RT Book, Section A1 Engels, Paul T. A1 Tremblay, L. N. A2 Hall, Jesse B. A2 Schmidt, Gregory A. A2 Kress, John P. SR Print(0) ID 1107711666 T1 Jaundice, Diarrhea, Obstruction, and Pseudoobstruction T2 Principles of Critical Care, 4e YR 2015 FD 2015 PB McGraw-Hill Education PP New York, NY SN 9780071738811 LK accesssurgery.mhmedical.com/content.aspx?aid=1107711666 RD 2024/10/04 AB Jaundice (hyperbilirubinemia) is seen in critically ill patients and can occur due to prehepatic, intrahepatic, or posthepatic causes.Biliary obstruction and acalculous cholecystitis are two common surgical problems requiring urgent intervention.For acalculous or calculous cholecystitis, cholecystectomy removes the inflamed and ischemic gallbladder and prevents recurrence and thus is preferred in those able to tolerate the procedure. A cholecystostomy tube is indicated for nonsurgical candidates.Diarrhea commonly occurs in critical illness (up to 60% of those on enteral feeds) and may be related to infection, medications, malabsorption, composition of the enteral feeds, or gastrointestinal disease.Clostridium difficile should be ruled out as the cause of diarrhea in the ICU or any patient with risk factors (particularly antibiotics or contact) as morbidity and mortality increase with delay in treatment.Fulminant Clostridium difficile can present as an ileus or with diarrhea in a toxic patient, and is associated with high mortality and frequent need for surgical intervention.Studies are ongoing to determine the optimal medical and surgical management of Clostridium difficile. Currently for severe cases enteral vancomycin plus intravenous metronidazole is suggested ± subtotal colectomy or ileostomy with colon lavage.Bowel obstruction should be ruled out prior to managing as pseudoobstruction.Commonest causes of adult small bowel obstruction are adhesions and hernia, whereas commonest causes of adult large bowel obstruction are colon cancer, sigmoid volvulus, and stricture from diverticulitis.Pseudoobstruction (nonmechanical obstruction) is managed by resuscitation, removing or limiting precipitants, using nasogastric or rectal tubes to relieve overdistension, and occasional endoscopic decompression or use of neostigmine in appropriate patients.