28438747 Intestinal Obstruction

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    INTESTINALOBSTRUCTION

    MSU Medical Students.

    Batch 2.Group 2.

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    CONTENTS

    Definition

    Introduction

    Etiologies

    Categories Pathophysiologiy

    Clinical Manifestation

    Investigations

    Treatment

    Complication

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    Definition

    Intestinal obstruction is a partial or completeblockage of the bowel caused by whether

    mechanical or functional obstruction of the

    intestines that results in the failure of theintestinal contents to pass through.

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    Introduction

    Mechanical obstruction is divided into:

    a) Obstruction of the small bowel (includingthe duodenum) and

    b) Obstruction of the large bowel.

    Obstruction may be partial or complete.

    a) About 85% ofpartial small-bowelobstructions resolve with non-operative

    treatment, whereasb) About 85% ofcomplete small-bowel

    obstructions require operation.

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    Etiologies

    Overall, the most common causes ofmechanical obstruction are adhesions,

    hernias, and tumors.

    Other general causes are diverticulitis, foreign

    bodies (including gallstones), volvulus

    (twisting of bowel on its mesentery),

    intussusception (telescoping of one segment

    of bowel into another and fecal impaction.

    Specific segments of the intestine are affected

    differently.

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    Aetiologies

    LOCATION CAUSES

    Colon Tumors (usually in left colon)

    Diverticulitis (usually sigmoid)

    Volvulus (sigmoid or cecum)

    Fecal impaction

    Hirschprung's disease

    Duodenum Adult Cancer of duodenum

    Cancer of head of pancreas

    Ulcer disease

    Neonates Atresia

    Volvulus Bands

    Annular pancreas

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    LOCATION CAUSES

    Jejunum and Ileum Adult Hernias

    Adhesions (common)

    Tumors Foreign body

    Meckel's diverticulum

    Crohn's disease (uncommon)

    Ascaris infestation

    Midgut volvulus

    Intussusception by tumor (rare)

    Neonates Meconium ileus

    Volvulus of malrotated gut

    Atresia

    Intussusceptiom

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    Categories

    Complete or Partial

    Mechanical versus Functional

    Small versus Large intestine Acute, Sub-Acute, Chronic

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    Mechanical vs. Functional

    A. Mechanical

    1. Extraluminal: adhesions (bands of scartissue), hernias, volvulus (twisted bowel),tumours.

    2. Intramural: tumors, IBD (e.g Crohns),strictures, paralytic, intussusception(telescoping bowel)

    3. Intraluminal (partial or complete): foreignbodies, fecal impaction, gallstones,bezoars, worms

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    Mechanical vs. FunctionalB. Functional Paralytic Ileus

    Failure of peristalsis to move intestinal contents:adynamic ileus (paralytic ileus, ileus) due to neurologic ormuscular impairment

    Accounts for most bowel obstructions

    Causes includea. Post gastrointestinal surgery

    b. Tissue anoxia or peritoneal irritation fromhemorrhage, peritonitis, or perforation

    c. Hypokalemia

    d. Medications: narcotics, anticholinergic drugs,antidiarrheal medications

    e. Spinal cord injuries, uremia, alterations in electrolytes

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    Pathophysiology

    1) In simple MECHANICAL obstruction, blockage occurs

    without vascular compromise.

    2) Ingested fluid and food, digestive secretions, and gas

    accumulate above the obstruction.

    3) The proximal bowel distends, and the distal segment

    collapses.

    4) The normal secretory and absorptive functions of the

    mucosa are depressed, and the bowel wall becomes

    edematous and congested.5) Severe intestinal distention is self-perpetuating and

    progressive, intensifying the peristaltic and secretory

    derangements and increasing the risks of dehydration

    and progression to strangulating obstruction.

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    6) Strangulating obstruction is obstruction with

    compromised blood flow; it occurs in nearly 25% of

    patients with small-bowel obstruction.

    7) It is usually associated with hernia, volvulus, and

    intussusception.

    8) Strangulating obstruction can progress to infarction and

    gangrene in as little as 6 h.9) Venous obstruction occurs first, followed by arterial

    occlusion, resulting in rapid ischemia of the bowel wall.

    10) The ischemic bowel becomes edematous and infarcts,

    leading to gangrene and perforation.11) In large-bowel obstruction, strangulation is rare (except

    with volvulus).

