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Intestinal ObstructionIntestinal Obstruction

Dr Bina RaviDr Bina RaviAssociate Professor and ConsultantAssociate Professor and Consultant

Department of SurgeryDepartment of Surgery

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Abdomen- Bowel sound Abdomen- Bowel sound

Present- Present- Mechanical obstructionMechanical obstruction

Not present-Not present- Adynamic obstructionAdynamic obstruction

(no gas under diaphragm)(no gas under diaphragm) Perforation Perforation

(gas under diaphragm)(gas under diaphragm)

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ObjectivesObjectives

Pathophysiology – dynamic, adynamicPathophysiology – dynamic, adynamic Cardinal features – history, Cardinal features – history,

examinationexamination Causes – small, large gut obstructionCauses – small, large gut obstruction Indications – contraindications for Indications – contraindications for

conservative Mxconservative Mx

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ObstructionObstruction

Dynamic – peristalsis, mechanical Dynamic – peristalsis, mechanical obstructionobstruction

Adynamic- paralytic ileus, non Adynamic- paralytic ileus, non propulsive Mesenteric vascular propulsive Mesenteric vascular obstruction or, pseudo obstructionobstruction or, pseudo obstruction

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Dynamic ObstructionDynamic Obstruction

Pain, distention, vomiting, absolute Pain, distention, vomiting, absolute constipationconstipation

Two- small gut – high , lowTwo- small gut – high , low Large gut Large gut Acute , chronic, acute on chronic or, Acute , chronic, acute on chronic or,

sub-acutesub-acute Simple – intact vascularitySimple – intact vascularity Strangulated – compromised vascularityStrangulated – compromised vascularity

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Intestinal obstruction: Intestinal obstruction: CausesCauses

Adhesion

Inflammatory

Carcinoma

Obstructedhernia

Fecalobstruction

Pseudoobstruction

Misc

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Causes –Dynamic obstructionCauses –Dynamic obstruction

Intra-luminal –impaction, FB, Bezoars, Intra-luminal –impaction, FB, Bezoars, gallstonesgallstones

Intramural- strictures, malignancyIntramural- strictures, malignancy

Extra-luminal- bands/adhesions, hernia, Extra-luminal- bands/adhesions, hernia, volvulus, intussusceptionvolvulus, intussusception

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Adynamic obstruction-causesAdynamic obstruction-causes

Paralytic ileusParalytic ileus

Mesenteric vascular occlusionMesenteric vascular occlusion

Pseudo obstructionPseudo obstruction

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PathophysiologyPathophysiology Proximal gut dilates- altered motilityProximal gut dilates- altered motility Below the obstruction – normal motility, Below the obstruction – normal motility,

immobileimmobile Proximal – increased peristalsis, dilates, Proximal – increased peristalsis, dilates,

reduced peristalsis, flaccidreduced peristalsis, flaccid Gas- bacteria. Aerobic/anaerobic, 90% N2Gas- bacteria. Aerobic/anaerobic, 90% N2 Fluid- dig. JuicesFluid- dig. Juices,,

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PathophysiologyPathophysiology

Dehydration and electrolyte imbalanceDehydration and electrolyte imbalance Reduced intakeReduced intake Defective absorptionDefective absorption VomitingVomiting Sequestration in gutSequestration in gut

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StrangulationStrangulation

Blood supply compromisedBlood supply compromised Venous return first affected, arterialVenous return first affected, arterial Hemorrhagic infarctionHemorrhagic infarction Translocation and systemic exposure Translocation and systemic exposure

to microbes/ toxinsto microbes/ toxins Morbidity/ mortality- age, extent, Morbidity/ mortality- age, extent,

Peripheral vascular failurePeripheral vascular failure

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Closed loop obstructionClosed loop obstruction

StrangulationStrangulation DistentionDistention NecrosisNecrosis perforationperforation

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Acute Intestinal Obstruction-CPAcute Intestinal Obstruction-CP

Location, age of obstruction, Location, age of obstruction, pathology, ischemiapathology, ischemia

PainPain VomitingVomiting DistensionDistension ConstipationConstipation Dehydration, Hypokalemia, fever, Dehydration, Hypokalemia, fever,

abdomen tendernessabdomen tenderness

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PainPain – severe, colicky, umbilical, lower – severe, colicky, umbilical, lower abdomenabdomen

