4-86
pylori or concurrent aspirin/NSAIDs use.
Evacuation/Consultation Criteria: Evacuate unstable and bleeding patients (melena, hematemesis). Con-
sult gastroenterologist or internist for uncomplicated ulcer disease, and a general surgeon for patients with
melena or hematemesis.
NOTE: Upper GI endoscopy or x-ray series may be required to conrm the diagnosis in garrison.
GI: Acute Organic Intestinal Obstruction
COL (Ret) Peter McNally, MC, USAIntroduction: Acute organic obstructions, which are partial or complete blockages in the bowels, are divided
into small and large intestinal causes. Both will present with acute onset of severe abdominal pain, distention
and nausea and vomiting. Prompt evaluation, decompression and surgical correction of the obstruction before
bowel infarction or perforation occurs are the keys to management. The percentages listed below are for
industrialized nations. Intussusception (20-30% of all obstructions in Africa and India where ascariasis is
endemic) and volvulus are much more common than cancers and diverticulitis in the developing world. Etiol-
ogy for small intestinal obstruction: adhesions (56%), hernias (25%), neoplasm (10%), other (9%). Etiology for
large intestinal obstruction: neoplasms (60%), volvulus (20%), diverticular stricture (10%), other (10%).
Subjective: Symptoms
Acute onset of severe, crampy abdominal pain with associated vomiting (usually feculent due to increased
bacteria in the gut) and abdominal distention; pain: in paroxysmal waves every 4-5 minutes for proximal
obstructions (less frequent for distal obstructions), and continuously for strangulated bowel; rectal bleeding is
consistent with mucosal ulceration from intestinal ischemia, inammatory bowel disease or malignancy.
Objective: Signs
Using Basic Tools: Inspection: Febrile, toxic, dehydrated from vomiting, distended abdomen with visible
peristaltic waves in small bowel obstruction.
Auscultation: Frequent, high-pitched bowel sounds occur in waves early, but the bowel may be silent later due
to peritonitis or bowel infarction. Borborygmi (loud bowel rumblings audible without stethoscope) correspond
to paroxysms of pain.
Percussion: Obstructed and dilated, gas-lled loops of bowel are often tympanic.
Palpation: A mass suggests the cause of obstruction. Check for hernias (inguinal, femoral, or umbilical),
surgical scars (adhesions).
Using Advanced Tools: Lab: CBC with differential and urinalysis for infection. Abdominal X-ray (if available):
free air, dilated loops of bowel, air-uid levels demonstrating obstruction.
Assessment:
Differential Diagnosis - causes of peritonitis (see section on Peritonitis), including appendicitis, chole-
cystitis, peptic ulcer disease, and diverticulitis; various types of food poisoning and gastroenteritis; large
neoplasms; labor (pregnancy)
Plan:
Treatment
- Place NG tube to decompress and keep NPO.
- IV uids to restore uid and electrolyte losses caused by vomiting (see Shock Fluid Resuscitation).
- Give antiemetic (e.g., Phenergan 25 mg IV, IM, or po) of choice, but no pain meds until sure of diagnosis
and awaiting evacuation (see Procedure: Pain Assessment and Control). Narcotics paralyze the bowel and
can mask worsening symptoms that may precede perforation. - Prepare for medical evacuation if symptoms persist for > 12 hours or if fever or peritoneal signs develop.
- IV antibiotics should be administered if peritoneal signs arise (must cover both aerobic and anaerobic
bacteria)
Single Agents: Cefoxitin 2 gm IV q 8 hr, cefotetam 2 gm IV q 12 hr, or cefmetazole 2 gm IV q 8-12 hr