GENERAL SURGERY
GENERAL SURGERY
Embedded Files
LARGE BOWEL OBSTRUCTION
LARGE BOWEL OBSTRUCTION
Introduction
5 minIntroduction
Introduce yourself and the group
Provide rationale for the session and relevance to clinical practice
Outline learning objectives:
- Demonstrate focused history taking from a patient presenting with likely large bowel obstruction (LBO)
- Perform an abdominal/GI examination and describe relevant clinical findings
- Suggest appropriate investigations and be able to interpret results to the level of an FY1 doctor
- Suggest a management plan for a patient with LBO in the acute setting and understand the basic principles behind ongoing management
Explain structure of session
Total time:
60 minNumber of students:
2-6Grade of students:
3rd to 5th year medical studentsCreated by:
Dr Emma SewartUploaded:
15th October 2019Last updated:
15th October 2019Resources needed for this session:
Resources needed for this session:
Patient, pen, paper
Students can scan the QR code opposite to view all investigation results on their phone as you work through the session.
Resources linked to this session:
Resources linked to this session:
Activity 1: History Taking and Examination
20 minActivity 1: History Taking and Examination
Ask the student(s) to take a focussed history from the patient, observed by the others and tutor if possible. Include past medical and surgical history, drug history, family history and social history. Ask a different student(s) to then perform a focussed examination. This should be observed by tutors if possible. Brief feedback on examination (<1min)
Activity 2: Diagnostic Reasoning
10 minActivity 2: Diagnostic Reasoning
Ask the student(s) to present key findings of the case. Discuss:
- What is the most likely diagnosis and why?
- What are the important differentials and why are these less likely?
- What investigations would be useful acutely and why?
- What are the commonest causes of this presentation?
Activity 3: Blood Gas Interpretation
5 minActivity 3: Blood Gas Interpretation
Review blood gas results from the patient if possible. If none are available, use the example opposite. Discuss the results.
Prompts for discussion:
- Is there a pH disturbance?
- Is this likely a metabolic or respiratory disturbance?
- What is the likely pathological process underlying this?
- How would this result influence your management?
Arterial Blood Gas Results Example
pH 7.31 (7.35 – 7.45)
PaO2 12.2kPa (10.0 – 13.1)
PaCO2 3.5kPa (4.9 – 6.1)
HCO3 31mM (22 – 28)
Lac 4.7mM (<2.0)
Activity 4: Investigations
5 minActivity 4: Investigations
Review the patients abdominal x-ray. If none are available, use the image opposite.
- Discuss common AXR findings in large bowel obstruction.
- How would you differentiate large vs. small bowel on AXR?
Activity 5: Advanced Imaging
minActivity 5: Advanced Imaging
Discuss the gold standard imaging modality for large bowel obstruction and its pros and cons.
If possible review the patients abdominal CT or the stack available online via the link below. Ask students to identify key anatomy:
- Liver
- Stomach
- Pancreas
- Spleen
- Kidneys
- Small bowel
- Large bowel
- Any key pathology!
Alternatively, review CT image opposite. What is the key pathology?
(yellow * : dilated caecum; blue dotted line: enhancing mass in sigmoid colon)
Work through an interactive CT image via this link.
Activity 7: Further Management
10 minActivity 7: Further Management
Review the acute management of unwell patient with LBO (if not already done).
Discuss the definitive management of large bowel obstruction secondary to colorectal cancer.
Consider the following points:
- What are the different operative and non-operative management options?
- What factors might influence the choice of management in the acute setting?
- What will be the next steps for this patient (staging, MDT, further surgery (or not) etc.)
Summary and Feedback
5 minSummary and Feedback
Questions
Identify and summarise key learning points (key three points if possible)
Feedback to student – highlight further learning needs
Feedback for teacher - ask students to provide feedback using the QR code opposite
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