Makindo Medical Notes

Related Subjects: Small Bowel Obstruction | Colonic (Large bowel) Obstruction | Caecal Volvulus | Small Bowel Ischemia | Hartmann's procedure | Sigmoid Volvulus | Acute Colonic Pseudo-obstruction |

RIF tenderness with radiological evidence of caecal distension and distal colonic obstruction is a critical sign indicating imminent caecal perforation and peritonitis. Follows Laplace's law as the tension in the wall is greatest where the diameter is maximal.

About

• Can result in an acute surgical admission.
• Elderly and those on steroids may have subtle findings.

Aetiology

• Obstruction leads to progressive bowel dilation.
• If untreated, bowel perforation can occur, usually at the caecum.

Causes

• Lumen: Polypoid tumour, constipation.
• Mural: Malignancy, ischaemia, diverticulitis stricture, radiation stricture, pseudo-obstruction.
• Extramural: Hernia, volvulus, intussusception.

Clinical

• Colicky abdominal pain and abdominal distension.
• Failure of passage of flatus and stool PR.
• Signs include guarding, peritonism, perforation, sepsis, and shock.

Investigations

• Bloods: FBC, U&E, ESR to check for raised WCC and abnormal electrolytes.
• Raised lactate suggests bowel ischaemia and sepsis.
• ECG: Can reveal MI or AF.
• Imaging: CXR may show free air if perforation occurred; AXR may reveal dilated bowel loops proximal to obstruction ("cut-off point").
• Double contrast CT: Preferred to determine obstruction's level and cause and assess bowel viability; may also show metastases.

Comparison

Management

• Resuscitation: Urgent fluid and electrolyte correction.
• Analgesia and antiemetics: Provide relief as needed.
• NG tube: Consider if vomiting; urinary catheter if needed.
• Emergency laparotomy and colonic resection with colostomy for cases with peritonitis, perforation, or necrosis.
• Antibiotics: Broad-spectrum to cover gram-negative and anaerobes.
• Palliation may be appropriate for some patients.

References

• Consult standard surgical references and clinical guidelines for large bowel obstruction management.