0:00

Now we're heading into the land of bowel obstruction,

0:03

patients with nausea and vomiting who are so

0:06

uncomfortable in the emergency department, who are

0:07

going to image to look for bowel obstruction and try

0:09

to diagnose the causes of their bowel obstructions.

0:13

So here is a classic KUB, similar to our scout image

0:16

on the last patient, where we can see those beautiful

0:18

dilated loops of small bowel.

0:20

Again, you can see the valvulae conniventes, or the folds of the

0:23

small bowel, going all the way across the dilated lumen.

0:26

It is midline in location, so as in real

0:29

estate: location, location, location.

0:32

That is the location of the small bowel.

0:34

We have relative decompression of the colon, and

0:36

this is in keeping with a small bowel obstruction.

0:38

No prizes for that.

0:39

You guys are all going to get that, right?

0:41

You know, I always like to ask my medical students,

0:43

what are the causes for small bowel obstruction?

0:46

They are adhesions,

0:47

hernias, inflammatory bowel disease, malignant

0:51

tumors, and of course gallstone ileus, if you

0:53

are in a medical student surgery clerkship.

0:55

But I always say that hernias get me home faster.

0:59

So that's the first thing I look for,

1:01

although it's not the most common cause.

1:03

Adhesions are the most common cause. Those hernias are

1:06

so easy to diagnose that they are very satisfying,

1:09

and then you are finished with that case much faster.

1:11

So I always suggest looking for hernias,

1:13

similar to our case where we saw that

1:15

beautiful obstructing umbilical hernia.

1:18

Let's talk hernia terminology: is the hernia reducible?

1:22

This is, of course, something on physical exam, but a

1:24

reducible hernia, you can just pop it right back in, and

1:27

the patient's situation is fixed, and everyone's happy.

1:31

Then there's the irreducible or incarcerated hernia.

1:34

The content cannot be placed into the abdominal wall

1:38

physically.

1:38

So these usually have a small defect

1:41

where the bowel is going through.

1:42

There's usually some free fluid in the

1:43

sac, and there may be some thickening.

1:45

It'll look like a little closed-loop obstruction.

1:47

Now, how do you remember the word incarcerated?

1:50

I always remember incarcerated:

1:52

okay, go to jail.

1:53

Go to jail.

1:54

But if you go to jail, you're still alive.

1:58

So that's better than being strangulated and dead.

1:59

52 00:02:01,755 --> 00:02:02,865 So I always say to myself, okay,

2:02

incarcerated hernias, I ended up in jail.

2:04

It wasn't the best night, but I'm still alive.

2:07

So that's a good thing.

2:08

As opposed to strangulated hernias, which are

2:10

incarcerated hernias that cannot be reduced, but

2:13

there's actually ischemia and death of the bowel.

2:16

So these cases will have lack of

2:17

enhancement on imaging, and that obviously

2:20

is even more of a surgical emergency.

2:23

So you have your reducible hernias by

2:25

physical exam; you're incarcerated,

2:28

you're in jail, but you're still alive.

2:30

Hernia.

2:30

And then you have your strangulated.

2:32

And unfortunately, that didn't go well for you.

2:35

So those are the terms you're going to

2:36

hear the surgeons throwing around.

2:38

They may ask you, is this a closed-loop obstruction?

2:40

Usually in the setting of an incarcerated hernia,

2:42

we don't throw that word out there,

2:44

and we're going to go into closed-loop in a while,

2:45

but it is indeed a closed-loop obstruction.