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    12) Perforation may occur in an ischemic segment (typically

    small bowel) or when marked dilation occurs.

    13) The risk is high if the cecum is dilated to a diameter 13

    cm.

    14) Perforation of a tumor or a diverticulum may also occur

    at the obstruction site.

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    Pathophysiology

    COLICKY PAIN due to excessive contraction PROXIMAL DISTENSION due to accumulation

    of fluid, gas

    Impaired absorption of fluid and electrolyte -DEHYDRATION

    SEPSIS - bacterial overgrowth due to stasis

    Impairment of venous & arterial flow -STRANGULATION, INFARCTION,

    PERFORATION

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    Clinical Features

    Colicky low abdominal

    pain

    Vomiting

    Abdominal distension

    Absolute constipation

    Others - dehydration,

    fever, tachycardia,

    oliguria, hypotension,

    peritonism

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    Manifestations Small Bowel Obstruction

    a. Vary depend on level of obstruction and speed ofdevelopment

    b. Cramping or colicky abdominal pain, intermittent,intensifying

    c. Vomiting

    1. Proximal intestinal distention stimulates vomiting

    center2. Distal obstruction vomiting may become feculent

    d. Bowel sounds

    1. Early in course of mechanical obstruction: borborygmiand high-pitched tinkling, may have visible peristaltic

    waves2. Later silent; with paralytic ileus, diminished or absent

    bowel sounds throughout

    e. Signs of dehydration

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    Manifestation Large Bowel Obstruction

    a. Only accounts for 15% of obstructions

    b. Causes include cancer of bowel, volvulus,

    diverticular disease, inflammatory disorders,

    fecal impaction

    c. Manifestations: deep, cramping pain; severe,

    continuous pain signals bowel ischemia and

    possible perforation; localized tenderness or

    palpable mass may be noted

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    Investigation

    FBC Electrolytes and Urea

    Plain supine AXR - dilated SB, central, valvulae

    coniventes, air fluid level Contrast X-rays barium/gastrograffin follow-

    through/enema

    CT scan with oral contrast

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    Treatment 1 - Resuscitation

    NBM

    Fluid replacement - IV fluid

    IV antibiotic Correction of electrolyte imbalance

    Nasogastric suction

    Monitoring - vital signs, fluid balance Adequate analgesia

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    Treatment 2 - Surgery

    Indications Non-resolving or failure of conservative treatment

    Perforation / peritonitis

    Underlying disease e.g hernia, crohns, tumour

    Avoid in obstruction due to adhesions

    High mortality in poorly resuscitated patients

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    Treatment 3 Resuscitation

    Surgerya. Laparotomy

    b. Hemicolectomy- Right / extended right / left

    c. Sigmoid colectomy

    d. Anterior resection

    e. Abdominoperineal resection

    f. Hartmanns procedure

    g. Colostomy

    Staged laparotomy

    1, 2 or 3-stage procedures

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    Complications

    a. Hypovolemia and hypovolemic shock can

    result in multiple organ dysfunction (acuterenal failure, impaired ventilation, death)

    b. Strangulated bowel can result in gangrene,

    perforation, peritonitis, possible septic shockc. Delay in surgical intervention leads to higher

    mortality rate

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    SBO

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    SBO

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    SBO

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    Intussusception Volvulus

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    Large-bowel obstruction. This

    chest radiograph demonstratesfree air under the diaphragm,

    indicating bowel perforation.

    Abdominal (KUB) film of a patient

    with obstipation. Dilation of the colon

    is associated with large-bowel

    obstruction.

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    Large-bowel obstruction.

    Gastrografin study in a patient

    with obstipation reveals

    colonic obstruction at the

    rectosigmoid level.

    Large-bowel obstruction. Contrast

    study demonstrates colonic

    obstruction at the level of the splenic

    flexure, in this case due to carcinoma.

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    Large-bowel obstruction.

    Abdominal (KUB) radiograph

    depicting massive dilation of

    the colon due to a cecal

    volvulus.

    Large-bowel obstruction.

    Contrast study of patient with

    cecal volvulus. The column of

    contrast ends in a "bird's beak"

    at the level of the volvulus.

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    Large-bowel obstruction.

    Massive dilation of the

    colon due to a sigmoid

    volvulus.

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    References

    1. Merck Manual Professional

    2. eMedicine (http://emedicine.medscape.com)

    3. MedlinePlus (http://medlineplus.gov)