Rosen & Barkin's 5-Minute Emergency Medicine Consult (774 page)

• Laparoscopy:
  
  • Useful when diagnostic imagining equivocal
    
  • Can differentiate congenital malrotation from volvulus
    

• Obstruction due to colonic tumor or diverticulitis
  
• Small bowel obstruction
  
• Ileus
  
• Intussusception
  
• Appendicitis
  
• Pelvic inflammatory disease and salpingitis, especially for cecal volvuli
  
• Ovarian torsion
  
• Perforated viscus
  
• Cyclic vomiting syndrome
  

• Meconium ileus
  
• Hirschsprung disease
  
• Duodenal atresia
  
• Meckel diverticulum
  
• Necrotizing enterocolitis (especially premature infants)
  
• Intussusception
  
• Appendicitis
  
• Medical conditions:
  
  • Colic
    
  • Henoch–Schönlein purpura
    
  • Inborn errors of metabolism
    
  • Trauma
    
  • Gastroesophageal reflux
    
  • Pyelonephritis
    
  • Meningitis
    

TREATMENT

• Establish IV assess
  
• NPO
  

• ABCs
  
• Aggressive fluid resuscitation with 0.9% NS bolus of 20 mL/kg (peds) or 2 L bolus (adult)
  
• NGT
  

• Obtain surgical and/or GI consultation
  
• NPO
  
• Correct hypovolemia and electrolyte abnormalities
  
• Preoperative broad-spectrum antibiotics if suspected sepsis or perforation
  

Sigmoid Volvulus

• Nontoxic patient:
  
  • Reduce volvulus nonoperatively with sigmoidoscopy:
    
    • 80–95% successful
      
    • 60% recurrence (within hours to weeks)
      
  • Follow with elective sigmoid resection and primary anastomosis (<3% recurrence)
    
• Toxic patient:
  
  • Emergent resection of sigmoid and any gangrenous bowel, with placement of end colostomy
    
• Endoscopic decompression with rectal tube placement:
  
  • Successful in 78% of patients with sigmoid volvulus; less effective for cecal volvulus
    
  • Recurrence is common
    
  • Elective surgical treatment after endoscopic detorsion
    

Cecal Volvulus

• Emergent operative reduction followed by colectomy and primary anastomosis (preferred), or cecopexy if the cecum is still viable (higher recurrence)
  

• Laparotomy within 1–2 hr to reduce risk for ischemia
  
• Surgical detorsion of bowel with resection of gangrenous bowel and a Ladd procedure is performed to prevent recurrent volvulus
  

• Ampicillin sulbactam (Unasyn): 3 g (peds: 100–200 mg/kg/24 h) IV q6h
  
• Cefoxitin (Mefoxin): 2 g (peds: 80–160 mg/kg/24 h) IV q6h
  
• Ceftriaxone 1–2 g IV q12–24h (peds: 50–75 mg/kg/d q12–24h) AND metronidazole 500 mg IV q8h (peds: 30 mg/kg/24 h q6h)
  
• Piperacillin–tazobactam 3.375–4 g IV q4–6h (peds: 200–300 mg/kg/d of piperacillin component q6–8h)
  

FOLLOW-UP

Admit with a surgical consult all suspected of having a volvulus.

None

• Surgical consultation necessary
  
• Atypical malrotation: Asymptomatic or symptoms of gastroesophageal reflux:
  
  • Close observation with repeat contrast study
    
  • Defer surgery
    

Surgical follow-up postoperatively

• Consider volvulus in any child <1 mo old presenting with vomiting:
  
  • Bilious vomiting is due to mechanical intestinal obstruction until proven otherwise
    
• Delayed diagnosis leads to increased morbidity, more often with adults than children:
  
  • 70% adults not diagnosed until >6 mo from initial presentation; most present with chronic abdominal symptoms
    
  • If gangrene present, mortality = 25–80%
    
• Operative repair for all adult patients
  
• Upper GI contrast series is the best initial test for children
  
• CT abdomen/pelvis is preferable for adults
  

• ASGE Standards of Practice Committee, Harrison ME, Anderson MA. The role of endoscopy in the management of patients with known and suspected colonic obstruction and pseudo-obstruction.
  Gastrointest Endosc
  . 2010;71(4):669–679.
  
