there is no immediate rush, especially in acute um la in large bowel rushing which has been going on for in, in chronic when there's no acute super imposition or there's no complication like ischemia or perforation to go in for emergency surgery. If these are not, these are not warranted or these are not there, then you could always think about less invasive procedures about keeping the patient more stable and getting a more definitive diagnosis, doing a sta a staging CT scan, chest, abdomen, pelvis and, and having your M BC discussion and coming back to the table to operate with this patient at um at a good time. So I think this will bring me to the end of my presentation and thank you for listening and I'll just allow you that any questions um from the audience. OK. Um Thank you very much for the very extensive and uh very brilliant presentation sale. Um I'm sure everyone would agree that uh this presentation has been very elaborate, um touching on all the RIC cases and the variable ways uh large bo presentations can present and um the ways to manage each of them. Um We can also all agree that Samu has done a good job in trying to bring it down to uh uh to take it to every level, from the level of the junior doctor to the level of the senior doctor. Um And we are really grateful um to have had this teaching from you sa um I noted quite a lot and I, I have a couple of questions, but in the meantime, please to our audience. Um if you have any questions, please feel free to drop them in the chat box and we will take them. Um We will take them as uh the, the presentation as this session goes on. Please drop your questions, feel free to drop any clarifications you need on any parts of the presentation. Um That's um yeah, any clarification on any part of the presentation. And um I'm sure our presenter will be happy to take them. Um Well, I will just start with um um some questions that I have. I was wondering um you mentioned that um as part of the management for lateral obstruction at some point, the erectile tube can be put in this under um endoscopy guidance. I was wondering how long is that left for? Um is it until complete resolution of symptoms or until definite surgical management is being carried out? Um I was wondering how long the erectile tube will be left for. Um Also, I was also thinking you mentioned that the um MRI would be preferred as an imaging modality for patients who are pregnant um bearing in mind that uh recent studies have shown that the the amount of radiation um produced by radiation exposure, uh that is enough to cause fecal, an uh fetal anomalies in pregnant patients for of pregnant patients is lesser, the amount of radiation exposure is lesser than the cut off for fecal an fetal anomalies. Um Would you say that um well, would you recommend that we still have an MRI done or would it be a sort of a senior decision uh as to whether having a CT MRI for large bowel obstruction just because we need to see the transition point also. Um But I would also like to ask, what do you think about the uh role of a primary ileocolic anastomosis versus a anastomosis in a patient presenting with an acute say acute and chronic large bowel obstruction? Thank you. Ok. So, um so I think with the, with the erectile tube it, it can be left in for even days. So, um it's not, it's not necessarily um in and out. You can actually, you can actually tape it to the thigh of the patient um and to leave it in. But the usually these are just um initial management techniques. Um because when you have a patient with Volos, um the the rotation of the patient does not necessarily fix it entirely. And because the sigmoid is one part of the, of the colon, which is um very um um flexible, um has its own um um uh miss entry and it's very mobile. So um the chances of this patient going back into Volvo is high. And secondly, you don't want to get this patient into um mucosa mucosa ischemia or necrosis or, or perforation. So, this Volos is, is derotated, but usually um you would go in and, and repair this patient and most of the times it will be. So there's things that you can do, you can do um fixing you fix the sigmoid to the to peritoneal wall, you plaster it in which ministries have shown that it is not still effective necessary because you, you could still get the, the physic off and then you, you, you can go back into both of those or you could um do a aig and um um colectomy take off the sigmoid and do a per anastomosis if it's safe to do it or do a man for the patient and and later do a reversal of the Haman. So there are many ways to look at it. But normally rectal tube can, can, can be inserted uh more than 24 hours and you can keep it for days. And concerning your second question about um sorry, what, what was the question again? Whether you can do a colo echo colonic anastomosis compared to an ileo um colonic um anastomosis is that the question, what was the question directly? So, I mean, that was the question, the feasibility of doing an ileocolic vessels or colic and which would be safer in a patient who presents acutely uh with large bowel obstruction with a patient with a large bowel obstruction. So, so, so, so usually, I mean, so I, I, um, uh anastomosis would, would mean that that means you've taken a very large section of the, of the bowel of the bowel out. Uh And sometimes most of the time it like done with patient with this uh polyposis syndromes or with patients with a lot of uh inflammatory processes like I BDS with extensive loss of the bowel. But like, like