Case Discussion... Intestinal Obstruction || #aetcm || #emergencymedicine ||

本站添加: 2026-05-15

[00:00:06]Welcome to AATSM channel. So let's start. A 52 year old male presented to emergency department with complaints of abdominal pain for 2 days, multiple episodes of vomiting for one day, abdominal distension for one day and absolute constipation for one day.

[00:00:23]uh on initial assessment airway was patent patient conscious and responding breathing respiratory rate is 24 per minute saturation 97%age on room air bilateral air entry present circulation wise pulse rate 112 per minute BP 100 bar 60 cap refill time less than 3 seconds and dehydration signs were there disability GCS 15 out of 15 no focal neural deficits and uh GRBS was 124 exposure wise temperature 38°C distended abdomen no external hernia noted so on uh history of presenting illnesses patient was apparently well 2 days prior when he developed sudden onset crampy central abdominal pain occurring intermittently every 10 to 15 minutes >> uh progressive abdominal distension was there and multiple episodes of vomiting which was greenish in color failure to pass tools and flattus Pain severity gradually increased. Vomiting relieve the pain.

[00:01:28]Uh no history of hemis fever.

[00:01:32]Past history previous >> any aggravating factors for the pain.

[00:01:35]You told relieving is pain is relieved with omitting. Right. Similarly is there any aggravating factors?

[00:01:41]>> Uh pain increases while having food actually.

[00:01:44]>> Okay. Immediately after food or after >> after some time.

[00:01:48]>> After some time. Is the pain associated with the uh increased frequency to uh go to the washroom?

[00:01:56]>> Uh no, he's not able to pass.

[00:02:00]>> Yeah, he's not able to pass. But does he have the sensation to pass? No. Fine.

[00:02:06]>> Okay. Uh on our uh CBC CRP point of care >> pass history.

[00:02:12]>> Past history. He had a previous abdominal surgery for appendicitis 2 years back. appendic and uh hypertension on regular treatment. Uh he's on Amloof IMG.

[00:02:25]>> Any other tablets?

[00:02:26]>> No, no other tablets. Uh on our point of care, CBC wise, hemoglobin 13.8, total count 15,200 and platelet is 2.8 lakh.

[00:02:37]>> Okay.

[00:02:38]>> Uh and uh RF wise, creatin 1.4, sodium 132, potassium 3.1. Potassium was on the lower side for this patient. Uh on uh AB on VBG, PH was 7.48 with bicarb 30, lactate 2.5. Metabolic calculosis mostly due to vomiting and mild dehydration also is there for this patient. So initially we wanted to rule out obstruction was there. So because uh patient was not passing stool. So we took an X-ray erect abdomen.

[00:03:11]>> So it's a constipation case right? Yes.

[00:03:13]So constipation is there absolute constipation obsupipation is there?

[00:03:17]>> Uh yes sir obstipation is there.

[00:03:19]>> Obsipation. How do you say it's obser?

[00:03:21]What is the difference between constipation and obsipation?

[00:03:24]>> When the gas is also not passing we tell it's obstation.

[00:03:29]>> Yeah. Uh unable to pass stool or pass gas we call this obsation. Okay. So observation is a much more specific feature of industry.

[00:03:41]>> Okay. So we did a okay let's go go go through that finally. So your primary diagnosis here is a suspected industal obstruction right?

[00:03:51]>> So uh what type of indust is it the acute indust obstruction or subaccute indust obstruction?

[00:03:56]>> Acute indust so what are different types of indust obstruction one as we told it can be acute or subaccute according to the time of flight isn't it? Now what are the other uh types of indust obstruction that >> other is mainly mechanical and functional. Yes, that is uh basically if it is uh due to any actual industrial obstruction due to a uh >> mechanical intrinsic or >> yeah intraaluminal or estral lumininal obstruction direct obstruction causing or lack of >> electrolyte lack of function of the intestine that is lack of peristoaltic movement due to lack hypocalemia sepsis is pancreatitis these things right. So uh you have functional as well as mechanical obstruction. What are the types of mechanical obstruction?

[00:04:53]>> Mechanical mainly small ball obstruction also is there. Large ball also is there.

[00:04:57]In small ball itself extrinsic and intrinsic is there. Extrinsic is posttop addition any tumors uh vvelvas hernia and all. Basically something that is obstructing into the lumen from outside the lumen isn't it?