Increases with peristalsis, later reducesIncreases with peristalsis, later reduces Severe pain - strangulationSevere pain - strangulation

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VomitingVomiting

High obstruction- violent High obstruction- violent

Low obstruction- slow onset Low obstruction- slow onset nausea/vomitnausea/vomit

Gradually digestive food changes to Gradually digestive food changes to feculent materialfeculent material

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DistensionDistension Greater if distal obstructionGreater if distal obstruction

Visible peristalsisVisible peristalsis

Peristalsis delayed in colonic obstructionPeristalsis delayed in colonic obstruction

Absent in Mesenteric vascular obstructionAbsent in Mesenteric vascular obstruction

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ConstipationConstipation

AbsoluteAbsolute

RelativeRelative

Absent in – Richter’s hernia, gallstone, Absent in – Richter’s hernia, gallstone, MVO, Pelvic abscess, partial MVO, Pelvic abscess, partial obstructionobstruction

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DehydrationDehydration

Vomiting, fluid sequestrationVomiting, fluid sequestration

Dry skin, poor venous filling, sunken Dry skin, poor venous filling, sunken eyes, oliguriaeyes, oliguria

Raised blood urea, Hb, - secondary Raised blood urea, Hb, - secondary polycythemiapolycythemia

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HypokalemiaHypokalemia

K, amylase, LDH – strangulation, raised K, amylase, LDH – strangulation, raised TLC or, leucopeniaTLC or, leucopenia

Fever – indicates – ischemia, Fever – indicates – ischemia, perforation, inflammationperforation, inflammation

Hypothermia – septic shockHypothermia – septic shock

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Abdomen tendernessAbdomen tenderness

Localized – ischemiaLocalized – ischemia

Peritonitis – infarction or, perforationPeritonitis – infarction or, perforation

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StrangulationStrangulation

Diagnosis is clinicalDiagnosis is clinical Features of obstructionFeatures of obstruction Persistent pain, Shock, local tendernessPersistent pain, Shock, local tenderness Non-responsive to conservative MxNon-responsive to conservative Mx Hernia strangulation – tender, irreducible, Hernia strangulation – tender, irreducible,

absent cough impulse, recent increase in absent cough impulse, recent increase in sizesize

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RadiologyRadiology

Supine/ erect plain abdomen filmsSupine/ erect plain abdomen films Small gut-Small gut- central, transverse, no gas- central, transverse, no gas-

coloncolon JejunumJejunum- valvulae connivantes- valvulae connivantes IleumIleum- featureless- featureless CecumCecum- round gas in RIF- round gas in RIF Large gut-Large gut- haustral folds haustral folds

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Supine Supine

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Sigmoid volvulusSigmoid volvulus

Dilated, no haustral patternDilated, no haustral pattern

Small gut- air and fluid levelsSmall gut- air and fluid levels

More the fluid levels, more distal the More the fluid levels, more distal the lesionlesion

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Inv:Inv:

Plain x ray- impacted foreign bodyPlain x ray- impacted foreign body

Fluid levels – non obstructing Fluid levels – non obstructing conditions – inflammatory bowel conditions – inflammatory bowel disease, acute pancreatitis, abdominal disease, acute pancreatitis, abdominal sepsissepsis

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TreatmentTreatment

3 measures3 measures

Intestinal drainageIntestinal drainage

Fluid and electrolyte replacementFluid and electrolyte replacement

Relief of obstructionRelief of obstruction

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Surgical MxSurgical Mx

Mx of segment at the site of Mx of segment at the site of obstructionobstruction

The distended proximal bowelThe distended proximal bowel

Underlying cause of obstructionUnderlying cause of obstruction

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SupportiveSupportive

NG tube drainageNG tube drainage

Na , water replacementNa , water replacement

AntibioticsAntibiotics

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Large gut Large gut

Ca or diverticular diseaseCa or diverticular disease Contrast study – pseudo-obstructionContrast study – pseudo-obstruction Caecal perforation- caecostomy, Caecal perforation- caecostomy,

ileostomyileostomy

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Adhesions/bandsAdhesions/bands