I earlier indicated the principle in um, bowel surgery in large bowel. It's not necessarily to, to, to try and achieve primary anastomosis at the point of, of surgery. And you must understand that the ilium anatomical, the ilium and, and colon have different sizes. And therefore, if you do an extensive resection, you would have AAA small bowel segment to actually anastomose. And sometimes you have to think about trying to do a side to si a side to side anastomosis of the ileum to the, the colon. And it can be quite challenging as compared to having a colon to colon and anastomosis. And, um, in patients with especially right-sided tumors, most of the times you can achieve your right hemicolectomy at the time of the same surgeries as compared to patients with, um, um, splenic fas or left-sided tumors because you have a short segment of, of, of bowel and most of the bowel, most of the bow on the colon on the left from this are usually contaminated with physis as compared to the bow on the right. So these are all usually surgeon technique intra op findings and what to do um, at the time of the operation. Ok. Well, thank you very much for that extensive explanation. I quite well. I, I agree with the, your rationale. Um, it's just that I've seen or I've seen it somewhere. I would have to look for it. But, um, where the, where they were considering ileocolic vessels to cholic anastomosis and they were in favor of a primary ileocolic anastomosis as they found that in the acute setting Cholo cholic anastomosis have higher risks of anastomotic leakage, which is a nightmare of every surgeon who does an anastomotic leak. I mean, the risk is always there. But, um, everyone is always wary of an, so I, I think the research or the, the, what, what you said is true and that's the same point I'm making that if you do a right, he, you'll be doing an Ileocolic anastomosis and, and it, it's safer because the right side of the colon is usually less. Um, but the bacterial content is lesser than the left side you get. And if you do, um, a, a tumor resection in the left and you were doing a alo uh anastomosis at the same time, you are likely to, to risk the, to risk the anastomotic leak because there's a high uh FICA content and bacterial load on the left you get. So I think it's just um down to the same point. Yeah. Yeah. Yeah. Yeah. Thank you very much. And my question on the CT versus MRI in pregnancy. What are you? So, so, so, yes, it's very true. So, um so, so currently, there's a lot of improvement in CTS and there's what we call low dose um CT scans which can achieve um um diagnostic um with uh low radiation. And um now this is offered to even pregnant women. Um and with, with consent, I mean, with need for CT S. So, so yes, you can go for CT. Um I just brought that up um because um for, for learning purposes, you also can go for the option of an MRI to avoid a CT at all. But I agree. There is low dose CT scans. Um OK. Yeah, thank you very much for that. I will just go to the chart box now to see questions. There's one question which has been put here and the p the person is asking what are the differentials for uria? Uria? This is, this is like taking into urology. Yeah. So, so, so if, if it is Uria with, with the, with the understanding that you have urine leaking in the, in the uh in the colon. So you have uh you have fes or you have dilation of urine into the fess or you have ps. So, so this, this can happen in um and fistulas and, and you can have them in patients with um chronic divert IBD diseases that form strictures that eventually erode into the, the bladder. And sometimes one of the things to bear in mind is that usually when you operate with patients with left sided tumors, you, you encounter the left urethra. So the left urethra is which which also retro and in your attempt of trying to mobilize the, the splenic fas and and the colon on, on the left, you can injure the, the urethra and you, you could have an intra leak um of urine also. Um and, and if you have a anastomosis, you probably may see the, but uh I think this is uh an area that may come in as a, it's a complication with diabetic and I BD diseases. Yeah. Yeah. Thank you very much for that. Just as an addition. And from my little experience also um patients with um metastatic or locally invasive Prosta prosthetic malignancies, um which sort of invade into the rectum. Well, in that case, we form a rectal um cycle. Yeah, fistula, which could also be a cause of um uria. So I hope that was um clear enough for the person who asked um just a, just a couple more clarifications on my end if that's all right. Um, I want you to please, um, come again with the, um, concept of the use of the s to you, uh, because it was, um, I've not seen it done in a, in a practical setting before but it seems like a very good, um, um, modality for patients who are not fit of anesthesia urgently or surgery. And, um, bearing in mind that as you thought, the scum, uh, is a high, is the main point for, is a key point for perforation in closed loop bowel obstruction. Yeah. So, so it, it's, it's not a common procedure and, uh, and it's not, I haven't seen one done myself. Um, it's not a common procedure. I think that's what I can see, but it's something that, uh, it's in literature and it's something that is, is an option on the table when you, you, you, you, you don't think you can send the patient to the, but the risk of perfusion is, is high and sometimes um when you have a patient with colonic um pseudo obstruction like the, the