[00:05:12]>> Okay. That is extrinsic. What is intrinsic?

[00:05:15]>> Intrinsic is any chronic condition like crrons TB strictures.

[00:05:19]>> Yes. Any chronic condition that will decrease the lumin size of the bubble.

[00:05:24]So as you told TB, Crohn's, granulating, granatus, lesions, ulcerative conditions, mass, colonic, ascending colon carcinoma or descending colon carcinoma, all these things will narrow the lumen size and cause constipation.

[00:05:43]Okay. So according to these intrinsic andic losses, we can identify type of constipation the patient will be having.

[00:05:54]Most of the extrinsic uh intestinal obstruction extrinsic causes of intestinal obstruction are acute or chronic.

[00:06:05]>> Extrinsic is mainly uh acute. No no actually chronic.

[00:06:10]>> Usually there will be chronic uh presentations. Patient may come with acute in obstruction but bubble bladder altered bubble bladder habits would be chronic in nature. Patient will be giving much more longer history of uh abdominal distension not able to pass tool properly or uh abdominal fullness even after passing uh going to washroom or patient can have altered bowel habits constipation history intermixed with periods of diarrhea it's classically seen in ascending colon carcinoma so these things can be there the only extrinsic condition usually that presence with acute indust obstruction is >> post >> post of adussions. If a patient has a previous surgical history in which adinsions are formed that can develop as acute indust obstruction then it can be >> uh hernia >> hernas obstructive hernas obstructive hernas in which the hernial mouth opening has reduced in size. It can go to obstruction can be partial obstruction or it can be complete obstruction and it can also lead to strangulation. So hemnia is one thing you should look for. So any indust obstruction cases when patient present when you suspect indust obstruction you should look for common areas of hemis that is umbilical parameical and inguinal regions. Okay. Then what else >> wallis and inception which is not very common in adults. It's much more common in children but elderly also we should look for sigmoid walls. Okay. So these are the extrinsic condition. Now what are the uh intrinsic conditions? Usually it's a very very chronic history only we'll get because it's a lumen narrowing which occurs in a very long time frame isn't it? Now coming to >> intral lumininal.

[00:08:11]>> Intrayalumininal.

[00:08:12]>> Intraluminal goldstone alas. Anything which is impacted like >> yes >> fal matter bzours.

[00:08:18]>> Bzource. Yes. Bzour is one of the things that can be missed because patient may not have any other history like gallstone central. Patient may have history of choleiccyitis kithasis history. Bizource can be completely missed. Then >> then fecal impaction.

[00:08:34]>> Fecal impaction chronic uh constipation uh with the severe dehydration can cause fecal impression hard and which will cause obstruction which will cause further obstruction. Correct. What else? Then other than this is all small intestine.

[00:08:50]Now large bowel in obstruction mainly because of colorctyl cancer then inflammatory bowel disease and vulvus also sigmoid and s any other intrinsic causes intral lumininal causes let's say emergency medicine physician means diverticulitis can cause industal eskemia can cause all that is true but those are not common things as emergency doctor what is another condition you should suspect especially seen in children what else also can >> foreign body injection of foreign bodies. Children are notorious for that, isn't it? Constipation, unexplained constipation in children, we should suspect foreign body. That is one thing.

[00:09:58]Adults, insertion of foreign body, purposeful insertion of foreign body, patient may not give history properly because they may be a bit shameful about it. So that history may not be very clear. But you should look for foreign bodies too.

[00:10:14]Okay, these are what Mechanical >> mechanical causes. So what are the other causes functional causes of indesop?

[00:10:22]>> Electrolyte abnormalities >> mostly >> hypocalemia >> hypoglymia hypocalemia is very classically associated with paralytic >> ilas then pancreatitis any use of opioids anticolinists >> then uh other than that sepsis >> can cause constipation. Okay. Sepsis uh as disease conditions it can be sepsis, it can be pancreatitis. Pancreatitis is mainly because there will be paronitis because of that. Then >> any other disease condition, >> any disease condition that will reduce pedestals which can cause edema, decreased heart rate, decrease BP, decreased sensorium, >> hypothyroidism.

