Transcript small bowel obstruction

Colon Mass
GARCIA to GO
Section B
45/ F severe colicky abdominal pain, abdominal
distention
1Month • Lost 15 pounds
PTA
3
weeks • Frequent episodes of watery stool alternating with hard, small caliber stools
PTA
• Nausea
• Abdominal pain
2 days
PTA • Abdominal distention
1 day
PTA
• Not passed any stool or gas in the last 24 hour
• Previously‐taken food twice
Hours • Moderately severe colicky abdominal pain
PTA • Abdominal distention
P.E.
Normosthenic not in any form of distress
 Her vital signs are top normal
 Chest and lungs are normal
 Abdomen is globularly distended, with
normal to hyperactive bowel sounds, soft,
and nontender
 Digital rectal examination is normal

Family History

(+)Colon cancer:
◦ Father at age 50
◦ Father’s sister at age 52

(+) Abdominal Cancer:
◦ Two of her cousins (alive and receiving
chemotherapy)
Eldest of 4 siblings (40, 36, and 33 years old) and
all of them are apparently well
 Unaware of her grandparents’ medical history

What is your clinical working
impression? Basis?
1. Obstruction
◦ Mass lesion
2. Irritable bowel Syndrome
Why Obstruction?
Colicky abdominal pain
 Abdominal distention
 Due to causes within the bowel lumen, within the wall
of the bowel, or external to the bowel (such as
compression, entrapment or volvulus).
 Complicated by
◦ dehydration
◦ electrolyte abnormalities due to vomiting
 Pain is felt lower in the abdomen and the spasms last
longer

Why IBS?
Functional bowel disorder
 Characterized by:

◦
◦
◦
◦
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chronic abdominal pain
discomfort
bloating
alteration of bowel habits in the absence of any
detectable organic cause
May begin life event or may begin at onset of
maturity without any other medical indicators
What are your immediate
diagnostic and therapeutic plans?

Complete blood count
◦ Abnormal levels may indicate bleeding

Fluid and electrolytes
◦ Determine changes brought about by patient’s vomiting and
diarrhea
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Plain X-ray
◦ useful for detecting free intra-abdominal air , bowel gas
patterns
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Colonoscopy
◦ for visualization of the entire colon and terminal ileum
◦ biopsy
Interpretation of the Abdominal
Films
Comparison of large and small bowel
obstruction features
Feature Obstruction
Small bowel
Bowel diameter (cm)
>3 and <5
Position of loops
Central
Number of loops
Many
Fluid levels
Many, short “Step Ladder”
(on erect film)
Bowel markings
Valvaulae
(all the way across)
Large bowel gas
No
Large bowel
>5
Peripheral
Few
Few, long
Haustra
(partially across)
Yes
Interpretation
There is a cut off point between the
transverse and descending colon due to
obstruction
 No volvulus seen
 No diverticulum
 No pneumoperitonium

What is your diagnosis now?
Other considerations? Bases?
SMALL BOWEL OBSTRUCTION

Abdominal pain
◦ Most small-bowel obstructions cause waves of cramping abdominal pain
◦ Pain occurs around the belly button (periumbilical area)
◦ If an obstruction goes on for a while, pain may decrease because the bowel stops contracting
◦ Continuous severe pain in one area can mean that the blockage has cut off the bowel's blood
supply => This is called a bowel strangulation and requires emergency treatment

Vomiting
◦ Small-bowel obstructions usually cause vomiting
◦ Vomit is usually green if the obstruction is in the upper small intestine and brown if it is in the
lower small intestine

Elimination problems
◦ Constipation and inability to pass gas are common signs of a bowel obstruction
◦ When the bowel is partially blocked, you may have diarrhea and pass some gas
◦ If you have a complete obstruction, you may have a bowel movement if there is stool below the
obstruction
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Bloating
◦ Blockages may cause bloating in the lower abdomen
◦ You may also hear gurgling sounds coming from your belly
◦ With a complete obstruction, your doctor may hear high-pitched sounds when listening with a
stethoscope
SMALL BOWEL OBSTRUCTION
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Pain tends to be colicky (cramping and intermittent) in nature,
with spasms lasting a few minutes
Pain tends to be central and mid-abdominal
Vomiting occurs before constipation
Depending on the level of obstruction, bowel obstruction can
present with abdominal pain, abdominal distension, vomiting,
fecal vomiting, and constipation.
Obstruction may be due to causes within the:
◦ bowel lumen
◦ wall of the bowel
◦ external to the bowel (such as compression, entrapment or volvulus)
LARGE BOWEL OBSTRUCTION
In the large intestine, obstructions are
most often caused by cancer
 . Other causes are severe constipation
from a hard mass of stool and twisting or
narrowing of the intestine that may occur
because of diverticulitis or inflammatory
bowel disease

