SMALL BOWELL OBSTRUCTION IN VIRGIN ABDOMEN for General Surgeon

1. SMALL BOWEL OBSTRUCTION
IN VIRGIN ABDOMEN (SBO-VA)
CAX

2. DEFINISI
Amara, Y., Leppaniemi, A., Catena, F., Ansaloni, L., Sugrue, M., Fraga, G.P., Coccolini, F., Biffl, W.L., Peitzman, A.B., Kluger, Y. and Sartelli, M., 2021. Diagnosis and management
of small bowel obstruction in virgin abdomen: a WSES position paper. World journal of emergency surgery, 16(1), pp.1-9.
Obstruksi pada usus kecil yang
menyebabkan gangguan transit konten
usus yang terjadi pada pasien tanpa
riwayat operasi regio abdomen

3. ETIOLOGI
70% disebabkan oleh adhesi
Keganasan
Hernia internal
Bezoar
Amara, Y., Leppaniemi, A., Catena, F., Ansaloni, L., Sugrue, M., Fraga, G.P., Coccolini, F., Biffl, W.L., Peitzman, A.B., Kluger, Y. and Sartelli, M., 2021. Diagnosis and management
of small bowel obstruction in virgin abdomen: a WSES position paper. World journal of emergency surgery, 16(1), pp.1-9.

4. Long, Brit et al. 2018. Emergency Medicine Evaluation and Management of Small Bowel Obstruction: Evidence-Based
Recommendations. Journal of Emergency Medicine, Volume 56, Issue 2, 166 - 176

5. Adhesive SBO

6. Pathophysiology
• Adhesions are fibrous bands of connective tissue that form in
response to trauma, surgical manipulation, or inflammation
Capillaries & Migration
of Fibroblasts
Peritoneal Damage
Bleeding Inflammation
Stable Fibrin matrix
Fibrinogen
Adhesion
Barmparas et al, J Gastrointest Surg 2010

7. Surgery Technique
Total # of
patients
Adhesion-related
readmission
Appendectomy
Open
Lap.
266,695
4,445
1.4%
1.3%
Cholecystectomy
Open
Lap.
141
7,103
7.1%
0.2%
Colectomy
Open
Lap.
121,058
930
9.5%
4.3%
Ileal pouch-anal
anastomosis
Open 5,268 19.3%
Laparotomy for
Trauma
Open 1,913 2.5%
Gynecological
procedures
Open
Lap.
24,998
773
17.1%
0%
Procedure related risk
Barmparas et al, J Gastrointest Surg 2010

8. Diagnosis – Anamnesis
Tanda Klasik
• Nyeri perut seperti kram
• Distensi
• Obstipasi akut
• Mual, muntah (semakin proximal,
semakin parah)
Karakter nyeri
• Diffuse dan ringan
• Tidak kolik
• Paroksisma berulang 10-30 detik dengan
pola crescendo-decrescendo
• Nyeri konstan menandakan strangulasi
Edil, B. H. (2013). Maingot's Abdominal Operations.
Riwayat
• Obstruksi usus sebelumnya
• Konstipasi kronis
• TIDAK ADA RIWAYAT OPERASI SEBELUMNYA
• Perubahan pola BAB

9. Diagnosis – Pemfis
Vital Sign
• Takikardia
• Hipotensi
• Oliguria
Inspeksi
• Distensi
• Defek hernia
Auskultasi
• Perubahan bising usus (Ileus menurun,
obstruksi meningkat)
• Metalic sound
Edil, B. H. (2013). Maingot's Abdominal Operations.
Palpasi
• Peritoneal sign (rebound, tenderness,
defans)
RT untuk menyingkirkan
kemungkinan impaksi fekal
atau kanker rektal letak rendah

10. Diagnosis – Laboratorium
Tidak ada lab yang spesifik
Dilakukan untuk mendeteksi kelainan metabolic yang dapat
mempengaruhi tindakan
DL, elektrolit, , BUN, SK, Urinalisis untuk deteksi sepsis
Peningkatan asam laktat diduga merupakan tanda awal
iskemia usus
Edil, B. H. (2013). Maingot's Abdominal Operations.