Oay and the life, the syndrome where there is no mechanical obstruction. So when you send the patient to theater, there's no mechanical obstruction. You are, you are not going to resect anything. You're, you're going to put the patient into on due anesthesia and probably do a different functioning or diversion stoma, which may be beneficial. But because there's no mechanical obstruction, if your medical and conservative treatment is not doing, this is also one of the modalities that um um have been recommended. However, most of the patients will do well um in um colonic obstruction with the conservative and with the neostigmine uh treatment and treating underlying causes. Yeah. OK. OK. OK. Thank you. Thank you very much for that. Um Just looking through the chat box, some uh uh one of remember of the audience has asked that you share your email. Um uh I believe the person wants to reach out to you if that's all right. Um My email on the screen for Lilian, if you're happy, the email is on the screen. Um OK. Another person is also asking for the slide presentations. I hope you'll be happy to upload the slides onto me la uh So we can all have a read through again and um consolidate what you've taught us so far. Um One last uh clarification from my end bearing in mind that colorectal cancers are a very common cause of large bowel obstruction. Um What would you say? What, what would be your comments regarding the fit test that the fi immunochemical um testing to sort of detect patients who are, who have this uh malignancy? And so, so that we can more or less uh carry out early procedures on them if needed and prevent them from going into bowel obstruction. And uh, also what do you, what do you reckon can be done in? We say low resource uh economies where fit test may not be available to detect uh, these patients who would benefit from early curative surgery, um, as opposed to having bowel uh surgery for bowel obstruction later. Ok. So I, I think, um, so first of all, fit test is good and I'm not sure any of us are, are on at the age of 60 years and above to qualify for a fit test from your GP. However, sometimes it's done even earlier if there's family history or there's suspicion for it. So, um, I don't have much to say, I just see the fit test is good and it, it may show awkward blood, it may show all these things and then it will lead to, um, colonoscopy to be done and you, we, you may pick bowel cancer and all those things. And it's very important because we've, in my presentation, I mentioned that 40% of, um, colorectal tumors will only present as an acute large obstruction. So the, the patient or the person will never know they have a colorectal cancer until they get a large bowel obstruction and present at the ene. And then that's where they, they get that diagnosis. So if you qualify, that's a good thing in countries or in places where they don't have regular or routine, um, endoscopic uh, screening or fit screening procedures, I think, I mean, that is a challenge obviously and I don't know what to say to the, to that. But, but clearly if you have a family history, if you have clinical symptoms, you have to present. And I think overseas, a lot of people present with acute large obstruction and then they are found to have tumors, er, unlike over here where they, they will probably be found because patient may get a CT for something else, a CT abdomen for, for a pancreas consent, a CT abdomen for, for a ana colic, a CT abdomen for something else in the tumor is, is diagnosed. So I think that's uh those are the differences. Yeah. Ok. Ok. Yeah, I agree. Thank you. Thank you very much. Uh Sama for the very extensive presentation. I'm certain that everyone who's coming in here today um would leave here with a clearer understanding of the etiologies of large bowel obstructions, um the clinical presentations, the diagnostic workup and the eventual management of this. Um So at this point, it will be safe to thank Doctor Samo for his brilliant presentation and um to end this teaching session if there are no further questions, um just by way of information, um the management of this um teaching group are encouraging interested individuals to join the social interest group of Africa. Uh And the link is posted in the chat box for interested individuals who have not joined. This is so that you can get regular updates on um activities going on within this um remarkable organization. You would also be expecting your valuable feedback at the end of this teaching session. So I would click, I would um make the feedback forms available shortly. Um If you don't get it now, you would get an email as long as you're registered um with the um link for the feed for to provide uh feedback for our presenter and for the session in home after this. After giving this feedback, um the certificate of attendance will be provided. So we would really want you to have, we would really want to get your feedback so we can continually improve our teaching skills and improve this organization as a whole. Um Thank you very much once again, um Doctor Samo for taking that time to um teach us on large bowel obstruction. Um If there are no other questions, I've just put the feedback um link on the chart, by the way for those interested so that they can click it Now, um If there are no other questions, I believe this would be a safe point to call it and evening. Thank you very much to everyone who has come in to join today and um enjoy the rest of your weekend. Thank you so much guys. Thank you. Bye bye.