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Medical and Surgical Management IDEAL

LABS/DIAGNOSTIC 1. Abdominal x- rays in both supine and upright positions ( This usually confirms the diagnosis. Findings include abnormal quantities of gas or fluid or both in the intestines. Also, a dilated colon without air in the rectum purely suggests obstruction.) 2. Complete Blood Count (CBC) -Electrolyte study (May reveal dehydration, loss of plasma volume and of possible infection. Also, electrolyte imbalance would also results as a consequence of large bowel obstruction)

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LABS/DIAGNOSTIC 1.Chest X-ray - this will show free air of perforated. 2.ECG 3. Abdominal Ultrasound - Sonography is as sensitive, but more specific, than plain abdominal X-ray in the diagnosis of Intestinal obstruction. Point-of-care ultrasound can answer specific questions related to IO that assist the acute care physician in critical decision making.

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Cont.. 2. CBC may also show a decreased Hematocrit level with evidence of chronic iron deficiency anemia. (this may suggest chronic lower gastrointestinal bleeding.) 3. Radiopaque contrast - Imaging of colon can be performed under the following circumstances: - if the diagnosis for obstruction is suspected but not yet proven. - to differentiate obstipation and obstruction. - if localization is required for surgical intervention
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4. Hematology 5. Blood Chemistry - to evaluate dehydration and electrolyte imbalance which can occur as a result of large bowel obstruction. 6. Differential Count - may show leuocytosis. Mild leukocytosis may be seen with obstruction or constipation. Severe leukocytosis should prompt reconsideration of the diagnosis. Ileus, secondary to an intraabdominal or extra-abdominal infection or another process, is a possibility.

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Cont.. 4. Barium Enema - this is commonly used if a detailed anatomic definition is required (especially with the right colon) 5. CT Scanning - Generally, not used initially in patients with large bowel obstruction unless a diagnosis has been made. - Also, the findings will not really alter the management because these patients will be explored and operatively decompressed regardless of the CT Scan findings.

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**NOTHING FOLLOWS**

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MEDICATIONS 1. Analgesics - usually prescribed especially when pain experienced is so severe. 2. Antibiotics - given to decrease colonic pathogens or to prevent possible infections. Here are some meds that are commonly prescribed : 1. 2. 3. 4. Clindamycin (Cleocin) Metronidazole ( Flagyl) Cefoxitin (Mefoxin) Piperacilin-Tazobactam (Zosyn)

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MEDICATIONS

Medications that were prescribed as are follows:


1. 2. 3. 4. 5. 6. 7. Tramadol 50mg IVTT (for pain relief) Paracetamol 300mg IVTT Cefuroxime 500mg IVTT ( antibiotic) Metronidazole 500mg IVTT Ranitidine 50mg IVTT Moxifloxacin 400mg IVTT Ketorolac 30mg

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TREATMENTS 1. Emergency Department Care - Initiated therapy directed at patient comfort and volume resuscitation . Ultimate goal: to decompress large intestine. 2. Resuscitation - For correction of fluid and electrolyte imbalance. 3. Nasogastric Decompression - to treat temporarily the obstruction, to prevent vomiting and aspiration. - directed primarily at supporting the patient.

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TREATMENTS

1. Nasogastric Decompression - Patient is with NGT - to prepare patient for surgery, to treat obstruction temporarily and to prevent vomiting with could cause possible aspiration. 2. Intravenous Fluid therapy - Patient is with IVF infused with I liter plain LR. - This was prescribed to correct or prevent any fluid imbalances or any possible dehydration.

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TREATMENTS 4.Consultation - obtain early consultation from a surgeon. Frequently, surgical intervention is indicated. 5. Intravenous Fluid and Electrolyte therapy - patient may be at risk for fluid and electrolyte imbalances or deficit. - Isotonic Saline or Ringers Lactate is commonly prescribed.

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TREATMENTS

3. Foley Bag Catheter - patient is attached to FBC. - this is used to empty bladder and prepare patient for surgery.

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SURGICAL MANAGEMENT ** Surgical care is directed at relieving the obstruction. 1. Diverting transverse loop colostomy Least invasive procedure for a very ill patient with a left colonic obstruction Permits relief of the obstruction and further resuscitation without compromising chances for a subsequent resection. 2. Laparotomy - Is a surgical procedure which involves making an incision through the abdominal wall to gain access to the abdominal cavity.

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SURGICAL MANAGEMENT Operation performed: ExLap, Transverse Colostomy with Fistula Surgical Care is directed at relieving the obstruction. Least invasive procedure for a very ill patient. Permits relief of the obstruction and further resuscitation without compromising chances for a subsequent resection -Ostomy is a surgical procedure used to create an opening for urine and feces to be released from the body. -Colostomy refers to a surgical procedure where a portion of the large intestine is brought through the abdominal wall to carry stool out of the body.

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DIET For cases with complete obstruction - NPO For Partial Obstruction - Clear Liquids DIET

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FULL DIET as tolerated

Post-op diet - NPO until bowel sounds return, then slowly progress to clear liquids, soft diet and then diet as tolerated. ** Post-operatively, Patient may have a colostomy, advise patient to limit raw vegetables, foods with high fiber (wheat bran cereals and bread) and gas forming foods.

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DIET (cont) Foods that sometimes need to be limited, in order to make it easier to manage your colostomy, include: Raw vegetables Skins and peels of fruit (fruit flesh is OK) Dairy products Very high fiber food such as wheat bran cereals and breads Beans, peas, and lentils Corn and popcorn Brown and wild rice Nuts and seeds Cakes, pies, cookies, and other sweets High fat and fried food such as fried chicken, sausage, and other fatty meats

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**NOTHING FOLLOWS**

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DIET

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Meanwhile,other foods can be helpful after a colostomy, to thicken the stool and minimize odors, including:
**NOTHING FOLLOWS** Yogurt (with live and active cultures) Cranberry juice Bananas Applesauce

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