what's up Ninja nerds in this video today we're going to be talking about ballop struction this is a part of our clinical medicine section if you guys like it it helps you please support us and you can do that by hitting the like button commenting down the comment section and subscribing also really urge you guys to go down the description box below click on the link to it goes to our website become a member there you'll have a lot of Premium features things like notes illustrations that are amazing on on top of that we're developing quiz questions and exam prep courses that I think are going to be super critical and helpful for those of you out there but check it out there's a lot more things there to offer on the website but let's talk a little bit about bow struction there's two types pretty straightforward mechanical functional with mechanical bow obstructions there's literally something that's blocking the Lumen right it's literally it's just a big old barricade within the Lumen that's preventing intraluminal contents food fluid any kind of like intestinal contents it's not being moved through the actual git right so this is the problem is that you're not having the proper movement of these contents there's not really an issue with motility so the actual smooth muscle here this is actually intact so motility is okay the problem that is existing here is that you have a physical obstruction so motility is fine but there is actually some type of physical obstruction and that's really where the issue is okay so there's a physical obstruction but there's no problem with motility motility is okay so that's the big big kind of things that I want you guys to understand with mechanical obstruction often times if anything the motility is actually increase because you have an obstruction here you can't move things along so what happens is the bowels are like okay I'll squeeze a lot harder to try to push this stuff along and so that's usually what happens is motility actually increases in the early phases usually motility goes away and the late late late late phages of bow obstruction at the point where they're actually at an es schic bow but that's the big thing for mechanical obstructions if we come over here now to functional obstructions it's a little bit different there's really no problem here where there's something in the actual Lumen obstructing the in luminal Contents so in this particular scenario there really is no physical obstruction that's not the issue whatsoever so because there's no problem with a physical obstruction what do you think is left motility the motility is actually going to be the problem so in these particular patients they have no good GI motility the muscle is actually going to be the issue here and if the muscle can contract it's supposed to induce what's called peristalsis and so in this particular sense this peristaltic wave that moves intraluminal contents down is not occurring and so this is the same concept you see how inter luminal contents are not moving it's just in this there's an obstruction normal motility here no obstruction and there's decreased motility and we can actually use that here there's decreased motility so this is really kind of the big differences here and these different types of obstructions right now when you look at these also in another particular way let's say I take a section because this is a section of the actual git that's a section of the git and I kind of make another little diagram another big thing here is is that whenever you look at mechanical obstructions they have this part here that's really kind of like crucial and helps you to identify the differences between them on radiographic images is that right here let's say is the physical obstruction so everything proximal to that is becoming distended so all this is distended bow everything up here above the transition Point everything below the transition point is decompressed that's I think super super helpful to think about when when you're looking at these radiographically right whereas here do you notice any transition point no so there's no transition point and I think that's what's super helpful and this sense the bow is actually distended throughout so they have distended bow Loops throughout their small intestine or throughout their large intestine and I think that's what's super helpful is that this is distended about only proximal to the obstruction decompressed distal this is distended bow throughout so let's actually write that down distended throughout okay so I think we have somewhat of a decent idea here about some of the small differences between mechanical and functional obstruction which is good because often times they can present similarly so often times these patients usually present with what's called C findings this is that classic finding that I want I want you guys to remember and so what this means is is they often times will have cramping abdominal pain abdominal distension vomiting and obstipation that's really the big features that are super classic so if a patient comes in cramping abdominal pain they have abdominal distension vomiting obstipation think do they have a bowel obstruction is it mechanical functional think about which one is blocking the contents which one's a problem with motility if it is I know that radiographically I'll be able to identify this based upon the pathophysiology but then once I've done that and I say hey I found the actual obstruction what's the cause and then more than that where is the obstruction is it only affecting the small bow or the large bow let's talk about that now so if we move on to the next part here let's say that we're only focusing on mechanical obstructions that affect the small and large bow for the small bow the most common cause by far is going to be be these surgical adhesions that stick between the bowels and obstruct it right so I want you to remember adhesions is a super super common cause by far the most common cause and I think one of the telltale