Bowel obstruction and Hernias - SLIME handout November 2013

Richard Marks - FY1

Hernias: "a protrusion of a viscus or part of a viscus outside the cavity which normally contains it"

There are many types of hernia, but the most important ones you should be focusing on for FPE are the direct vs indirect inguinal hernias, with awareness of incisional and femoral types. Only look at others, e.g. Richter's hernias, if you're feeling flashy. Remember other types of hernia involve the stomach, vertebral discs, brainstem etc.

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Clinically pointless to differentiate on examination between a direct or indirect, but loved by medical finals examiners. The key involves reducing the hernia, obstructing the superficial ring (midpoint of the inguinal ligament) and then trying to make the hernia re-appear. The gold standard is at surgery: where is it in reference to the inferior epigastric vessels.

Complications:

  • Bowel obstruction
  • Incarceration
  • strangulation
  • Necrosis
  • Peritonitis
  • Death!

Investigationsare based on the presentation:

- Painless and reducible, consider USS but prepare for elective surgery with your investigations based on age/co-morbidities (e.g. FBC, U&E, ECG)

- Painful and strangulated: all bloods including G&S, amylase, erect CXR to rule out a perforation and abdo xray to exclude obstruction.

Management:

- Conservative: for example, smoking cessation, weight loss, support bands

-Medical: analgesia, weight loss

-Surgical: elective surgery (or more emergent theatre if warranted!!) Repair can be laproscopic or by open techniques. Post-operative rest is important!

Bowel obstruction

There are FOUR CARDINAL SIGNS of obstruction you should be aware of:

1) Vomiting

2) Abdominal distension

3) (absolute?) constipation

4) Colicky abdominal pain

The causes can be split into intra-luminal, intramural or extramural; but the most common causes include faecal impaction, cancers, adhesions and hernias

Acute management:

Drip and suck: i.e. IV fluids and an NG tube to "suck" out stomach fluids. The stomach can produce 9 LITRES per day, and so being simply NBM is not enough to "rest" the intestines

Analgesia, bloods, AXR and erect CXR, catheterisation and potentially CT are also important steps in treatment, but an early surgical opinion is valuable in-case theatre is required. Strangulated bowel needs urgent surgery, where-as less urgent cases may resolve with a trial of enemas.

The role of xrays in obstruction:

Large bowel obstruction (left) and small bowel (right)

Large: Peripheral bowel pattern, larger calibre with semilunar folds which do not go all the way across the width of the lumen (note: may appear so at certain angles)

Small: Multiple loops of bowel, in the centre of the abdomen, with obvious valvuli conniventes which are folds that go from wall-to-wall