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Category: bowel obstruction

Adhesions, Internal Hernia And Bowel Obstruction

December 15, 2018 2:35 pm

Adhesions are fibrous bands of scar tissue that form during the healing process. Following surgery, many people live normally with this scar tissue. However, they are also the cause of bowel obstruction when the adhesions form in such a way that causes a segment of the bowel to either get trapped, or form a “knot”. In both of those cases, the end result is a partial narrowing or a complete blockage of the intestines. This is called bowel obstruction.

Without treatment, the blocked parts of the intestine can die, leading to serious issues. However, with prompt medical care, intestinal obstruction often can be successfully treated.

Other causes of bowel obstruction:

  • In children, the most common cause of intestinal obstruction is telescoping of the intestine (intussusception).
  • Intussusception telescoping of the interstine
  • Hernias — portions of intestine that protrude into another part of your body
  • Inflammatory bowel diseases, such as Crohn’s disease
  • Diverticulitis — a condition in which small, bulging pouches (diverticula) in the digestive tract become inflamed or infected
  • Twisting of the colon (volvulus)
  • Impacted feces
  • Colon Cancer
Adhesion band with trapped bowel

 

Internal Hernia

In patients who haven’t Bariatric / weight loss surgery or an untouched GI track, bowel obstruction may manifest itself by symptoms of loss of appetite, constipation, nausea, vomiting, enlarged abdomen, abdominal pain, cramping, with no passage of gas or bowel movements.

However, patients who have had a weight loss surgery (Duodenal Switch, or the Gastric Bypass) because of the parallel limbs of the small bowel, the symptoms outlined above may not present. The diagnosis of a bowel obstruction, when suspected, should be identified with CT scan of the abdomen and pelvis with Oral and IV contrast. A CT scan with no oral contrast or water instead of oral contrast is inadequate and may lead to a delay in diagnosis and surgical intervention. Examples of Bowel Obstruction CT findings were discussed previously.

The treatment for an internal hernia and adhesions causing a bowel obstruction depending on the severity may range from observation to  surgical intervention in order to release the small bowel from the constraints of the adhesions.

Lymphatic Channels

May 22, 2018 8:21 am

We are all aware of the arterial and venous systems. Arteries take the oxygenated blood from the heart to the organs and the veins take the blood back to the lungs to unload the carbon dioxide and reload oxygen to be taken back to the organs. In addition to the arterial and venous vascular systems, we also have the lymphatic channels that flow into the lymphatic system.

The Lymphatic channels and system may be new to some, however, it is the third vascular network that is much less defined. The Lymphatic system collects fluids that has left the artierial/venous vascular system along their travel outlined above and take it back to the venous system. The lymphatic vessels transport this fluid to the lymph nodes throughout the body where the nodes filter the fluid of bacteria and harmful substances. Eventually, the fluid makes it way back to the venous system via the Superior Vena Cava. Additionally, Lymphatics collect the lipids within the GI tract and transport them to the venous system for metabolism. Most of the time these serosal lymphatic vessels are very small and hard to notice on the bowel.

Example of Lymphatic channels

The following image is in a patient who had small bowel obstruction. The obstruction had resulted in vascular congestion at the base of the mesentery. The congestion had effected the low pressure system of the veins and the lymphatics disproportionately more that the arterial system. The white-milky tubular structures are the lymphatic channels filled with lipids.

lymphatic channels
Visible white lymphatic channels

There are three layers to the small intestinal lymphatic system, in the villi, submucosal and serosal layers and has the unique ability to transport absorbed intra-lumenal nutrients. There is a need for further research in the areas of health, obesity and disease in regards to the lymphatic system.

Internal Hernia And Bowel Obstruction

August 21, 2015 7:49 pm

Whenever there is a bowel resection with anastomosis made there will be a defect in the mesentery (the tissue that holds the blood supply and the nerves etc going to and from the bowel)  that needs to be closed. In this particular case, the stitches that were used to close the defect were intact and yet the tissue had separated from it. The result is an internal hernia. This can cause bowel obstruction, where by a loop of the bowel can go through the defect and kink the bowel causing the blockage. In some cases, the internal hernia may reduce itself with intermittent symptoms of the bowel obstruction and in other cases it may require immediate emergent surgery.  A CAT scan with oral and IV contrast is needed after Duodenal Switch to visualize the alimentary and bioliopancreatic limbs.

Symptoms may include but are not limited to:

  • nausea
  • vomiting
  • abdominal bloating
  • abdominal tenderness
  • cramping abdominal pain
  • diarrhea, constipation
  • feeling of inability to completely empty bowels
  • fever
  • severe abdominal pain.
Screen Shot 2015-08-19 at 3.53.05 PM
Mesentery Defect site of Internal Hernia

Bowel Obstruction After DS

August 20, 2014 12:47 am

One of the potential complications of any abdominal surgery is Bowel Obstruction.  If the treating physician (usually the primary care, or the emergency room doctor) is not absolutely clear of the anatomy of a patent post duodenal Switch or the Gastric bypass  surgeries this will pose a diagnostic dilemma. In intact anatomy the GI tract start at the mouth and ends up at the rectum as a long tube. After the Duodenal Switch the small bowel has two parallel limbs, the alimentary limb brings the food down from the stomach, and the biliopancreatic limb brings down the biliopancreatic secretions. These two limbs join and form the common channel.