[00:11:24]not hypothyroidism per se can go into obstruction. uh then drugs >> potassium decreasing drugs plastics that's why I asked earlier is any other medicine is own so it can be loop diuretics that can cause hyponetriia hypocalemia these things can cause industal obstruction it can be other potassium binding drugs >> u that can cause hypocalemia then what as you told >> opioids >> opioids patient is having carcinoma patients, chronic pain patients on opioids, not only morphine, it can be traumadol too. Tromodol is much more commonly prescribed. So chronic opioid use can cause decreased pestic movements causing industal obstruction. Other >> anticolin >> anticolinergic drugs can cause then >> sympathy of mimetic drugs can cause all these things can cause uh indocinal obstruction features. Okay. Uh so these are the causes of indust obstruction. Now how to evaluate industrial obstruction? So we have to identify it is it small B or large B >> large B. So basically what will you do?

[00:12:48]>> Take an X-ray erect abdomen.

[00:12:49]>> Basic investigation of choice is X-ray erect abdomen that will help us identify whether it's a large bowel obstruction or small >> small bowel obstruction. Okay.

[00:13:00]>> So if it is small we identify based on the 369 rule also. So in 3 cm if it is small ball, 6 cm if it is seeum, 9 cm it is column. Uh then we identify large ball based on the hostations.

[00:13:19]>> Small small ball on the basis of pway according to the fat strandings in the colon. Ifrations are very prominently seen you can say it's a large bubble obstruction. If it's a small bubble obstruction will not be there. Okay, that's one thing. As you told air pockets, how much air pocket should you want? Not air pockets, air fluid level, right? What is air fluid level? It's a transition point in which there is a fluid level on the lower side and associated with a air pocket above making a horizontal distinctive border. Isn't it? That's a air fluid level. So, how much do you want? How many air fluid levels do you want?

[00:14:00]>> Four or more than four.

[00:14:02]>> Three or more, right?

[00:14:04]>> Minimum three. Three is physiological.

[00:14:06]>> More than three. Four. Four or more.

[00:14:08]Four or more is pathological. Okay. So we are saying three is physiological.

[00:14:13]What are the three airflow levels? You can be normalized in nature.

[00:14:18]Normally seen >> funal gas shadow. Fal gas shadow can be a full abdomen with the air. Okay. The fundus is one. Then >> then seem can have one gas shadow diodinum can have one gas shadows. Other than that any other gas shadows in any other areas we should suspect patient to have in obstructions. As you told according to the size of airflow level in small bubbles it will be the smallest 3 cm maximum and large bubbles will be the biggest with 9 cm up to 9 cm it can be there. Okay.

[00:15:04]>> Okay. Then uh we can also do an USD to check the peristis movement is there.

[00:15:10]>> So what will you find >> decrease peristis?

[00:15:13]Decreased pistalsis is is a thing. So firstly dilated bubble loops. Dilator bubble loops with two and from motion.

[00:15:24]>> Okay. If two and from motion is there and dilated bubble loops is what you look for. Two and from motion you may not get also because there will be if significant air collection is there in the bubbles it can scatter the ultrasound and you may not get a good uh visual field. But you can see whether dilated loops are there or not.

[00:15:44]Ultrasound can help you in that way. Uh what else?

[00:15:49]>> Then in ultrasound you can also look for if there is any free fluid.

[00:15:53]>> Free fluid. But if free fluid is there what will you suspect?

[00:15:58]>> I mean perfor >> perforation you can suspect perforation with free fluid. That's all. But in perforated uh indust obsession with perforation you will have features of >> guarding >> paratonitis. Yeah guarding rigidity rebound all these things will be there.

[00:16:13]So that is another condition. What else ultrasound can rule out for you hernas you can look at the hernial site and see whether her is obstructed or strangulated. So ultrasound can help you rule out hernia as a cause of industrial obstruction isn't it? Okay. Now any other uh extrinsic causes of industal obstruction mass lymph nodes and all these things what do you want?

[00:16:43]>> CCT >> CT. So the gold standard for indust obstruction diagnosis is >> CCT.