LARGE BOWEL OBSTRUCTION
Symptoms of large-bowel obstruction can include:
 A bloated abdomen
 Abdominal pain, which can be either vague and mild, or sharp and
severe, depending on the cause of the obstruction
 Constipation at the time of obstruction, and possibly
intermittent bouts of constipation for several months
beforehand
 If a colon tumor is the cause of the problem, a history of
rectal bleeding (such as streaks of blood on the stool)
 Diarrhea resulting from liquid stool leaking around a partial
obstruction
 Blockages caused by cancer may cause symptoms such as
blood in the stool, weakness, weight loss, and lack of appetite.
COLON CANCER
About half of all large-bowel obstructions
are caused by colorectal cancer
 Undiagnosed colon or rectal cancer may
cause a gradual narrowing of the large
intestine's inner passageway
 Usually patients experience intermittent
constipation for a while before the bowel
finally becomes obstructed

Symptoms of colorectal cancer depend
on the location of tumor in bowel and
whether it has spread to elsewhere in the
body (metastasis)
 Symptoms and signs are divided into:

◦ Local
◦ Constitutional (affecting the whole body)
◦ Metastatic (caused by spread to other organs)
LOCAL
 Tumor that is large enough to fill the entire lumen of the
bowel may cause bowel obstruction.
 This situation is characterized by constipation, abdominal
pain, abdominal distension and vomiting as seen in the
patient
CONSTITUTIONAL
 If a tumor has caused chronic occult bleeding, iron
deficiency anemia may occur
 This may be experienced as fatigue, palpitations and noticed
as pallor (pale appearance of the skin)
 Colorectal cancer may also lead to weight loss generally
due to a decreased appetite
METASTATIC
 Colorectal cancer most commonly spreads
to the liver
 This may go unnoticed, but large deposits in
the liver may cause jaundice and abdominal
pain (due to stretching of the capsule)
 If the tumor deposit obstructs the bile duct,
the jaundice may be accompanied by other
features of biliary obstruction, such as pale
stools
Work-ups
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Biopsy
◦ necessary to confirm the diagnosis
Colonoscopy
◦ inspects the entire length of your colon with a little
camera
◦ detects colon cancer, ulcers, inflammation and other
problems in the colon
◦ Localize the tumor
CT scan
◦ Most accurate to detect metastasis in LN, liver
Virtual colonoscopy
Management
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Nasogastric suction
IV fluids
◦ 0.9% saline or lactated Ringer's solution for
intravascular volume repletion
◦ Urinary catheter to monitor fluid output
◦ Electrolyte replacement should be guided by test
results
◦ In cases of repeated vomiting, serum Na and K
are likely to be depleted
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IV antibiotics if bowel ischemia is suspected
◦ 3rd generation cephalosporins
Management

Surgery to remove any obstructing lesion
◦ Gallstone- enterotomy
◦ Prevent recurrence- repair of hernias, removal of
foreign bodies, lysis of the offending adhesions if
any
◦ Disseminated intraperitoneal cancer- bypassing
the obstruction, either surgically or with
endoscopically placed stents
◦ Obstructing colon cancers- single-stage resection
and anastomosis, diverting ileostomy and distal
anastomosis, diverting colostomy with delayed
resection
How did this finding alter your
previous management plan?
A proctosigmoidoscopy is done 4 hours after admission and reveals the
following at the 18 cm level.
Scope can not be inserted further. Biopsies are taken.
Optimum Treatment Strategy
Surgery is the ONLY hope for CURE
 Adjuvant chemotherapy for Colon CA

◦ Stage III disease
◦ High risk Stage II disease
 Obstruction / Perforation
 High grade histology
What is/are your objective/s in
treatment?
What do you think should
be performed?
1.
2.
3.
Colectomy
Subtotal Colectomy
Other types
- Right hemicolectomy and left hemicolectomy
- Transverse colectomy
- Sigmoidectomy
- Total colectomy
- Total proctocolectomy
Colectomy
•
Resection of any part of the colon entails mobilization & ligation of the
corresponding blood vessels.
•
Lymphadenectomy: usually performed through excision of the fatty tissue
adjacent to these vessels (mesocolon), in operations for colon cancer
•
When the resection is complete, surgeon has the option of immediately
restoring the bowel,
– by stitching or stapling together both the cut ends (primary anastomosis)
– creating a colostomy
•
Several factors are taken into account, including:
– Circumstances of the operation (elective vs emergency);
– Disease being treated;
– Acute physiological state of the patient;
– Impact of living with a colostomy, albeit temporarily;
– Use of a specific preoperative regimen of low residue diet and laxatives
(so-called "bowel prep").
•
An anastomosis carries the risk of dehiscence (breakdown of the
stitches),
– lead to contamination of the peritoneal cavity, peritonitis, sepsis and
death.
•
Colostomy is always safer, but places a societal, psychological and physical
burden on the patient
Subtotal colectomy

