DIFFERENTIAL
Crohn disease, ulcerative colitis, infectious enterocolitis, colorectal cancer,
celiac sprue, endometriosis
DIAGNOSIS
■ Exclude organic causes
■ Labs: CBC, LFTs, albumin, ESR, celiac sprue serologies
■ Stool: O&P, C. difficiletoxin
■ Consider referral for endoscopy and colonoscopy if symptoms are severe.
TREATMENT
■ Provide reassurance.
■ Tactfully explain visceral hypersensitivity and validate symptoms.
■ Dietary trials: Lactose-free, high-fiber diet
■ Antispasmodics:Dicyclomine, hyoscyamine, peppermint oil
■ Antidepressants:Desipramine, amitriptyline, fluoxetine, paroxetine
■ Constipation-predominant type:
■ ↑Fluid intake.
■ Provide bowel habit training.
■ Tegaserod 6 mg BID
■ Osmotic laxatives
■ Diarrhea-predominant type: Loperamide, cholestyramine
Large-Bowel Obstruction
Mechanical colonic obstruction is due to a physical barrier that prevents the
passage of bowel contents through the GI tract. Unlike SBO, the cause is
rarely adhesions or hernias. The common causes are listed in Table 11.9.
SYMPTOMS/EXAM
■ Symptoms include abdominal pain, distention, nausea, vomiting, and
inability to pass flatus or stool.
■ Exam is notable for abdominal distention, hypogastric abdominal tender-
ness to palpation, vomiting that is feculent if the obstruction is low, tympa-
nitic abdomen, high-pitched increased bowel sounds early, and decreased
or absent bowel sounds late in the course.
DIFFERENTIAL
Small-bowel obstruction, pseudo-obstruction, paralytic ileus, constipation, fecal
impaction
DIAGNOSIS
■ AXR: May demonstrate air fluid levels, free air, masses, and may localize
the obstruction to the large bowel
■ Labs: Leukocytosis, hemoconcentration, and electrolyte abnormalities
■ CT: Contrast-enhanced exam may delineate location of obstruction, etiology,
and partial vs complete obstruction.
■ Contrast enema/sigmoidoscopy: May reveal location and cause of obstruction
TREATMENT
■ Insertion of NGT, NPO status, fluid resuscitation, electrolyte replace-
ment, and broad spectrum preoperative antibiotics are required.
ABDOMINAL AND GASTROINTESTINALEMERGENCIES