signs that'll help you guys to remember this one is that it's often usually due to abdominal surgery so look in the history for multiple abdominal surgeries in their history cuz this is going to be some of that scar tissue that's remaining there a second one is going to be hernas so let's say here is the inguinal Canal or the femoral canal and a piece of bow herniates out through that that space of that Canal now you're pinching on the bowel creating a transition point just like here it's pinching on the bout creating a transition point this is hernas hernas I think the big ones to remember are going to be ones that can easily be incarcerated and unfortunately strangulated and this is going to be you want to watch out for femoral ones these are the scary ones and inal ones and often times they'll complain of pain in those particular areas and when you go to examine them you may find that visible palpable Mass the third and final one I would say is not as high yield because it's not as super common but you want to think about it in the Pediatric population and this one I would say is going to be into susception right and in this scenario you want to think about this in like young children uh and it's usually going to happen near the ilocal junction they have this thing called a mec's diver mechel diverticulum and it creates this kind of like little leading point that causes the ilum to kind of get sucked in and telescoped into kind of like the inner part of the seeum so you see how this is the inner like the proximal bowels right here imagine here I have my left hand is the proximal bow here's the distal bow it gets sucked into the actual inner segment of the distal bow and it creates a little transition Point therefore I'm shock ction so this is going to be in young children and usually they'll have something called a meckel diverticulum that this will kind of cause this lead point to lead into this kind of telescoping you usually get the ILO secal Junction all right for the large bow what's causing the transition point the mechanical obstruction it's usually pretty straightforward it's some type of like tumor usually it's in luminal in the scenario of uh usually this is a neoplasia or neoplasm um and This Is Us usually in the setting of something like Colo rectal cancer could it also be extrinsic compression from some type of intraabdominal tumor besides from the git sure could be but I'd say colar rectal cancer will probably be the more common one and then the last one really interesting one here is going to be a twisting of the bow and this is called a volvulus now volvulus is really interesting and it's usually can occur in two forms uh it can Ur in children uh usually in the mid gut region but that's what affect the small bow sigmoid colon is usually going to be the distal part of the large intestine and so that'll affect the large bow so you're going to see this more in adults so seniors who have chronic constipation the poop builds up and that sigmoid colon causes it to become distended and it literally twists on itself creates this two kind of lead points and twists on itself and create the transition points so this would be something to look for in chronic constipation especially in the elderly all right so with all of this being said we now have at least a differential that we can form whenever we say oh this patient has a small bowel obstruction what's the causes they have a chronic or they have a large bowel obstruction what's the causes with that being said let's now take the next step here patient comes in they have K findings you think that they get an X-ray and you see some potential findings that would suggest more of a non- mechanical obstruction related bow obstruction so it's more functional and physiological so then you're thinking okay if it's affecting the small bowel there's a special disease for this one and you see how there's no transition point it's literally the the muscle of the bowel is paralyzed and what we do here is we call this one we call this a par IC ilas and a paralytic ilas is essentially when you have dilated Loops of small bowel that are pretty consistently throughout the entire small bowel usually greater than like 3 cm usually that's kind of like our number that we say that it's greater than 3 cm for that dilation there that would be suggestive of a paralytic ilas if there's no transition point with a compressed distal bowel so then you have to ask yourself the question what in the heck would cause my smooth muscle to become paralyzed and not contract well there's a couple different things and we use the peas pneumonic we say it could be due to an infection of the peritoneum like peritonitis right so does a patient have peritonitis got to spell this stuff correctly guys so if they have peritonitis so inflammation or infection of the parium now I still didn't spell correctly here let's fix this par tontis now in this patient who has peritonitis what happens is they get inflammation of the perenium the perenium literally is going to cover the actual GI organs and so if they get inflamed sometimes it can actually cause that smooth muscle to not contract very well so that could be one potential cause another one is it could be due to are they having some type of post abdominal surgery you went around there mucked around in the abdomen those bowels are are going to have a little bit of a tough time being able to get back to the normal contracted activity so it could be postoperative sometimes this could be because of the surgery itself or it could because of the medications that were given so some of the anesthetic medications like the sedating medications the paralytics ETC it also could be because the pottassium is low the potassium is really important and it has a very significant effect on you know a lot of the contractile activity of the actual smooth muscle and so if the potassium is early what's called hypokalemia that could also paralyze that smooth muscle temporarily lastly probably the most common one