Management of 73 year old lady with SBO

Syed Irfan Kabir S0897200

The first step that I will take for this 73 year old lady would be to take a second and
look at her from the end of the bed and decide whether she appears distressed or
comfortable, as that will direct my initial management along two paths;
1) traditional method of historyexaminationmanagement
2) simultaneous resuscitation and history taking using ABCD approach

Presuming the lady is haemo-dynamically stable my approach would be as follows:

History:
Pain Type, nature, onset, radiation, shifting, alleviating/exacerbating factors,
associated symptoms, previous occurrence
VomitingType, colour, amount, contents, association with pain/food intake
Important to ask about bowel habits, ability to pass flatus at present , urinary
symptoms, known hernias, Weight loss, fatigue, food intake, health of other family
members
Also ask about history of gallstones, volvolus
Other Hospital Admissions

Past History:
Already known as above

Allergies and medications If any

Social History: Already known

EXAMINATION: Signs of dehydration/ GCS/Observations( pulse, SaO2, BP, Resp

Rate, Temp)

Abdominal Examination: InspectionDistension, pattern of respiration, scar

marks, visible swelling
Palpation tenderness, rebound tenderness, rigidity,
peritonism, any clinically palpable Hernia, mass in the abdomen
Percussion dull/tympanatic/peritonism
Auscultation present/absent, tinkling/non-tinkling
Per-Rectal Examination: Palpable mass, empty rectum/full, distended/collapsed

Also examine the RESPIRATORY/CVS systems

Investigations:
FBC WCC, HGB, Platelet levels
U&E Renal Function/electrolyte abnormality
LFT Liver Function
Amylase pancreatitis
Coagulation Screen need for Vitamin K
CRP
ABG’s degree of acidosis
ECG MI
 Erect CXRair under diaphragm/Pneumonia/aspiration
ABD-XR distended loop of bowel/ cut off point
Urine dipstick nitrates/ketones
BM hyperglycemia

Differential Diagnosis:
1) Obstruction secondary to
Adhesions (60%)
Hernia (20%)
Malignancy (5%)
Volvulus
Gallstone Ileus
Carcinoid
Intussusception
Stricture (Ischaemic, Crohn’s, TB)
SMA Syndrome
2)Ileus
3)Pseudo-Obstruction
4)Sepsis

Initial Management:

The decision to perform surgery or not plus its urgency would depend on
the findings on history, examination and investigative results, however the initial
management stays the same in either case. This would include:

IV Fluids upto 5 litre of them may be required N-saline/hartmans

O2 therapy if appropriate
Urinary catheter with hourly urine output monitoring to assess resuscitation
Analgesia for pain opioids/paracetamol (nsaids avoided at this stage)
Anti-emeticscentral/peripheral acting
NG suctionto empty stomach contents
Broad spectrum Antibiotics if appropriate
Regular observations 1-4 hourly
Regular clinical review for signs of deterioration/peritonism

Further Imaging: If no immediate indication for surgery then further imaging would
be of benefit:

CT: imaging of choice intra luminal/extra luminal cause

Gastrograffin contrast imaging: if contrast passes through small bowel
in 6 hours unlikely absolute obstruction plus shown to decrease hospital stay in
adhesive obstruction conservatively managed
MRI: not as sensitive as CT and not readily available

Indication for Surgery:

Strangulated obstruction
Peritonitis
Failure to improve within 72 hours
 Deterioration in clinical state

Incision incase of Surgery

Depending on cause
Incision of indecision commonly employed
References:

“SBO: optimising radiological investigation and non-surgical management” Maglinte

DD; Radiology 218(1):39-46
“Guidelines for management of SBO” Diaz JJ junior; J TRAUMA. Jun 2008;64(6):
1651-64
“Acute Intestinal Obstruction: Diagnosis and Managament” Burke M; Hosp Med
2002; 63:104-107

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