[00:16:49]>> CCT it's a contrast enhance CT is the gold standard. Why we want contrast mainly for lumininal causes. CT is the gold standard for intestine obstruction but CT cannot give you a clear diagnosis unless contrast is used because contrast helps you identify intra luminal causes but for estral luminal causes you just want to know whether in obstruction is there or not a plain CP is good enough but to get proper uh what to say clinical uh differentiation what is causing it you want contrast why I as this patient's created was uh 1 uh 38 1.4 >> 1.4 So that is at the cutff level right at the cutff level this patient going into contrast can develop contrast induced nephritis it's a CT contrast right so what will you do will you do contrast or not >> we not suspecting any because he had a previous history of appendictomy so we expecting extra >> yes so you want to know uh whether it's endoc obstruction if it is it is adashion induced indust obstruction or uh what is the level of indust obstruction isn't it because of this you want CT >> so when you say CT uh for this patient when you want to send CT for this patient >> what will you ask your radiologist to do or what will your radiologist do >> find the transition >> that is diagnosis part is 1.4 four, right?

[00:18:31]>> You should you score >> low osmolar low ionized contrast vessically ioden based contrast material. So it has less uh osmolar uh gradient which will not affect kidneys so much. So in this condition you can ask for vasipac uh contra CT. Okay. Then once contradity is taken how will you diagnose patient is having indust obstruction dilate the bubble loops airflow level and what you call >> transition point.

[00:19:09]>> Transition point. Transition point is the point in which you can identify this level there is obstruction that is the uh loss of pedalsis from the affected area nonaffected area. Okay. So these are the radiological investigations you can do to diagnose intestinal obstruction and classify what type of intestinal obstruction you are having in whether it's induminal estral whether it's uh extrinsic causes or something like that right so what about functional >> electrolytes you have >> so you have to send blood for that what are the investigations that you send >> one is mainly electrolytes >> electrolytes >> especially potassium pot. Then >> then you have to look for lactate.

[00:19:56]>> Potassium. You got to look for hypoglymia and potassium. Is calcium?

[00:20:02]>> Calcium.

[00:20:04]>> Hypercalcemia. Hypocalcemia can cause increased production of >> stones.

[00:20:12]Stones grown bones. Hypalmia. Right. So patient can have chronic abdominal pain due to hypogmia.

[00:20:20]can cause dislo of gallstones too.

[00:20:23]Patient can develop impaction isn't it?

[00:20:26]>> Okay. So calcium, sodium, potassium has electrolytes. Then what you want >> infection features >> you want a total counter you want a CRP to look whether it's a noninfective cause for indust obstruction or whether in the obstruction itself has become infective indust obstruction itself has become infective or when perforation has happened. What else?

[00:21:00]What are the other functional causes?

[00:21:02]Thyroid >> thyroid >> you want a TSH and free T4 3T3 level to look whether patient is in midsimoma but patient in msidimoma when you suspect it should be other features of should be there as we told earlier bradicardia and radia hypotension or near normal BP associated with other features of hypothyroidism isn't it with edema non pitting ed it's not like for all industry you should suspect hypothyroidismic patients that we are suspecting isn't it? Okay. So these are the other investigations that you should look for.

[00:21:41]Okay. Now what is the management way?

[00:21:44]>> First you have to keep the patient milk per oral.

[00:21:47]>> Okay.

[00:21:47]>> When fluid should be given.

[00:21:49]>> Okay. That is very important. All these patient will be severely dehydrated because their fluid intake will be very low. First of all because of abdominal pain and abdominal distension they will not be taking anything. orally. Second thing, they'll be vomiting a lot. So they are actively losing water also. So these patients will be usually very dehydrated. So fluid resuscitation is important in these kind of patients.

[00:22:13]What type of fluid will you give >> so >> isotonic fluids preferably renaled because these patients omitted out a lot potassium hypoglymia is a possibility isn't it? So you want to give a ringal light if not if you don't have it then only go for >> normal sal okay then >> then nasogastric tube >> ng tube nogastric tube or nasogenal tube you can insert why you want to insert that >> aspirate uh >> why you want to aspirate >> so that uh regurgitation should not >> yes decompression >> decompression >> it's industal decompression you don't want the pressure to build up because any increase in pressure will be transmitted proximally making the patient abdominal dysfunction uh at vomiting and on the patient vomit patient there's increased risk of aspiration to prevent the aspiration risk you can put a NG tube oral tube and decompress by continuous aspiration what else >> pantop and support and what will you not give >> proinetic >> prokinetic agent Name one progenic case that you will avoid >> peromeide should not be used in this kind of case.

[00:23:37]Dome peridome and all should not be used. Then what else?