I think chronically is pain meds and so patients who are taking opiates whether this be in large doses acutely or whether this be in large doses chronically these medications definitely decrease the actual contractile activity of the smooth muscle so if you think about these things all they are going to do is pretty straightforward is they're going to act on the smooth muscle of the small bowel or the large bowel and they are going to inhibit this actual muscle and so you'll have a decrease in the motility but you'll have no physical obstruction if I have a decrease in motility can I move things along the actual small bow or the large bow no and so you'll have distended bowels because they're going to stay in that area okay same thing exists in a patient who has dilated large bowel all right usually if it kind of dilates different parts here so if you kind of dilate out the large bowel like the the transverse colon or the ascending colon or the descending colon then this is kind of different so this is actually what we refer to as colonic Pudo obstruction colonic pseudo obstruction sometimes they also give this the terminology a Giles syndrome okay a Gil syndrome and B basically what happens here is that you have dilated Loops of large bowel usually The Telltale sign is that seeum is gargantuous usually when the large bowels themselves are like greater than 6 cm so if it's getting to the point where these poppies like these parts are greater than 6 cm or the seeum is like greater than 9 cm then man this is getting Pretty stinking bad and you want to watch out for that so if the see is getting really big and the other parts of the large Val getting really big they're distended throughout no decompressed distal bow or transition Point really suggest more about functional obstruction same thing though both of these in the small large bow whether it's colonic pseudo obstruction paralytic ilas are usually due to these particular causes it's not a mechanical obstruction like in these scenarios here that we talked about now that we've talked about mechanical and functional ballop structions and how they'll present let's now talk about the complications of these all right guys so now we're going to move into the next part here which is when a patient who has a bowel obstruction they come in right they present with that c findings the cramping abdominal pain abdominal extension vomiting obstipation or constipation right you're like okay is this more of a mechanical is it a functional again you'll base that on some of the radiographic findings in their clinical history and then if you're thinking you know if it is a small versus a large bow how do I really differentiate that again more of a radiographic type of thing that you'll kind of Base it on um now when a patient who also has again a mechanical or I'd say functional ball obstruction they are at risk for some potential complications and some of these that you should be aware of are the following so the first one is hypovolemia these patients can become like pretty significantly volume depleted and it's kind of a multifactorial mechanism behind it so pretty straightforward though here we have a patient who we're going to say has a bowel obstruction um and there's the transition point right it's a mechanical type but either way things aren't moving along if things aren't moving along then the back pressure from all of this kind of uh obstruction Point causing proximal distension will cause some of the fluid to start backing up and you'll have this retrograde expulsion if you will of intraluminal contents so then what's going to be the effect here is the result is you'll have have some retrograde expulsion you know what that's a fancy word for that's a fancy word for vomiting so these patients will have pretty significant vomiting and when they have this intense vomiting they're going to vomit up multiple contents one of that is going to be lots of water electrolytes and so some of the things that they are going to lose is they're going to lose a ton of there's going to be decreased in the amount of water and sodium and if there's a decrease in the water and sodium with inside of the bloodstream or let's actually say they're vomiting up a ton so they're going to have water and sodium loss that right there in itself is going to contribute to hypovolemia so this is one of the reasons why these patients will become hypovolemic now when a patient has hypovolemia what are some of the ways that these patients could look well I think it's pretty straightforward is that if you have a lot of this loss of fluid they may present with a decreased skin turer they may present with some tacac cardia they may present with some dry mucus membranes right they may even present with some hypotension these are common features of hypovolemia and I think that's one of the first things to be able to look for is do they have any flat jugular veins um do they have any decreased skin turg do they have any dry mucous membranes do they have decreased urine output tacac cardia hypotension these are things to say look for the other mechanism that explains their hypovolemia which is really interesting is when you have this actual distension What's Happening Here is this wall distension so this bowel distension what it starts doing is it actually starts leading to compression right so you're going to have this bow wall distension and what it's going to do is it's going to start compressing some of the structures in the actual bow wall like the veins and the lymphatics and as a result you'll develop a lot of bow wall edema so that's the other thing is that you're going to have bow distension which presents as will then lead to Bow wall ademia because imagine here whenever this bowel is becoming like significantly stretched because of all of this distension here because of all this fluid and intraluminal contents inside of this brown structure here there's going to be lymphatics and veins and they're being compressed you can't drain things