11. Modalitas diagnosis
A. Plain X-rays
• Sensitifitas: 70%
• Tanda patognomonik small bowel obstruksi:
• Multiple air-fluid level
• Distensi small bowel
• Tidak adanya distribusi udara di lumen colon
B. Water-soluble contras strudies
Jika kontras tidak mencapai kolon pada pemeriksaan x-ray abdomen yang diambil
setelah 24 jam, hal ini merupakan penanda gagalnya non-operatif managemen
Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2017 update of the evidence-
based guidelines from the world society of emergency surgery ASBO working group. World J Emerg Surg. 2018 Jun 19

12. C. CT Scan
• Sensitifitas 90%
• Tanda dimana operasi tidak dapat ditunda:
• Tanda dari close loop
• Bowel ischemia
• Cairan bebas
D. USG/MRI
Dapat digunakan bila tidak tersedia CT scan, dan pada wanita hamil
Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2017 update of the evidence-
based guidelines from the world society of emergency surgery ASBO working group. World J Emerg Surg. 2018 Jun 19

13. Paulson, E. K., & Thompson, W. M. (2015). Review of Small-Bowel Obstruction: The Diagnosis and When to
Worry. Radiology, 275(2), 332–342. doi:10.1148/radiol.15131519
(https://doi.org/10.1148/radiol.15131519)

14. Diagnosis - Radiologi
Foto Polos
• Air fluid level multiple
pada usus yang dilatasi
• Hilangnya gambaran
udara usus di bagian distal
• Fekalisasi konten usus
kecil menandakan
obstruksi kronis
• Gambaran udara bebas di
rongga abdomen
menandakan adanya
perforasi
Kontras
• Menggunakan barium
atau kontras hiperosmolar
• Dapat digunakan untuk
terapeutik, akan tetapi
mekanismenya belum
dapat dijelaskan
• Kontraindikasi : obstruksi
komplit dengan
kecurigaan strangulasi
atau perforasi
CT Scan
• Pilihan pertama dalam
diagnosis SBO
• Dapat mengetahui
underlying disease, lokasi,
grade obstruksi, zona
transisi
• Gambaran edema
mesenterik, cairan bebas
intraperitoneal, tanda
small bowel feces
keperluan operasi
Edil, B. H. (2013). Maingot's Abdominal Operations.

15. Paulson, E. K., & Thompson, W. M. (2015). Review of Small-Bowel Obstruction: The Diagnosis and When to
Worry. Radiology, 275(2), 332–342. doi:10.1148/radiol.15131519
(https://doi.org/10.1148/radiol.15131519)

18. A barium meal and follow-through after 100 mL undiluted
Omnipaque dye insertion through a nasogastric tube
showing dilated small bowel loops (up to 4.3 cm) and
prolonged transit (>7.5 h) without the flow of contrast into
the large bowel, suggestive of high-grade small bowel
obstruction.

19. Abdominal CT Scan
Sensitivity 80-93%
Contrast does not pass transition zone
Colon with little gas or fluid
Fecalization of small bowel

20. Long, Brit et al. 2018. Emergency
Medicine Evaluation and Management
of Small Bowel Obstruction: Evidence-
Based Recommendations. Journal of
Emergency Medicine, Volume 56, Issue
2, 166 - 176

22. Tatalaksana SBO-VA
• Tindakan operasi
Jika tatalaksana secara non-operatif gagal, tindakan laparotomi
eksplorasi masih menjadi tatalaksana primer. Tindakan operatif
berkurang pada 16% pada pasien SBO-VA dengan mengaplikasikan
Water Soluble Contrast Agent
Amara, Y., Leppaniemi, A., Catena, F., Ansaloni, L., Sugrue, M., Fraga, G. P., ... & Ten Broek, R. P. (2021). Diagnosis and management of small bowel
obstruction in virgin abdomen: a WSES position paper. World journal of emergency surgery, 16(1), 1-9.

