SBO and Diverticulitis (HBS edition) MINHAO ZHOU MD

Transcription

1 SBO and Diverticulitis (HBS edition) MINHAO ZHOU MD

2 Important CME Information DISCLOSURE INFORMATION: The planners of this activity and the speaker, Rouzbeh Mostaedi, MD, do not have affiliations with any corporate organizations that may constitute a conflict of interest with this presentation. CME CREDIT: Attendees must sign in to receive the online evaluation survey for this presentation. CME Credit will only be issued to attendees who complete the evaluation survey within the next 30 days.

3 SBO SBO is a Mechanical obstruction of the bowel Adhesions Hernia Volvulus Tumors, GS ileus, bezoar, etc.

4 SBO So what does a surgeon care about when we get consulted for SBO? What abdominal surgery has the patient had? Does the patient have a hernia. Patient has had a CT (ED PE) Very good at finding hernias Buzz words for obstruction dilated bowel, transition point Buzz words for surgery free air, free fluid, thickened bowel, closed loop, complete bowel obstruction, volvulus

5 CT reads: Mild or moderately dilated bowel.? Transition point, suspicious, can not rule out, consider,. psbo, ileus.. Diagnosis of SBO in patients with no previous abd surgery and no hernia is always suspect. Additional GI/tumor work up needed? NGT or no NGT? Is the stomach distended on CT? Is patient bloated? Is patient vomiting?

6 SBO GG protocol

7 Gastrografine is a great laxative. This is both diagnostic and therapeutic Contrast usually gets to colon w/in 6 hours if not by 24 hrs. If contrast does not reach colon w/in 24 hrs. Surgery highly likely.

8 223 patients with 235 episodes of ASBO 84.2 % NOM, 18.5% operative 1.5% of the patients with contrast in colon needed operation

9 Vast majority of SBO are from adhesions from previous surgery. Vast majority of those resolve with non op management. GG protocol can both be diagnostic and therapeutic. Abdominal surgery adhesions SBO due to adhesions If we operate more adhesions??? Future SBO Absolute indication for surgery: complete bowel obstruction, ischemic/perforated bowel Relative indication for surgery: Frequency, duration, severity

10 Special considerations Patients with hx of RYGBP. Anatomy is altered Many points for internal hernia and volvulus May not have any of the classic SBO symptoms Surgery consult early

11 Large bowel obstruction Colon cancer until proven otherwise Relevant hx is if and when they had their last colonoscopy Need scope if able to tolerate prep, enema vs full prep depending on the level of the obstruction Complete obstruction will need surgery

12 When you consult surgery for SBO 1) what surgeries has the patient had. 2) Is pt vomiting? Distended? Last flatus? Last BM (clinical signs of SBO) 3) Or is this just a radiographic dx of SBO Pt on chronic opioids, constipation, will have chronically dilated SB and will always be read as possible psbo on imaging.

13 Diverticulitis Incidence of Diverticulosis 33-60% Incidence of Diverticulitis for people with diverticulitis 10-25% Wide spectrum of disease from uncomplicated out pt management to emergent operation CT REQUIRED to confirm dx of diverticulitis. LLQ pain Diverticulitis regardless of hx

14 Uncomplicated disease CT proven uncomplicated diverticulitis requires abx treatment? True False

15 AVOD (Antibiotika Vid Okomplicerad Divertikulit Swedish for antibiotics in uncomplicated diverticulitis ) Trial Open Multicenter RCT Oct 2003-Jan Surg department in Sweden and 1 in Iceland.

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18 No abx group got IVF only Abx group got IV broad-spectrum abx (according to the participating center s routine, covering G- and anaerobic bacteria. Eg. Combination of 2 nd or 3 rd gen cephalosporin plus flagyl or a carbapenem, or zosyn)

19 10 (3.2%) allocated to no abx were started on abx for increasing fever, CRP, abd pain, no complications.

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21 Uncomplicated disease CT proven uncomplicated diverticulitis requires abx treatment? True False

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23 Hinchey I and II Perc drain of diverticular abscess based on expert opinion and observational studies, no Type I evedence. Reported failure rate 15-30%

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28 Diverticulitis The more we can delay acute surgery the better Surgery does not cure diverticulitis. Only removes section of colon that is causing the recurrent/acute symptoms. Still have the 10-25% incidence of diverticulitis like any one else with diverticulosis All patients do need up to date colonoscopy if possible prior to any planned operation

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30 REMINDER ABOUT CME CREDIT Attendees must sign in to receive the online evaluation survey for this presentation. CME Credit will only be issued to attendees who complete the evaluation survey within the next 30 days.