like fluid and blood out of the actual bow wall so it'll become adius if you have a super emitus let's kind of like represent that here with kind of thickening up now we're going to thicken up this puppy now it's all kinds of thick this bow wall is much more aditus and swollen if it's much more aditus what do you think is going to happen it's going to make it really hard for fluid to be absorbed so now the absorption the movement of fluid from the bowel into the actual bloodstream is going to be inhibited so this will be decreased fluid absorption as the result so there'll be some decreased fluid absorption the other concept is that if you have decreased fluid absorption you're not bringing water and sodium and all those things into the bloodstream what's going to happen to the volume with inside of your bloodstream it's going to decrease so these patients will develop hypovolemia because because of that as well you know what else with all that bow wall edema you know what else happens is that it actually causes more fluid to be secreted into the actual from the bow wall into the Lumen and so this is another thing is that you will actually also increase fluid secretion into the Lumen of the bowel so you have increased fluid secretion and decreased fluid absorption this is is also going to lend to the development of hypovolemia so we now have an understanding here that when a patient experiences stretching of their bow wall becomes super distended this stimulates bow wall edema and bowal edema will decrease fluid absorption increase fluid secretion which will lend to the formation of hypovolemia in combination with water and sodium losses from vomiting so look for that as a potential thing in these patients to be super dry decrease uh skin turg dry mucus membranes tacac cardia hypotension flat jugular veins the next concept here is when these patients vomit they're not just vomiting up water and sodium they're also going to be vomiting up other types of electrolytes and one of these are going to be pottassium so there's going to be an increase in potassium L what is that called whenever you have low potassium hypokalemia so these patients can also develop hypo calmia all right so we have hypokalemia because of the increased potassium loss the other thing that they're going to lose is they're going to lose a lot of protons in their stomach acid so you especially if you have a small bowel obstruction you're going to be vomiting up large amounts of hydrochloric acid and so because of that they'll lose lots of protons so there'll be an increase in there proton loss and that increase in proton loss will lead to what happens if you're spitting out protons you're going to have less of those protons present within the bloodstream so less protons means the pH will go up and it's a metabolic cause not a respiratory cause so this is called metabolic alkalosis all right so out of this if a patient comes in the things that you will be able to somewhat identify are going to be signs of hypovolemia such as tacac cardia flat jug of veins decreased skin turer dry mucus membranes Tacho cardia hypotension you're not going to really see any features of these generally unless they're super super severe these are more laboratory findings this is more of a clinical finding okay so look for that in these patients hypotension tacac cardia and dry kinds of physical exam findings once we've done that the other big complication here that I think is really important is balis keemia so whenever these patients have all of this obstruction here again there's going to be distension of the bow wall this distension of the bow wall one of the first things that actually starts happening is again you compress the veins and the lymphatics first as you have increasing intraluminal pressure right so as there's higher in luminal pressure you're going to compress the veins and then what else will you compress you'll compress the lymphatics the bow wall becomes a dius but as the intraluminal pressure really really Rises so we develop High high high high intraluminal pressure what's going to happen is you're going to start compressing the next thing which usually isn't a super easily compressible structure and that's going to be the arteries and so there's small little arteries that run Within These bow walls what if they're compressed what do they deliver oxygen so in this scenario where they have bow wall edema that's just you're having difficulty getting fluid and blood out of the bowel wall if I can't get oxygen rich blood into to the bowle wall it'll start to become es schic so high intraluminal pressure will then stimulate what the problem with this is this will stimulate arterial compression and arterial compression will lead to bowel esmia so now you're not going to be able to get oxygen to the actual bow wall what happens as a result of this well the problem is is that as you start doing this particular areas start becoming dead so this may become more of a dead tissue and this tissue may start becoming dead and this might start becoming dead you get the point right there's areas of necrotic tissue because of the prolonged esea the complication that can arise from this is what's terrifying because naturally let's actually use this there is bacteria that are a part of our natural GI flora and naturally our GI wall is really good at preventing things from translocating but if it's now damaged and it's lost its natural barrier function what's going to happen these bacteria can translocate across that es schic area and so if a patient experiences something called a bacterial translocation this can cross the actual gut wall and get into the bloodstream and if this gets into the bloodstream what's going to happen these patients can develop bacteremia and sepsis so the thing that can potentially arise is this can potentially increase the risk or stimulate the formation of the patient becoming septic how does sepsis generally present well generally it can present in a couple different ways one