NMS. Casos Clínicos

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Part II ♦ Specific Disorders

Q: Does the initial assessment and management change in any way as a result of the following findings? Case Variation 8.1.1. One-day duration of present illness ◆ ◆ You would be suspicious of a more proximal obstruction in the GI tract. Proximal obstruc- tions tend to have less abdominal distention on physical examination. The management remains unchanged. Case Variation 8.1.2. No previous abdominal surgery ◆ ◆ Adhesions may develop with no prior surgery, but other causes such as a hernia, small or large bowel tumors, tumors metastatic to the bowel, or inflammatory processes should also be suspected. Case Variation 8.1.3. Heme-positive stool in rectum ◆ ◆ Increased suspicion of an obstructing tumor or ischemic bowel is warranted. Case Variation 8.1.4. No bowel movements but still passage of flatus ◆ ◆ If the patient has no bowel movements but continues to have flatus, this is termed a partial small bowel obstruction . The radiographic picture may show the usual findings but also may show air in the colon or rectum. Partial small bowel obstruction is more likely to resolve without surgery and is less likely to have a complication such as ischemia or perforation. Case Variation 8.1.5. Small amount of diarrhea ◆ ◆ This finding is also typical of a partial obstruction . You should also suspect a fecal impac- tion and severe constipation as a cause of the diarrhea. Gastroenteritis is another possible explanation, although the overall picture is not typical of this diagnosis. Examination for fecal impaction is appropriate. You should otherwise manage the patient for a partial small bowel obstruction. Case Variation 8.1.6. Presence of an inguinal hernia ◆ ◆ An inguinal hernia, a common cause of obstruction, may go unrecognized preoperatively in patients who are overweight or have altered consciousness (Fig. 8-4). If present, this condition requires urgent repair and relief of the bowel obstruction because of the risk of strangulation. Case Variation 8.1.7. A Clark level 4 melanoma that was excised 2 years ago ◆ ◆ Melanoma is the most common tumor that metastasizes to the intestine. It frequentlymanifestsasabowelobstructionandcanpresentmanyyearsorevendecadeslater. Tumor-related obstructions often do not resolve with nonoperative management , and surgery is indicated. Even so, the tumor is often extensive, and surgical resec- tion is not possible. The patient should have a laparotomy to establish a diagnosis and to relieve the obstruction. Common causes of intestinal obstruction are shown in Figure 8-5. ◆ ◆ Even a patient with known tumor may have an obstruction due to another cause such as adhesions. However, if it is an unresectable tumor, the prognosis is poor. SAMPLE