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Sun Jan 25 04:35:51 GMT 2009

Bowel sounds play an important role in my decision making. Borborygmi and I will be back quickly. If no bowel sounds, I will think it to be an ileus and watch.  Critical to observation is sudden cessation of bowel sounds, spike in WBC or sudden tachycardia. These are indications of ischemic bowel. Immediate laparatomy is indicated. 

After 2-3 days of watching, I will put down barium If it hits a blockage and does not move beyond point for 6 hours I will go in. Very importantly, however. I, MYSELF, must see it stop. Most radiologist watch it for 4 hours from ingestion, not point of obstruction and call it an obstruction.  This is incorrect. This is (as Dr Mttox would say) VOMIT

The CT is not as accurate as serial films at q2h intervals following barium ingestion.
Norman

Norman McSwain MD
Trauma Director, Charity Hospital
Professor of Surgery, Tulane University
New Orleans LA
504 988 5111
norman.mcswain at tulane.edu <mailto:norman.mcswain at tulane.edu> 

________________________________

From: trauma-list-bounces at trauma.org on behalf of moore677 at aol.com
Sent: Sat 1/24/2009 10:10 PM
To: trauma-list at trauma.org
Subject: ACUTE CARE SURGERY QUESTION

Not trauma, but is acute care-related question.? How many of you would operate on postoperative partial small bowel obstruction which persists 2 weeks after failed conservative management, including TPN?? Which of you would go longer than 2 weeks, and if so, how long would you wait if the patient did not have a fever or elevated WBC and a benign abdomen??

I did a RHC on a patient with a cecal volvulus who was 1 week s/p lap Nissen.? She developed signs of pSBO 1 week after hemicolectomy and was managed for 17 days with no improvement.? Traditional teaching has been to wait at least 2 weeks then operate.? Preop imaging included a CT scan and an UGI/SBFT.? UGI/SBFT had no contrast to anastomosis at 8 hours and ?extra-luminal contrast in RUQ (where anastomosis was).

After being in that belly, I think I should've waited as long as possible, and maybe longer than that.? She had horrible adhesions.? Anastomosis was fine and no internal hernia.

Dell.............

Forrest "Dell" Moore, MD, FACS
Trauma Critical Care Surgery
Co-director Trauma & Surgical ICU
St. Joseph's Hospital and Medical Center
Phoenix, AZ
Cell 480 284 1703
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