is they may have fever they may have tacac cardia they may have an increased white blood cell count and then eventually they can kind of go downhill and develop hypotension and features of shock multi-organ system dysfunction so I think this is one of the scary things about bowal schia another thing that's actually helpful and they can try to test you on this for the exam is that whenever tissues are screaming because they're not getting oxygen they kind of kick into anerobic respiration and they pop out this molecule that can kind of be somewhat indicative of esmia and so here this tissue here it's going to start pumping out it's going to kind of kick into anerobic respiration and it'll pump out molecules called lactate and so whenever you see a patient who has a bowel up structure ction and then their lactate starts climbing that is really an ominous sign that they may start beginning to develop bowal schemy and there are high risk of sepsis so you have to watch out for that let's see that we go to the next step patient you know develops bow wallemia but then what happens is the intraluminal pressure continues to rise and we come to this last scary particular issue here so now ballemia patient can develop sepsis can develop increases in lactate but what if the intraluminal pressure continues to rise we continue to develop more and more esea of the bow wall there's more destruction of the bow wall and now these areas of esea are very weak and susceptible portions of the bow wall and if the pressure Rises up enough it may cause this portion to perforate and if these do perforate now you create an opportunity for everything that's in the actual Bal Lumen to escape out into the perenium what is this called perforation so the next thing that can potentially rise here is these patients can develop what's called a perforation a bow wall perforation now the scary thing about a bow perforation is that these patients will have scary signs uh particularly one of the big things things is they'll have intense abdominal pain if this patient does develop a bowel perforation another thing that can happen is bacteria can spill out of the actual Lumen into the actual parium and what can happen is these patients can develop peritonitis now the problem with this is that you this can look a lot of different ways right so we said that bacteria could spread in the example above that it could translocate into the bloodstream in this situation it's going to translocate but it's going to translocate Into the parium Now the things that are really helpful here is that peritonitis usually will present with findings of perianal findings so for example you want to watch out for severe abdominal pain you want to watch out for guarding you want to watch out for rigidity you want to watch out for Rebound tenderness so when you press into their abdomen you take your hand off it causes intense pain so when a patient has perianal findings and on top of that features of bacteria leaking in to the parum and causing inflammation like fever and increased white blood cell count think about peritonitis from a bowel perforation if they present with maybe increased abdominal pain because they have bow wall es schea and now they have fever they have lucco yosis and they have a bump up in their lactate it may lend you more to thinking about bow wallemia so increased lactate abdominal pain in combination with potential fevers of sepsis bmia perianal findings plus fever plus lucyisanerd the other thing is when you perf a bow not only does bacteria leak out here guess what else leaks air there's going to be air naturally within our bowel so now these are going to be bacteria that actually leak out there's going to be air here let's actually be cool here and we'll we'll put some like I don't know some like circles here this represents air and this also will leak out what is it called whenever air leaks out into the perenium it's called a numo parium so another potential finding here that you want to watch out for is not just peritonitis because bacteria leaks out and cause inflammation and infection of the perenium but watch out for air that leaks into the perenium and this is called a num numo parium the reason why I'm telling you this is when a patient comes in with a bowel obstruction the usually the the significant fear is these two ballemia and bowel perforation often times you're training their abdominal exam to see if it gets worse if it does it could lend to esia if they're lactate climbs it definitely suggest esea then watch out for risk of sepsis if their abdominal exam becomes significantly worse with findings of peritonitis you're concerned about bow perforation and one of the big things here is that sometimes what can really help to seal that diagnosis is that air leaked into the parum and it can be visible on actual radiographic images and that's why this is important now let's move into the next step here which is talking about how do we diagnose B obstructions the next thing that we have to talk about here after we've kind of gone through the B obstruction is how to really diagnose it how do I know if it's a small B obstruction how do I know if it's a large B obstruction how do I know if it's a paralytic ilas how do I know if it's maybe even potentially a uh A gilvie syndrome or colonic pseudo obstruction well first thing is again you have to ask yourself the question because this is the most utmost importance here is did they perforate so did they come in originally with cramping abdominal pain abdominal distension vomiting having had a bowel movement in a couple days and all of a sudden they present with searing abdominal pain they present with rigidity guarding rebound tenderness reduced bowel sounds fevers lucyisanerd dominal X-ray and look to see if I see air underneath the parene if I do and they're hemodynamically unstable signifying that they may becoming septic or a little bit then I need to take them right to the O and I'll do an inoperative diagnosis I'll find the actual