0071643192.pdf

SYMPTOMS

■ The site and cause of the obstruction will determine presentation.

■ Crampy and intermittent abdominal pain, bilious emesis with proximal

obstruction and feculent emesis with distal obstruction, and inability to

pass stool or flatus

■ Ileus is associated with nausea, vomiting, obstipation, abdominal pain, and

distention.

EXAM

■ Early:Mild abdominal distention, abdominal tenderness may be mild and

diffuse, tympanic to percussion, increased high-pitched bowel sounds

■ Late: Distention, decreased peristaltic waves and bowel sounds, acute

abdomen with strangulation and perforation

■ Ileus: Mild abdominal tenderness, minimal distention, and decreased bowel

sounds

DIFFERENTIAL

Acute appendicitis, pancreatitis, gastroenteritis, large-bowel obstruction,

pseudo-obstruction

DIAGNOSIS

■ Labs: Leukocytosis, hemoconcentration, electrolyte abnormalities, ele-

vated serum amylase

■ AXR: Dilated small-bowel loops with air fluid levels (findings may be

absent in early, closed-loop, or high SBO); “string of pearls”sign, which

are small air pockets, may be present; absence of air in colon if late

obstruction (see Figure 11.4); free air with perforation

■ CT: Contrast-enhanced CT is highly accurate for making the diagnosis. It

delineates partial vs complete obstruction, level, and type of obstruction,

and may demonstrate the cause. It is also helpful in differentiating

between ileus and obstruction.

TREATMENT

■ Partial SBO: It may be managed expectantly. NGT suction, bowel rest,

and fluid and electrolyte replacement are required. Surgery may be

required if obstruction does not resolve with conservative management.

■ Complete SBO: Surgical intervention is often required. NGT suction, NPO

status, and fluid and electrolyte resuscitation should be initiated preoperatively.

ABDOMINAL AND GASTROINTESTINAL

EMERGENCIES

TABLE 11.5. Causes of Adynamic Ileus

Postoperative or trauma

Acute intraabdominal inflammatory process (peritonitis)

Electrolyte abnormalities

Medications

Severe medical illness

Pain from adynamic ileus is

usually more constant and

less intense than mechanical

small-bowel obstruction.

Plain abdominal radiographs

are 70–80% sensitive for

detection of SBO as ileus may

mimic AXR findings. CT is

80–90% sensitive.