🔴Specific Causes Of Bowel Obstruction (Part 3)

🔰Abdominal Adhesions (40%)
▪︎Most Common Cause Of Bowel Obstruction After Abdominal Surgery

▪︎Peritoneal Irritation During Abdominal Surgery Results in Local Fibrin Production That Produce Adhesions Between Opposed Surfaces

▪︎Adhesions Start To Form Within Hours Of Abdominal Surgery & Results in Lower Small Bowel Obstruction (No Large Bowel Involvement)

🔹Causes Of Peritoneal Irritation During Abdominal Surgery

1. Acute Inflammation During Surgery

2. Foreign Material Use (Silk Sutures / Gauze / Talc & Starch)

3. Abdominal Infection (Peritonitis / TB)

4. Chronic Abdominal Inflammation (Crohn's)

5. Radiation Enteritis

🔹Prevention Of Adhesions
1. Use Laparoscopic Surgery
2. Washing Peritoneal Cavity With Normal Saline To Remove Clots
3. Decrease Contact With Gauzes
4. Cover Sites Of Anastomosis & Peritoneal Surfaces

🔰Bolus Obstruction

🔶A. Gallstones ileus
▪︎Large Stone Causes Direct Erosion Into The Wall Of Gallbladder Then Descends Into The Duodenum & Results in Recurrent Attacks Of Small Bowel Obstruction (Intermittent Incomplete Obstruction)

▪︎More in Elderly

🔹Radiological Features Of Gallstones ileus (Rigler's Triad)

1. Small Bowel Obstruction (Air-Fluid Level & Bowel Loops Distension)


2. Pneumobilia (Air in Biliary Ducts)

3. Mineral Shadow Of Abdomen (Calcified Gallstones in Abdomen Outside The Gallbladder)

🔶B. Food impaction
➡️ Total Or Partial Gastrectomy (Stomach Removal) Results in Unchewed Food Pass Directly Into The Duodenum & Results in Food Impaction & Small Bowel Obstruction

🔶C. Trichobezoars
➡️ Hair Digestion in Psychiatric Patients (Eating Hair)

🔶D. Phytobezoars
➡️ High Fibers & Vegetables Intake With (Previous Gastric Surgery Or Hypochlorhydria Or Loss Gastric Peristalsis) Results in Undigested Fibers Accumulates in Small Bowel & Causing Obstruction

🔶E. Stercoliths (Fecolith)
➡️ Hard Fecal Material Accumulation Results in Bowel Obstruction

🔶F. Worms
➡️ Accumulation Of Ascaris lumbricoides Results in Small Bowel Obstruction & Risk Of Bowel Perforation & Peritonitis (Specially in Amoebiasis)

🔰Strictures (15%)
▪︎Inflammatory (Small Bowel TB Or Crohn's) & Malignant (Lymphoma) Strictures Results in Subacute & Chronic Bowel Obstruction

🔰Hernia (12%)
▪︎External Or Internal Hernias Contain Bowel Loops Can Undergo Obstruction If The Neck Of Hernia is Narrow

🔰Closed-Loop Obstruction
▪︎Obstruction Occurs At Both Proximal & Distal Points Of Bowel
▪︎Mostly Due To Malignant Stricture Of Colon
▪︎No Distension At Proximal & Distal Bowel Loops (Distension Only At Site Of Closed Loop)


🔰Adynamic Obstruction

🔶A. Paralytic Ileus (Some Known Causes)
▪︎Failure Transmission Of Peristaltic Waves Due To Neuromuscular Failure Leads To Fluid & Gas Accumulation & Absolute Constipation (Nothing Pass)

🔹Causes Of Paralytic Ileus

1. Postoperative After Abdominal Surgery ➡️ Spontaneous Resolution in 24-72h

2. Intra-Abdominal Sepsis

3. Reflex Ileus ➡️ After Spine Or Ribs Fracture / Retroperitoneal Hemorrhage / Plaster Jacket Application

4. Uremia & Hypokalemia (Low K)

🔶B. Pseudo-Obstruction (Unknown Causes)
▪︎Bowel Obstruction in Absence Of Mechanical Or Acute Abdominal Causes

🔹Types Of Pseudo-Obstruction

📍1. Small Bowel Pseudo-Obstruction
▪︎Present As Recurrent Episodes Of Subacute Obstruction
▪︎Dx By Exclusion
▪︎Mx By Metoclopramide & Erythromycin

📍2. Large Bowel Pseudo-Obstruction (Ogilvie's Syndrome)
▪︎More Common
▪︎Present As Acute Or Chronic Large Bowel Obstruction & Caecal Distension
▪︎High Risk Of Caecal Perforation (When Diameter >14 cm)
▪︎Need Immediate Mx By ➡️ Neostigmine Or Colonoscopic Decompression

🔰Clinical Pearls

▪︎Persistent constant abdominal pain (loss of colicky pattern) = STRANGULATION until proven otherwise

▪︎Caecal diameter >12–14 cm in large bowel obstruction = high risk of perforation (emergency decompression needed)

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أدوات الجراحة مهم جدا
ملف شبه شامل
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Thoracic outlet syndrome
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Summary for DVT management
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Chronic limb ischemic
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Acute limb ischemic
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شرح د.الأمين النور
Examination of lower limb ischemia
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🔴 DD OF NECK SWELLINGS
━━━━━━━━━━━━━━━━━━
🔰 1) Midline Swelling

▪︎ Submental LNs enlargement
Site in submental triangle

▪︎ Thyroid isthmus nodule
Moves with swallowing
No movement with tongue protrusion

▪︎ Dermoid cyst

▪︎ Thyroglossal cyst
Moves with swallowing and tongue protrusion

▪︎ Subhyoid bursitis
Moves with swallowing and tongue protrusion
Tender (important clue)

▪︎ Laryngocele
- Resonant
- Expansile with cough

▪︎ Others
- Lipoma
- Sebaceous cyst
- Haemangioma
- Prelaryngeal & Pretracheal LNs

━━━━━━━━━━━━━━━━━━
🔰 2) Submandibular Triangle

▪︎ Submandibular LNs enlargement
Multiple
Can be rolled over mandible

▪︎ Submandibular salivary gland enlargement

▪︎ Others
- Lipoma
- Sebaceous cyst
- Haemangioma
━━━━━━━━━━━━━━━━━━
🔰 3) Carotid Triangle
▪︎ Upper cervical LNs enlargement

▪︎ Carotid body tumor
Moves side to side
No up & down movement
Pulsatile

▪︎ Carotid aneurysm

▪︎ Branchial cyst

▪︎ Cold abscess

▪︎ Others
- Lipoma
- Sebaceous cyst
- Haemangioma

━━━━━━━━━━━━━━━━━━
🔰 4) Posterior Triangle

▪︎ Cystic hygroma (Lymphangioma)
Since birth
Lower posterior triangle
Blue, translucent
Not pulsatile

▪︎ Sternomastoid tumor (Torticollis)
Resembles wry neck
▪︎ Enlarged LNs
▪︎ Cervical rib
Hard swelling
Tingling + numbness (medial forearm)
± Raynaud’s phenomenon

▪︎ Neurofibroma (brachial plexus)

▪︎ Cold abscess

▪︎ Pharyngeal pouch

▪︎ Pneumatocele
Resonant
Expansile with cough
At base of neck

▪︎ Others
- Lipoma
- Sebaceous cyst
- Haemangioma
━━━━━━━━━━━━━━━━━━
🔴 Why LNs enlargement is the 1st DD of Neck swelling?

From > 600 LNs in body About 200–400 are found in the neck

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Examination of the Breast - Surgery - Prof. Ashraf Khater