area where they perfed and I'll treat it accordingly if they do not have an numo parium and they're not hemodynamically unstable and I see on the abdominal x-ray that they have dilated B loops and I see a lot of air fluid levels indicating that there's probably a transition point then I'm definitely scared that they have an AAL obstruction and the most definitive way to diagnose AAL obstruction is to get a CT of the and pelvis when you do this it'll really help you to identify if it's mechanical or if it's a functional obstruction oftentimes an abdominal x-ray can do that but CT abdomen pelvises will give a little bit of a better idea for example do I see a transition point do I see an area where I see the obstruction and I see the naring of the bow wall with proximal distension and distal decompression if I do not that kind of suggests more of a functional ballop struction also make sure that you're listening to their abdomen when you osculate do you hear absent bowel sounds because absent bowel sounds indicate that they're probably more towards the functional obstruction side because usually in your structural obstructions you start off with hyperactive and then eventually you progress to almost hypoactive or absent bowel sounds so again absent bowel sounds with the absence of a true transition Point suggests a functional obstruction then you just have to determine where is that point is it involving only really the small bowel maybe a little bit of the colon or is it only involving the large F so if I see dilated colon seeum is greater than 9 cm the Colon's greater than 6 cm at multiple Parts it's only that it's a gilvie syndrome colonic pseudo obstruction but if I see something like this here or or if I do see this this is oh boy look how huge their seeum is look how large their actual transverse colon is this is super obvious for a Gil syndrome and they're not going to see a lot of small bow Loops that are super dilated and distended so this definitely does not suggest an ilot all right another CT scan that suggests in this case this is a CT scan that suggests very large and dilated and distended large bowel now if I go the other route I have a patient that I now think has an ilas that'll really only be dilated small bowel predominantly so I'll look and I'll see that the small bow is greater than 3 cmet at multiple points maybe they have some colon involvement maybe they have some parts of their colon that are greater than 6 cm either way if they have both and I see no no mechanical transition point I see absent bowel sounds on their on oscilation I think it's probably a paralytic ilas and here you can see that they have multiple areas of dilated small bow loops and they even have a little bit of dilated large colon here too but there's no transition point with air fluid levels that really more likely suggests that they have an ilas and again here's a CT scan that would identify an ilas here you have small dilated small ball loops and maybe even some dilated large ball loops but again no mechanical transition point if I do a CT at the abdomen of pelvis and I see a mechanical transition point and I see collapsed distal bowel or de decompression I see the transition point and maybe even proximal distension of the bowels I definitely think that this is a structural or mechanical obstruction to add to that if I go and osculate their belly often times in the beginning stages of an obstruction they'll develop what's called boramy which is very hyperactive very high pitch tinkling bow sounds over time as it gets worse and the bow wall becomes es schic the bowel sounds will start to become more hypoactive and absent but in the earlier stages they'll be very hyperactive this right here screams mechanical bowel obstruction so I need to then figure out is it small or large if I look at the small bowels and they're dilated greater than 3 cm I see a transition point with air fluid levels it's a small bow obstruction and again you can see here that there is multiple areas of of dilated ball loops and look at some point right here I can see that there's probably some type of transition Point here somewhere here is there's a massive kind of transition Point causing proximal distension and distal decompression same thing here look I can actually see that there's some type of area here that's really really narrowed and all of this stuff here that's dilated is more proximal distension and then again anything distal to this point right here would be decompressed bow so there's a transition Point proximal distension distal de compression super common characteristic of again a spbo if I look at their CT scan and it shows that they have a dilated colon so the seeum is greater than 9 cm the Colon's greater than 6 cm and I see a obvious transition point it's likely a large B obstruction and again that's usually going to be in the form of like coloral cancer or some type of volvulus so here you can see that there's an obvious dilation of the distal colon parts of it here as well and then it's kind of cutting off somewhere here so I noticed that there's definitely a transition Point somewhere in this vicinity and I have disle decompression because I can't really see the bow a little bit further down here again here's another Point here where you can see again very large distension of the large bow here distension of the large bow here and at some point around this vicinity there is some type of transition point with distal decompression all right that covers the diagnostic approach we've now diagnosed if it's a ilas a gilis small bow large B obstruction using the context of again is it hemodynamically unstable or pneum parium to guide if it's an interoperative diagnosis and if it's not using the X-ray first then using the CT scan to identify definitively that it is a mechanical or or structural and then to identify the difference between small and large and also the CT scan will help to identify maybe even the ethology as well how do we treat these for mechanical bow upst