Bowel Obstruction Medical Slides

Present the protocol: administer Gastrografin (water-soluble contrast) 100 mL via NGT after initial resuscitation. Obtain abdominal X-ray at 4-8 hours (some protocols at 24 hours). If contrast reaches the colon → high likelihood of resolution with conservative management (sensitivity 97%, specificity 96%). If no colonic contrast → unlikely to resolve, consider surgery. Meta-analysis shows Gastrografin reduces length of stay by 1.8 days and may reduce need for surgery (mild therapeutic effect via osmotic action drawing fluid into bowel lumen). Contraindications: suspected strangulation, peritonitis, complete obstruction with clinical deterioration.

Present the critical CT findings requiring urgent surgery: (1) Mesenteric haziness/fluid (most sensitive early sign), (2) Bowel wall thickening and hyperenhancement (mural edema), (3) Reduced or absent wall enhancement (ischemia — late sign), (4) Pneumatosis intestinalis (intramural gas — late sign), (5) Porto-mesenteric venous gas (late sign, high mortality), (6) Closed-loop obstruction (C- or U-shaped loop with radial mesentery converging to a single point — 45% strangulation risk). Key teaching point: no clinical sign or CT finding is 100% sensitive for strangulation — if clinical suspicion exists despite equivocal imaging, operative exploration is warranted.

Present the management algorithm: Emergent presentation (perforation, peritonitis) → emergency surgery (typically Hartmann procedure — resection with end colostomy). Non-emergent complete obstruction → two options: (1) Self-expanding metallic stent (SEMS) as bridge to elective single-stage surgery — allows decompression, optimization, and potentially primary anastomosis. (2) Emergency surgery with primary resection. The CReST trial (2020) showed stenting had higher technical failure and 30-day complication rates than expected, tempering enthusiasm. ESGE 2020 guidelines recommend stenting as bridge to surgery for left-sided malignant obstruction in patients at high surgical risk, while emergency surgery remains appropriate for fit patients. Right-sided obstruction → primary resection with ileocolic anastomosis.