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Bowel obstruction

Clinical Discipline(s)/Organ System(s)
Digestive System, Gastroenterology & Hepatology, General Surgery
Progress Test Topic(s)
Digestive, Seriously ill patient
Description
A 68 year old NZ European/Māori man presents to the Accident and Medical Centre with vomiting and abdominal distension. He has also noted that his bowels have not moved for 4 days and he is not passing wind.
Applied Science for Medicine 
   - Anatomy of the abdomen and pelvis
   - Pathophysiology of bowel obstruction
   - Genetics of colorectal malignancy
   - Progression of cancer: pre-cancerous to cancer to metastatic disease
   - Mechanisms and controls of vomiting and peristalsis
   - Pharmacology of metoclopramide, domperidone, ondansetron and scopolamine
Clinical and Communication Skills 
   - Elicit a history from a patient with vomiting; include relevant questions for underlying GI tract malignancy
   - Perform and record an examination of the abdomen, including genitalia, hernial orifices and rectal examination. Recognise peritonism, surgical scars and bowel obstruction
   - Indications for CT abdomen, abdominal ultrasound
   - Interpret abdominal X-ray, full blood count, electrolytes, creatinine, liver function tests, coagulation screen, erect chest X-ray
   - Differential diagnosis of vomiting and absolute constipation
   - Stage colorectal cancer using Dukes criteria and TNM system; its impact on survival and treatment
   - Perform a nasogastric tube insertion
   - Management of bowel obstruction: conservative, endoscopic and surgical, including assessment and management of perioperative anaesthetic risks
   - Management of colorectal cancer: surgical, oncological and palliative approaches
   - Understand the different types of stoma, their special care and where they are placed. Role of the stoma nurse
Personal and Professional Skills 
   - Consent for intimate examination and use of chaperone
   - Delivering life-changing news
   - Empathise with patients with cancer
   - Ethical and legal issues related to the use of genetic information for the individual and family/whānau
Hauora Māori 
   - Consideration of patient and whānau needs with regards to ‘breaking bad news
   - Understanding of inequities in bowel cancer outcomes for Māori compared with non-Māori, and application of this to clinical decision making and management
   - Understanding of inequities in access to cancer services and quality of medical care for Māori, and application of this to clinical decision making and management
   - Acknowledgement of the disproportionate impact of illness on whānau employment/income, and therefore availability and models of caregiving
Population Health 
   - Epidemiology of colorectal cancer in New Zealand
   - Screening programmes for colorectal cancer including analysis of risks and benefits
Conditions to be considered relating to this scenario
Common
adhesions, abdominal hernias, volvulus, colorectal cancer, Crohn's strictures, perforated viscus, peptic ulcer disease, diverticulitis, ileus, pseudo-obstruction
Less common but 'important not to miss'
closed loop obstruction, intra-abdominal sepsis, systemic sepsis
Uncommon
intussusception, pyloric stenosis, superior mesenteric artery syndrome