CommonestCommonest Fibrin – adhesions-fibrinous, fibrousFibrin – adhesions-fibrinous, fibrous Appendectomy , gynaecological op.Appendectomy , gynaecological op. Bands- congenital, bacterial peritonitis, Bands- congenital, bacterial peritonitis,

greater omentum causing bandgreater omentum causing band Mx- conservative – 72 hrs –lap Mx- conservative – 72 hrs –lap

adhesiolysisadhesiolysis

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Special obstructionsSpecial obstructions

Int. herniaInt. hernia – foramen of Winslow, hole in – foramen of Winslow, hole in the mesentery, hole in transverse the mesentery, hole in transverse colon, defects in broad ligament, cong colon, defects in broad ligament, cong diaphragmatic hernia, paraduodenal diaphragmatic hernia, paraduodenal fossae, intraperitoneal fossaefossae, intraperitoneal fossae

Mx- release the ring, reduction of Mx- release the ring, reduction of herniahernia

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Enteric stricturesEnteric strictures

TB, Crohn’s, Ca, lymphomas, TB, Crohn’s, Ca, lymphomas, stricturoplastystricturoplasty

Bolus obstructionBolus obstruction – food, gall stone, – food, gall stone, trichobezoars, phytobezoars, trichobezoars, phytobezoars, stercoliths, wormsstercoliths, worms

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Ac IntussusceptionAc Intussusception

Proximal gut enters distal gutProximal gut enters distal gut Adults – lead point, polyp, submucosal Adults – lead point, polyp, submucosal

lipoma, tumor, lipoma, tumor, Colo-colic – Colo-colic – adultsadults Pathology- inner tube, outer tube, Pathology- inner tube, outer tube,

returning of middle tubereturning of middle tube Strangulating obstruction- ileoileal, Strangulating obstruction- ileoileal,

ileocaecal, ileocolicileocaecal, ileocolic

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Clinical pictureClinical picture

Severe attacks of pain – lasts few Severe attacks of pain – lasts few minutesminutes

Later - red currant jelly stoolLater - red currant jelly stool Exam –between episodes-50-60% Exam –between episodes-50-60%

sausage shaped lump – empty RIF –sausage shaped lump – empty RIF –Sign de DanceSign de Dance

P/R – blood stained fingerP/R – blood stained finger Later vomit, distensionLater vomit, distension

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RadiologyRadiology

Plain film – absent caecal gasPlain film – absent caecal gas Ba enema- claw signBa enema- claw sign CT scanCT scan Mx- Hydrostatic reduction with enemaMx- Hydrostatic reduction with enema Operative reductionOperative reduction Recurrent – 5%- anchorage of ileum to Recurrent – 5%- anchorage of ileum to

ascending colonascending colon

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Differential diagnosisDifferential diagnosis

Acute enterocolitisAcute enterocolitis

Henoch Schoenlein perpuraHenoch Schoenlein perpura

Rectal prolapseRectal prolapse

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VolvulusVolvulus Axial rotation of bowel at its Axial rotation of bowel at its

mesenterymesentery Congenital or secondaryCongenital or secondary Small intestine, caecum, sigmoid-Small intestine, caecum, sigmoid-

commoncommon Small gut- spontaneous, vegetable Small gut- spontaneous, vegetable

consumption – untwistconsumption – untwist Caecal – clockwise- females- lap . Caecal – clockwise- females- lap .

Untwist, resection if gangreneUntwist, resection if gangrene

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SigmoidSigmoid

AnticlockwiseAnticlockwise

Bands, overloaded colon, large Bands, overloaded colon, large mesocolon, narrow pelvic mesocolic mesocolon, narrow pelvic mesocolic attachmentattachment

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TreatmentTreatment

Flexible sigmoidoscopy/ rigidFlexible sigmoidoscopy/ rigid Laparotomy- untwistingLaparotomy- untwisting Viable – fixing to retroperitoneumViable – fixing to retroperitoneum Resection – Paul Mickulikz- gangreneResection – Paul Mickulikz- gangrene Sigmoid colectomy/ Hartmann’s Sigmoid colectomy/ Hartmann’s

procedure later re-anastomosisprocedure later re-anastomosis

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Compound volvulusCompound volvulus

Rare, ile-osigmoid knottingRare, ile-osigmoid knotting

GangreneGangrene

Laparotomy - Decompression, Laparotomy - Decompression, resection and anastomosisresection and anastomosis

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ThanksThanks

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