structions you have to then kind of again alleviate the area of where the obstruction is occurring and sometimes that may require surgery however if we don't require surgery it's nice to kind of supportively take care of these patients so oftentimes it's a lot of supportive care so first thing that we're going to do is try to decompress the bowel and this is going to be done again non-surgically so how do we do this often times in patients who have small bowel obstructions they have a lot of fluid and food and fluid and air that are built up in their small bowels and it's causing a lot of distension a lot of vomiting a lot of nausea a lot of abdominal pain often times it's best to put an NG tube in and suction out a lot of those contents and that'll alleviate a lot of the vomiting a lot of the abdominal distension and a lot of the abdominal pain it's also best to avoid anything going down the oral cavity until they' started to resolve that obstruction because if not you're just going to cause again more air food and fluid to build up cause more abdominal pain more distension and more vomiting so keep them n decompress their bowel by suctioning out some of the contents when you put the NG tube in and then replace replace the fluids that they're not taking in from eating and drinking with IV fluids until they've resolved impartial obstructions especially ones that are due to a lot of Edema you can give them a medication called gastor graphin gastrograffin may be something that you take in and what happens is it moves through the actual bowels it can generate a little bit more of an osmotic gradient and it can pull fluid out of the bowel walls so you know the bow walls get super aditus as you compress the veins and as you compress the lymphatic vessels and so the bow walls can get really emitus if I pull some of the water from that emitus bowel I may be able to reduce the extent of the obstruction so sometimes in partial obstructions where gastor graphin can actually make its way through it can pull some of the water in that vicinity if it's a complete obstruction it's not going to help and actually could make it worse so again gastrograph and a little bit more beneficial for those partial obstructions the next one is what if the patient does have bmia in other words I see that they have an intense elevation in their lactate maybe they're developing some concerning signs of sepsis or they perfed in these particular situations it's usually Co complete or closed loop obstructions so complete means that they're not passing any stool they're not passing any gas right partial they can pass stool they can pass gas a closed loop same thing but this one is really really scary because you've pinched off both ends this area will most certainly become aeic and have a high risk of perforation so these two are very very high risk obstructions with very high risk of ES IA and perforation in these particular scenarios often times you're going to have to take these patients to do some type of surgical or intervention so one is you open them up or you do a laparoscopic study and you go in and you find the area of where the obstruction is and then you kind of remove that obstructed material maybe it's clearing off the adhesions maybe it's freeing up the hernia from the actual defect in the abdominal or pelvic wall maybe it's kind of taking a into subception and trying to improve that or pull that un telescope that that area um if it's a colorl Mass often times that may resolve uh that may require some type of like surgical reection if it's a volvulus sometimes you can actually do an endoscopic procedure where you go in and you actually detor that area so it is important to remember that surgical interventions may be required or endoscopic interventions especially if they have a volvulus you can go into the particular vicinity of where the volvulus is and help to detor that area now in patients to have functional ballop structions this is not something that you have to require any type of procedure unless they do perfect rate or they develop alemia often times it's the same thing you decompress their bowel you give them IV fluids while they're not eating or drinking you maintain them not eating any Dr or drinking anything until their bowel is actually healed and then if they have a lot of V vomiting nausea abdominal pain distension put in the NG tube in suction out some of that material and that'll help to relieve the abdominal pain the distension the nausea and the vomiting the other thing that may help especially in patients who have a lot of ailie syndrome they have a lot of air and food and fluids that are kind of like sitting particularly in their large bowel you can put a rectal tube in and it'll decompress that distal bowel and that may be somewhat helpful but more particularly in a gily syndrome it's important to remember that bowel motility is the problem and these it's obstruction and you have to fix the obstruction and this it's motility so improve their motility oftentimes you can do laxatives this may help a little bit and then sometimes in patients who don't respond to things like CNA or things to um like polyethylene glycol or maybe lactulose then you can go to the route of Neo stigma which is more of a Kind it helps to particularly increase the acetylcholine in the synapsis of the smooth muscle and increase contraction of the smooth muscle so it have to move things along but usually this is more of your last line medical therapy in patients who have severe ballemia due to the ilas or agilis or they do perf in this particular scenario you actually do have to do a surgical procedure where you go in and actually close off the area of the perforation maybe reect out the actual disease segment of the bowel and that's really important to remember when you would do this one all right all right my friends that's ball obstruction I hope it made sense I hope that you guys really did enjoy it and like it and as always thank you love you and until next [Music] time