[00:23:42]Why is the patient coming to you?

[00:23:45]>> Pain management.

[00:23:45]>> Pain management. Patients being complained or coming to you is pain management. So pain should pursue right.

[00:23:51]What pain medication will you give?

[00:23:55]Paris set.

[00:23:57]Sure. Anything higher.

[00:24:02]>> What will you not be given? Should not be >> all opioids you should avoid because all opioids main complication is constipation. So since there is a possibility of functional uh intestinal obstruction, opio should be with her. But if it is a extrinsic intestinal obstruction what can you do? You can give opioids.

[00:24:26]Why? Because most of the extrinsic intestinal obstruction will require surgical management. So if your surgeon is like okay this patient requ is fine otherwise opioid should be should not be not should be should not be given. Okay. What else now? Any prophylactic things you need to give?

[00:24:49]>> Antibiotics.

[00:24:51]>> Prophylactic antibiotics can be given.

[00:24:53]What prophylactic antibiotic will you give?

[00:24:56]>> What is the coverage you want?

[00:24:59]>> Gram negative.

[00:25:01]>> Gram negative coverage and >> anob.

[00:25:04]>> Anorobic maximize a gram negative and anorobic coverage. So what will be your antibiotic of choice as profile not for treatment?

[00:25:14]Flu fluorocin loons has good gram negative coverage right. So any first generation cypro floin flin you can give and cover gram negative and anorobic coverage you can add >> anobol metronol you can give okay so these will be your antibiotic of choice so injections proin 500 mg uh with metronol 500 mg IV will cover the patient and profile actually. Now what if this patient is having perforation?

[00:25:53]Patient is having perforation peronitis patient is in early features of shock.

[00:25:59]What will be your uh antibiotic of choice?

[00:26:04]>> We can give soson salam but it still covers only g negative or cancer.

[00:26:14]You can give >> asobact. It has good anorobic coverage and has good gram coverage. So that will cover or else you can give any sephilosporins with metronome. You just have to add a metronome. If you can add a metronome any sephilosporins any third generation sephilosporins are good enough. Not first and second preferably third generation. If you want a single drug then you will request.

[00:26:43]Okay, that is your antibiotic of choice.

[00:26:45]Now uh >> okay now what else?

[00:26:51]>> Now we have to then look for any peronitis sign.

[00:26:55]>> Okay abdominal g so monitoring will be abdominal girth.

[00:27:00]So uh take the two anterior superior leg spine points and take the two antiox spine points and uh keep looking at the abdominal distension every second to see whether even after nogastic tube insertion decompression patient is having size >> increase in size. Okay.

[00:27:27]Anything else to be looked into?

[00:27:32]Hypotension with patient >> any features of perforation a sudden hypotension sudden unexplained ticardia acute increasing pain. Uh if these things are there go for regarding rigidity test. The patient is develop nuance regarding rigidity suspect perforation paron. Okay.

[00:27:51]Anything else?

[00:27:55]Any supplementation you want to do?

[00:27:58]Potassium.

[00:28:00]>> Potassium supplementation if and when to cure.

[00:28:05]So this is a classical industry. Yes.

[00:28:07]Right. So what if your patient tells you he's having abdominal discomfort, mild abdomen distension, but he's passing stools, not completely or not fully he is not satisfied with his bubble habits, but he's passing some amount of stro. Will you suspect intestine obstruction or not?

[00:28:29]>> Yes, obstruction can happen even if there is no constipation.

[00:28:34]>> Correct. Even if constipation is not there, indestinal obstruction can be there especially in what conditions?

[00:28:44]>> First stages of indust obstruction.

[00:28:45]>> First stages of indust obstruction is correct or >> if it is small bubble obstruction if it is small bubble obstruction patient already has four stools in the large bubble patient can always navigate that >> isn't it? So patient can be like today morning also I went to toilet but right now having acute onset of abdominal pain and patient developing obstruction the small bubbles isn't it okay any obstructed hernia any intestinal local intestinal eskeemia can irritate intestines to develop uh in obstruction but patient can still pass to is it so absolute constipation is not end necessity to diagnose the patient to have intestinal obstructions.

[00:29:37]Okay. So any acute abdominal pain uh and col especially collic abdominal pain associated with increase in abdominal girth or distension associated with persistent omitting which release the pain you should suspect understand That's importance.