• Cappell MS, Batke M. Mechanical obstruction of the small bowel and colon.
  Med Clin North Am
  . 2008;92:575–597.
  
• Durkin ET, Lund DP, Shaaban AF, et al. Age-related differences in diagnosis and morbidity of intestinal malrotation.
  J Am Coll Surg
  . 2008;206(4):658–663.
  
• Louie JP. Essential diagnosis of abdominal emergencies in the first year of life.
  Emerg Med Clin North Am
  . 2007;25:1009–1040.
  
• Madiba TE, Thomson SR. The management of cecal volvulus.
  Dis Colon Rectum
  . 2002;45(2):264–267.
  
• Nehra D, Goldstein AM. Intestinal malrotation: Varied clinical presentation from infancy through adulthood.
  Surgery
  . 2011;149:386–393.
  

See Also (Topic, Algorithm, Electronic Media Element)

Bowel Obstruction

CODES

• 537.89 Other specified disorders of stomach and duodenum
  
• 560.2 Volvulus
  
• 751.5 Other anomalies of intestine
  

BASICS

• 3 phases:
  
  • Nausea: Unpleasant sensation prior to vomiting
    
  • Retching: Rhythmic contractions of diaphragm, abdominal muscles, intercostals that bring gastric contents up the esophagus
    
  • Vomiting: Forceful retrograde expulsion of gastric contents through the mouth
    
• Vomiting center in medulla coordinates vomiting through vagus, phrenic, spinal nerves
  
• Irritated by impulses from the GI tract, pharynx, vestibular system, heart, genitalia, or via stimulation of chemoreceptor trigger zone (CTZ) in the area postrema of the brain by medications, toxins, or hormones in circulation
  
• CTZ response mediated by dopamine D
  ₂
  , serotonin (5-HT
  ₃
  ), cholinergic, and histamine receptors:
  
  • Medications providing symptomatic treatment of vomiting antagonize these receptors
    

• GI:
  
  • Appendicitis
    
  • Boerhaave syndrome
    
  • Bowel obstruction or ischemia
    
  • Cholecystitis, biliary colic
    
  • Gastric outlet obstruction, gastroparesis
    
  • Gastritis
    
  • Gastroenteritis (e.g., infectious)
    
  • GI bleeding
    
  • Hepatitis
    
  • Inflammatory bowel disease
    
  • Pancreatitis
    
  • Peptic ulcer disease, dyspepsia
    
  • Perforated viscus
    
  • Peritonitis
    
• Neurologic:
  
  • Elevated intracranial pressure (ICP)
    
  • Intracranial blood
    
  • Labyrinthitis, vertigo
    
  • Meningitis
    
  • Migraine
    
  • Stroke
    
  • Tumor
    
• Endocrine:
  
  • Adrenal insufficiency
    
  • Diabetic ketoacidosis (DKA)
    
  • Hypoparathyroid, hyperparathyroid
    
  • Hypothyroid, hyperthyroid
    
  • Uremia
    
• Pregnancy:
  
  • Hyperemesis gravidarum
    
  • Nausea/vomiting of pregnancy
    
• Drug toxicity:
  
  • Acetaminophen
    
  • Aspirin
    
  • Digoxin
    
  • Theophylline
    
• Therapeutic medication use:
  
  • Antibiotics
    
  • Aspirin
    
  • Chemotherapy
    
  • Ibuprofen
    
• Drugs of abuse:
  
  • Narcotics/narcotic withdrawal
    
  • Alcohols
    
• Genitourinary:
  
  • Gonadal torsion
    
  • Nephrolithiasis
    
  • UTI/pyelonephritis
    
• Miscellaneous:
  
  • Carbon monoxide or organophosphate poisoning
    
  • Electrolyte disorders
    
  • Glaucoma
    
  • Motion sickness
    
  • Myocardial infarction/ischemia (MI)
    
  • Pain
    
  • Post-procedural (after anesthesia)
    
  • Self-induced (eating disorders)
    
  • Sepsis/shock