In normal anatomy, bowel obstruction may present with nausea, vomiting, abdominal cramps, inability to pass gas, and/or have bowel movements. In this case, the X-ray will also show dilated loops of bowel and if oral contrast is given with the X-ray, there will be no contrast past the obstruction. Think of it as a garden hose that has been kinked and no water is going thru.

Bowel Obstruction After DS
Bowel Obstruction After DS

In this upper GI- the contrast travels down the small bowel and the entire small bowel is the same caliber. This is normal study with no evidence of obstruction. In a patient with the DS, the patient my have the biliopancreaitc limb obstruction, with an identical X-ray as above, since the oral contrast given will never get to the biliopancreatic limb and it will not show if it is dilated or not. 

In duodenal switch operation, a patient may have complete obstruction of the alimentary limb, with nausea, vomiting and abdominal pain, and yet have bowel movements because the content of the biliopancreatic limb is getting to the common channel. Similarly, a patient with biliopancreatic limb may have nausea, but no vomiting, because the obstructed biliopancreatic limb is not connected to the stomach and the content can’t not be expelled from the stomach.

Bowel Obstruction After DS
Bowel Obstruction After DS

It is critical to make sure that a patient with a suspected bowel obstruction after the DS, is evaluated with the understanding that the common signs and symptoms, and the diagnostic workup will not provide an accurate picture. A patient with the DS or RNY, can have bowel obstruction and still have bowel movement, and no vomiting.

Bowel Obstruction After DS
Bowel Obstruction After DS

A patient with suspected bowel obstruction should have CT scan of the Abdomen with oral and IV contrast. The cardinal findings will be “dilated loops of bowel with no contrast within the lumen of the bowel”. This is highly suspicious for bowel obstruction after DS, where the regular x ray will not pick this up. Additionally, abnormal liver function test may suggest biliopancreatic limb obstruction.

Bowel Obstruction After Duodenal Switch

August 19, 2014 4:47 pm

One of the potential complications of any abdominal surgery is Bowel Obstruction.  If the treating physician (usually the primary care, or the emergency room doctor) is not absolutely clear of the anatomy of a patent post duodenal Switch or the Gastric bypass  surgeries this will pose a diagnostic dilemma. In intact anatomy the GI tract start at the mouth and ends up at the rectum as a long tube. After the Duodenal Switch the small bowel has two parallel limbs, the alimentary limb brings the food down from the stomach, and the biliopancreatic limb brings down the biliopancreatic secretions. These two limbs join and form the common channel.

In normal anatomy, bowel obstruction may present with nausea, vomiting, abdominal cramps, inability to pass gas, and/or have bowel movements. In this case, the X-ray will also show dilated loops of bowel and if oral contrast is given with the X-ray, there will be no contrast past the obstruction. Think of it as a garden hose that has been kinked and no water is going thru.

Bowel Obstruction After DS
Bowel Obstruction After DS

In this upper GI- the contrast travels down the small bowel and the entire small bowel is the same caliber. This is normal study with no evidence of obstruction. In a patient with the DS, the patient my have the biliopancreaitc limb obstruction, with an identical X-ray as above, since the oral contrast given will never get to the biliopancreatic limb and it will not show if it is dilated or not.

In duodenal switch operation, a patient may have complete obstruction of the alimentary limb, with nausea, vomiting and abdominal pain, and yet have bowel movements because the content of the biliopancreatic limb is getting to the common channel. Similarly, a patient with biliopancreatic limb may have nausea, but no vomiting, because the obstructed biliopancreatic limb is not connected to the stomach and the content can’t not be expelled from the stomach.

Bowel Obstruction After DS
Bowel Obstruction After DS

The images of fluid filled loops of bowel are highly suspicious.

Bowel Obstruction After DS
Bowel Obstruction After DS

It is critical to make sure that a patient with a suspected bowel obstruction after the DS, is evaluated with the understanding that the common signs and symptoms, and the diagnostic workup will not provide an accurate picture. A patient with the DS or RNY, can have bowel obstruction and still have bowel movement, and no vomiting.

A patient with suspected bowel obstruction should have CT scan of the Abdomen with oral and IV contrast. The cardinal findings will be “dilated loops of bowel with no contrast within the lumen of the bowel”. This is highly suspicious for bowel obstruction after DS, where the regular x ray will not pick this up. Additionally, abnormal liver function test may suggest biliopancreatic limb obstruction.