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CONSTIPATION
Shermin Shakil
CASE #1
• A 54 year old man is admitted to the hospital with
complaints of crampy abdominal pain & bilious
vomiting that has lasted for 3 days. He has not had a
bowel movement or passed flatus for the last 2
days. A few years ago, he had an appendectomy for a
perforated appendicitis with no Post. Op. complications.
Physical exam reveals a pulse of 100/min, blood
pressure of 110/60mmHg, temp. 37.5C. His abdomen is
distended with hyperactive and tympanic bowel
sounds. There is no abdominal tenderness to
palpation. His haemoglobin is 15.4, WBC 10,000
• Most likely diagnosis?
DYNAMIC- ADYNAMIC-No
Peristalsis is mechanical
working against a obstruction
mechanical Peristalsis absent or
obstruction inadequate
Paralytic
ileus
Pseudo-
obstruction
DYNAMIC
• Stricture
Fecal impaction • Malignancy
Foreign bodies INTRAMURAL • Intussusception
INTRALUMINAL
bezoars • volvulus
Gallstones
EXTRAMURAL
• Bands/
adhesions
• hernia
According to the speed of onset of
obstruction
Acute (usually in small bowel) – Rapid and severe
Abdominal US-Target
sign Contrast enema-
claw sign
• CT scan—most sensitive radiologic method to
confirm
TREATMENT
• either a barium or water-soluble contrast enema, which
both confirms the diagnosis of intussusception, and in
most cases successfully reduces it
• surgical reduction is required if enema fails
• Pre-operatively, fluids and electrolytes are given and
nasogastric decompression is done
• In a surgical reduction, the surgeon opens the
abdomen(transverse right sided incision) and manually
squeezes the part that has telescoped. If the surgeon
cannot successfully reduce it, or the bowel is damaged,
they resect the affected section
Case# 4
• A 50 year old male resident of Mardan presents
with sudden onset of abdominal distention and
pain for the past 6 hrs. He has not passed feces
and there was one episode of vomiting on his
way to the hospital. There is no surgical history.
On examination, pulse is 90, BP is normal, and
he is afebrile. The abdomen is markedly
distended & tender. Bowel sounds are inaudible.
• Diagnosis
• Volvulus
VOLVULUS
• Twisting of a portion of bowel about its
mesentry.
obstruction to lumen
vascular occlusion in mesentry
• Volvulus Neonatorium
• Sigmoid Volvulus
• Caecal Volvulus
SIGMOID VOLVULUS
• Rotation occurs in the anticlockwise direction
• Predisposing factors:
▫ Overloaded pelvic colon
▫ Long pelvic mesocolon
▫ Narrow attachment of pelvic mesocolon
▫ Band of adhesions
PRESENTATION
INDOLENT
FULMINANT
Insidious
Sudden onset,
onset, slow
severe pain , early
progressive
vomiting, rapidly
course,less
deteriorating
pain, late
clinical condition
vomiting
CECAL VOLVULUS
• More common in females in fourth and fifth decades and
usually present with classic features of obstruction.
• Ischemia is common
• At first obstruction is partial with passage of flatus &
faeces.
• In 25% of cases, examination– palpable tympanic
swelling in midline or left side of abdomen
OMEGA SIGN
BEAK SIGN
TREATMENT
• SIGMOID VOLVULUS:
• Flexible/rigid sigmoidoscopy and insertion of a
flatus tube---deflation of gut. Tube should be
secured in place with tape for 24hrs and repeat
X-ray to ensure that decompression has
occurred.
• deflation will resolve the acute problem,
provided that the ischemic bowel is excluded.
• In elderly with co morbidities and recurrent
episodes of volvulus---resection or two point
fixation with combined
endoscopic/percutaneous tube insertion.
• If bowel is viable—sigmoid colon is fixed to the
posterior abdominal wall.
• Cecal volvulus
• Ischemic volvulus—resection
• Viable—reduced. Further management—fixation
of cecum to the right iliac fossa
(caecopexy)and/or a caecostomy.
Case #5
• A 50 year old obese female presents to the opd
with complains of intermittent colicky
abdominal pain , abdominal distention, nausea
and vomiting. She is giving history of episodic
pain in right hypochondrium for last 1 year. On
examination, pulse is 100 bpm. There is mild
tenderness, abdominal distention and absent
bowel sounds.
• Diagnosis
• Gallstone ileus
Gall stone ileus
• Gallstone ileus is an uncommon complication of
gallstone disease, occurring in about 0.5% of cases.[4]
• It accounts for only about 1-4% of causes of intestinal
obstruction
• Investigations :
• XRAY abdomen—small bowel obstruction, penumobilia ,
radiolucent gall stones ( rigler’s triad)
• CT Scan
Rigler’s triad:
The characteristic radiological sign of gallstone ileus is Rigler’s triad,
comprising: small bowel obstruction, pneumobilia and an atypical mineral
shadow on radiographs of the abdomen.
may be tender