23. Tatalaksana Non-operatif
• Penggunaan Water Soluble Contrast Agent (WSCA) 100 ml
Gastrografin
• Puasa
• Penggantian cairan dan elektrolit
• Dekompresi dengan NGT
Amara, Y., Leppaniemi, A., Catena, F., Ansaloni, L., Sugrue, M., Fraga, G. P., ... & Ten Broek, R. P. (2021). Diagnosis and management of small bowel
obstruction in virgin abdomen: a WSES position paper. World journal of emergency surgery, 16(1), 1-9.

24. Non-operative management
• Resusitasi cairan
• Koreksi elektrolit
• Nutritional support
• Pencegahan aspirasi
Melanjutkan NOM >72 jam tidak dianjurkan pada kasus dengan high
output decompretion tube, tanpa perbaikan klinis.
Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2017 update of the evidence-
based guidelines from the world society of emergency surgery ASBO working group. World J Emerg Surg. 2018 Jun 19

25. Management of SBO-VA
• Operative management laparotomy
• Strajina et al. reported negative finding in 20 %
• Recurrence rates 1 -10%;

26. Indikasi operasi pada small bowell obstruksi:
• Persisten obstruksi >72 jam
• Drainase (NGT) > 500 cc pada hari ke-3
• Peritonitis atau iskemia:
• Nyeri perut bertambah hebat
• CRP >75mg/l
• WBC > 10.000/mm
• Cairan bebas intraperitoneal > 500 ml
Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2017 update of the evidence-
based guidelines from the world society of emergency surgery ASBO working group. World J Emerg Surg. 2018 Jun 19

27. 1: Perforation
• Any patient with peritonitis or free air-
indicating perforation should go
straight to OR

28. 2: Ischemia
• Any patients with concerning signs/symptoms for
gangrenous or ischemic bowel should also go to the OR
ASAP

29. Signs of bowel ischemia
•Clinical: sensitivity 40-50%
• Hypotension
• Tachycardia
• Fever or leukocytosis,
• Lactic acidosis
• SIRS response
• Deterioration in exam

30. 3: High grade, or closed loop SBO
• Patients with high grade SBO, or those with closed loop
obstruction should be strongly considered for early operative
management

31. Signs of high grade SBO
> 25mm
Air-fluid levels of
differential height
in the same loop
Air fluid width of
25 mm or more

32. SBO in the virgin abdomen
• Historically
• Primary causes: hernia and volvulus
• Currently
• Primary causes: malignancy, IBD
• All cases of SBO in a virgin abdomen should be taken for
operative exploration due to high failure rate of NOM and
concern for malignancy

33. Bologna guidelines for diagnosis and management of adhesive
small bowel obstruction (ASBO): 2017 update of the evidence-
based guidelines from the world society of emergency surgery
ASBO working group. World J Emerg Surg. 2018 Jun 19

34. Br J Surg. 2010 Apr;97(4):470-8.
Water-Soluble Contrast (WSCA) –
Diagnostic and Therapeutic role
•50–100ml Gastrografin or 40ml
Urografin administered orally
•Abdominal plain radiographs
after 4 h, 8 h or 24 h to follow
contrast through the GI-tract

35. Water soluble contrast
• Hyperosmolar radiopaque agent
• Potential aid in prognosis
• Passage of contrast into LB may predict successful NOM
• Failure of progression predicts need for OR
• Theoretically decreases bowel wall edema and may promote
resolution of SBO

36. If the contrast reaches the colon within 4–24 h,
obstruction will resolve without operation in 99% of
patients.
Br J Surg. 2010 Apr;97(4):470-8.
Water-Soluble Contrast (WSCA) –
Diagnostic and Therapeutic role
Timing n Sensitivity Specificity PPV NPV
4-8h 312 95 99 100 85
24h 196 99 97 99 97

37. Take home message
• Melanjutkan NOM >72 jam tidak dianjurkan pada kasus dengan high
output decompretion tube, tanpa perbaikan klinis.
• Jangan menunda operasi jika didapatkan penanda stangulata,
iskemik, dan peritonitis.
• Tindakan preventif pada intestinal adhesi dengan meminimalkan
manipulasi pada usus dan penggunaan bahan adhesi barrier.