1. Presenters

2. 21-5-2009 1pm
Mr. J.J
66 Yr
Colicky pain abdomen with distension – 4days
Vomiting– 4days
Last stools - 3days back
Fever – 1day

3. Admitted at local hospital on 18-05-2009
USG abdomen – normal study
Endoscopy – Dilated stomach with stasis
AXR – dilated stomach & small bowel loops.
Treated conservatively
Since previous day evening breathing difficulty following
aspiration while feeding
Known Type 2 DM, HTN on oral medication
No H/O IHD, Asthma, COPD

4. O/E
Septic , Severely dehydrated, febrile – 100 F
Pulse – 140/min
BP – 100/60 mm of Hg GRBS – 216 mg%
SPO2 – 94% - O2 mask
Abdomen
distended
non tender
No mass, no hernias
BS++
Chest
Rales – more at right CVS, CNS – NAD
P/R
small amount liquid stool
No palpable mass

5. CXR
Patchy hyper dense zones – Rt upper, middle zones
AXR
Dilated small bowel loops
ECG – WNL
? Aspiration Pneumonia (Septicemia) due to
? Small bowel obstruction

6. Rx
-SICU
O2 mask
Fluid resuscitation
Antibiotics – Tazobactum + piperacillin,
Metronidazole
NBM
RT Aspiration + drainage

7. RFT
RBS 150 mg/dl
Urea 13 mg/dl
Creatinine 0.7 mg/dl
Sodium 135 meq/l
Potassium 4 meq/l
Chloride 104 meq/l
LFT
Total bilirubin 0.8 mg/dl
Direct bilirubin 0.1 mg/dl
Total protein 6.2 g/dl
Albumin 4.2 g/dl
SGOT 25 IU/l
SGPT 35 IU/l
ALP 110 IU/l
Gamma GGT 25 IU/l

10. 17000/cumm

13. 22-05-2009
Right lower abdomen transverse incision
Omental band – compressing the distal ileum –
released - Obstruction relieved
Bowel viable
No other pathology seen
Post op
3 days in SICU
2FFP +2PCV
Improved
Shifted to ward 26-05-2009
Discharged 30-05-2009

14. 12-10-2009
Mrs. R
F/22 yr
C/C, History
Recurrent pain abdomen – 5 days
Associated vomiting – multiple times
partially digested food
Admitted in hospital 5days back – 1day
Last stools 2 days back
No h/o dysuria, fever, loose stools

15. LMP 10 days back, regular menstrual cycles
No co-morbid medical illness
LSCS – few months back
O/E
Screaming with pain abdomen
Dehydrated, afebrile
PR- 86/min
BP – 120/80

16. Abdomen
soft, tender left lumbar quadrant
RS, CVS, CNS – NAD

29. 23/10/2009
Mr. S
M/30 yr
C/C
Pain abdomen – 1week
colicky, no radiation
relieves with medication
became severe since previous day
vomiting – 3days
4-5 times/day
undigested food
Admitted in Govt hospital previous day

30. No h/o fever, dysuria, loose stools
Last stools – 3days back
Known APD on PPI – 1year
Alcoholic – quarter whisky daily – 5yr
Smoker – 2 pack beedis/day – 15yr
No h/o abdominal surgeries

31. O/E
Conscious, oriented
Dehydrated
Febrile – 101 F
PR – 98/min
BP – 130/90

32. Abdomen
No Hernia

33. P/R – NAD
CVS, RS, CNS – NAD
AXR erect – outside – multiple air-fluid levels
USG Abdomen - outside – normal study

36. Blood reports - ok

44. 06-11-2009 2 AM
Mr. B. M.B
M/65 yr
C/C, History
Sudden enlargement of the Preexisting swelling over
umbilical region (4 yrs) with pain since 3 days with
breathing difficulty.
Vomiting since 3days, undigested food
Not passed flatus/ stools since 3 days
No h/o fever, dysuria
Alcoholic – regular- ?years

45. Hypertensive on medication
No h/o DM/TB/IHD/Asthma
O/E
Conscious, oriented, pallor, afebrile
Tachypnoeic, dehydrated, icteric
Pulse – 120/min
B.P – 150/90 mm of Hg
R.R – 38/min
SPO2 – 98% - room air

46. P/A
20cm x 20cm globular
Tense, tender swelling over umbilical region
engorged veins +, right inguinal hernia repair scar +,
BS absent
Inguinal , external genitalia – NAD
RS
Clear
Bil. NVBS
CVS, CNS - NAD