Resection of part of the colon or a
resection of all of the colon without
complete resection of the rectum.
Other types
•
Right hemicolectomy and left hemicolectomy
– resection of the ascending colon (right) and the descending colon (left), respectively.
– When part of the transverse colon is also resected, it may be referred to as an
extended hemicolectomy
•
Transverse colectomy is also possible, though uncommon.
•
Sigmoidectomy is a resection of the sigmoid colon, sometimes including part or all of
the rectum (proctosigmoidectomy).
– When a sigmoidectomy is followed by terminal colostomy and closure of the rectal
stump, it is called a Hartmann operation;
– usually done out of impossibility to perform a "double-barrel" or Mikulicz colostomy,
which is preferred because it makes "takedown" (reoperation to restore normal
intestinal continuity by means of an anastomosis) considerably easier
•
Total colectomy
– When the entire colon is removed
– also known as Lane's Operation
•
Total proctocolectomy
– Rectum is also removed
How would you prepare the
patient for surgery?
Colon cancer staging
AJCC stage
TNM stage
TNM stage criteria for colorectal
cancer[38]
Stage 0
Tis N0 M0
Tis: Tumor confined to mucosa;
cancer-in-situ
Stage I
T1 N0 M0
T1: Tumor invades submucosa
Stage I
T2 N0 M0
T2: Tumor invades muscularis propria
Stage II-A
T3 N0 M0
T3: Tumor invades subserosa or
beyond (without other organs
involved)
Stage II-B
T4 N0 M0
T4: Tumor invades adjacent organs or
perforates the visceral peritoneum
Stage III-A
T1-2 N1 M0
N1: Metastasis to 1 to 3 regional
lymph nodes. T1 or T2.
Stage III-B
T3-4 N1 M0
N1: Metastasis to 1 to 3 regional
lymph nodes. T3 or T4.
Stage III-C
any T, N2 M0
N2: Metastasis to 4 or more regional
lymph nodes. Any T.
Stage IV
any T, any N, M1
M1: Distant metastases present. Any T,
any N.
Operability
Cardiopulmonary status
 Co-morbid conditions

◦ Nutritional status
◦ Renal function
◦ Liver function
Pre-operative preparation
•
subcutaneous heparin or low
molecular weight heparin
– Patients undergoing surgery for colorectal
cancer are at risk of venous thrombo-embolism
and wound and/or deep intra-abdominal sepsis
•
•
graduated compression stockings
prophylactic antibiotics (cephalosporin
and metronidazole)
– All patients should receive antibiotics effective
against both aerobes and anaerobes at induction
of anaesthesia
•
Mechanical bowel preparation
What other considerations should you
take into account prior to surgery?
Previous colon resection
 Significant obesity
 Major illnesses
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◦ Diabetes Mellitus
Considerations
Proper staging of the disease
 Consider chemotherapy before
laparotomy
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◦ Highly vascularized area

Consider metastases
◦ Liver metastases: remove during laparotomy
Further Plans
Chemotherapy
 Used to reduce the likelihood of
metastasis developing, shrink tumor size,
or slow tumor growth
 In colon cancer, chemotherapy after
surgery is usually only given if the cancer
has spread to the lymph nodes (Stage III)
Further Plans
Radiotherapy
 Not used routinely in colon cancer, as it
could lead to radiation enteritis, and it is
difficult to target specific portions of the
colon
 Indicated for pain relief and palliation
targeted at metastatic tumor deposits if
they compress vital structures and/or
cause pain
Further Plans

Other treatments have included the use
of localized infusion of
chemotherapeutic agents into the
liver, the most common site of metastasis.
Follow up after surgery
Why?
 85% of colon cancer recurrences occur
within 3 years from after resection of
primary tumor
 Colon cancer resection (stage II and III)
should undergo regular surveillance for at
least 5 years following resection
Physical Exam
American Society of Clinical Oncology (2005)
recommends physical examinations every 3-6
months for the first 3 years, every 6 months
during years 4 and 5, and subsequently at the
discretion of physician and based on individual
risk assessment
 Hidden occult blood

Blood test
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CEA
◦ Every 3 months in patients with stage II or III
disease for at least 3 years and every 6
months in years 4 and 5.
Scans
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Computerized tomography (CT) of the chest
and abdomen
◦ Annually for at least 3 years after resection of
primary tumor
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Colonoscopy
◦ 3 months after
◦ In the absence of high-risk pathology on the first
colonoscopy or increased susceptibility for colon
cancer, follow-up colonoscopy should be performed
at 3 years after surgery and then, if normal, once
every 5 years thereafter.