49. High blood sugars – 424 mg/dl
WBC – 13800/cumm
HB – 7.5 g%
Sodium – 135meq/l
Potassium – 3.7 meq/l
Chloride – 107 meq/l

57. Post-operative
SICU
Ventilator for 24 hrs
LFT elevated – up to 4th postop day, started
improving
Financial constraints
Discharged at request
Doing well at local hospital

60. Adhesions (usually postoperative)
Hernia
External (e.g., inguinal, femoral, umbilical, or ventral hernias)
Internal (e.g., congenital defects viz paraduodenal,diaphragmatic
hernias or postoperative secondary to mesenteric defects)
Neoplastic
Carcinomatosis
Extraintestinal neoplasms
Intra-abdominal abscess
CAUSES OF SMALL BOWEL OBSTRUCTION
Lesions Extrinsic to the Intestinal Wall

61. Lesions intrinsic to the intestinal wall
Congenital
Malrotation
Duplication/Cysts
Inflammatory
Crohn’s disease
Infections
Tuberculosis
Actinomycosis
Diverticulitis
Neoplastic
Primary neoplasms
Metastatic neoplasms
Traumatic
Hematoma
Ischemic Stricture
Miscellaneous
Intussusception
Endometriosos
Radiation enteropathy/Stricture

62. Intraluminal obstruction
 Gall stone
 Enterolith
 Bezoar
 Foreign body

63. Adhesions
Hernia
Neoplasm
Crohns
Miscellaneous
Adhesions ~60%
Hernia ~10%
Neoplasm ~20%
Crohns ~5%
Miscellaneous <5%
CAUSES OF SMALL BOWEL OBSTRUCTION

64. Inflammatory fibroid polyp causing
INTUSSUSCEPTION
Inflammatory fibroid polyp is a rare, benign, non neoplastic
lesion of the GIT
Originates from submucosa and grows as a polypoid mass
Most common in stomach rarely in colon and small bowel
lesion was first described by Vanek in 1949

65. Synonyms
Eosinophilic granuloma
Hemangiopericytoma
Polypoid fibroma
Gastric fibroma with eosinophilic infiltration
Eosinophilic gastroenteritis
Polyp with eosinophilic granuloma
Inflammatorypseudotumor

66. Inflammatory fibroid polyps are found in all age groups but
peak incidence is between the 6th & 7th decade
Macroscopically - sessile or a pedunculated polypoid lesion .
Usually non-encapsulated and shows an ulceration in the
overlying mucosa
Microscopically-Shows cellular proliferation possibly originating
from the submucosa.

67. Clinical symptoms is according to the location
Stomach -symptoms are vomiting, epigastralgia and bleeding.
Small bowel-Intussusception and obstruction
Colonic -colicky pain, weight loss, diarrhea, bleeding and
anemia
The treatment is surgical resection of the lesion.

68. Internal hernias are defined as herniation of a viscus, usually
the small bowel, through a normal or abnormal aperture within the
peritoneal cavity.
These hernias may be either congenital or acquired.
Its incidence has been reported to be 1-2%.
This herniation may be persistent or intermittent.
Internal hernia is a rare cause of small bowel obstruction with a reported
incidence of 0.2-0.9%.

69. Internal hernias are paraduodenal in 30%-50% of cases,
and two-thirds of these occur on the left side.
Right and left paraduodenal hernias are separate entities,
differing in embryologic origin.
The left mesocolic hernia is a result of anomalous rotation
of the midgut into the developing mesentery of the
descending colon.
The sac lies to the left of the duodenum, and the inferior
mesenteric vessels constitute the anterior free margin

70. MESOCOLIC (OR PARADUODENAL) HERNIAS
Mesocolic hernias are unusual congenital hernias in which the
small intestine herniates behind the mesocolon.
Result from abnormal rotation of the midgut and have been
categorized as either right or left

72. Patients most commonly present with symptoms of acute or
chronic small bowel obstruction.
Barium radiographs will demonstrate displacement of the small
intestine to the left or the right side of the abdomen.
CT with IV contrast may demonstrate displacement of the
mesenteric vessels and evidence of intestinal obstruction, if
present.

73. Operative management of patients with a left mesocolic hernia
Incision of the peritoneal attachments and adhesions along the right side
of the inferior mesenteric vein
Reduction of the herniated small intestine from beneath the inferior
mesenteric vein.
The neck of the hernia may be closed by suturing the peritoneum
adjacent to the vein to the retroperitoneum