Bowel ObstructionsMaingot's Abdominal Operations, 11th EditionOleh:Diah Anis Naomi, S.KedDicky Aditya Dwika, S.KedFadia Nadila, S.KedMaradewi Maksum, S.Ked

DEFINITIONBowel obstruction occurs when the normal propulsion and passage of intestinal contents does not occur

Involving the small intestine, the large intestine, or generalized.

Caused by physical blockage of the intestinal lumenIneffective motility without any physical obstruction

Lesions Extrinsic to the Intestinal WallLesions Intrinsic to the Intestinal WallADHESIONS:Post-operative, Congenital, Post-inflammatoryCONGENITAL:Intestinal atresia, Meckels diverticulum, duplicationsHERNIA:H. External abdominal wall, H. Internal, H. IncisionalINFLAMMATORY:Chrons disease, eosinophilic granulomaCONGENITAL:Annular pancreas, malrotation, Omphalomesenteric duct remnantINFECTIONS:Tuberculosis, actinomycosis, complicated diverticulitisNEOPLASTIC:Carcinomatosis, Extraintestinal neoplasmNEOPLASTIC:Primary or metastatic neoplasms, appendicitisINFLAMMATORY:Intra-abdominal abscess, Starch peritonitisMISCELLANEOUS:Intussusception, endometriosis, radiation stricture, intramural hematoma, ischemic strictureMISCELLANEOUS:Volvulus, Gossypiboma, Superior mesentric artery syndromeINTRALUMINAL/OBTURATOR OBSTRUCTION:Gallstone, enterolith, phytobezoar, parasite infestaion, swallowed foreign body

Intra-Abdominal CausesExtra-Abdominal CausesINTRAPERITONEAL PROBLEMS:peritonitis, intra-abdominal abscess, post-operative , chemical (gastric juice, bile, blood), Autoimmune (Serositis, vasculitis) & Intestinal ischemia (arterial or venous, sickle cell disease)METABOLIC ABNORMALITIES:Electrolyte imbalance, sepsis, lead poisoning, porphyria, hyperglicemia, hypothiroidsm, uremiaRETROPERITONEAL PROBLEMS:Urolithiasis, pyelonefphritis, metastasis, pancreatitis, retroperitoneal traumaTHORACIC PROBLEMS:Myocardial infarction, congestive heart failure, pneumonia, thoracic traumaMEDICINES:opiates, anti-cholinergic, alpha-adrenergik agonists, antihistaminesMISCELLANEOUS:Spinal cord injury, pelvic fracture, head trauma, chemotherapy, radiation therapy, renal transplantation

PathophysiologyDISTENTION, ABSORPTION & SECRETIONINTESTINAL MOTILITYCIRCULATORY CHANGESMICROBIOLOGY & BACTERIAL TRANSLOCATIONHowever, the pathophysiology remains unclear.

Distention, Absorption, and SecretionNitrogenFermentation of sugarsproduction of carbon dioxide by interaction of gastric acid and bicarbonates in pancreatic and biliary secretionsdiffusion of oxygen and carbon dioxide from the bloodDistention

Distention, Absorption, and Secretion

Distention, Absorption, and Secretion

Distention, Absorption, and Secretion

Intestinal MotilityIntestinal motility are disruption of the normal autonomic parasympathetic (vagal) and sympathetic splanchnic innervation.

Early phase of bowel obstruction,Intestinal contractile activity increases propel intraluminal contents past the obstruction

Later phase of bowel obstruction,The contractile activity diminishes intestinal wall hypoxia exaggerated intramural inflammation

Circulatory Changes

Microbiology and Bacterial Translocation

in the presence of obstruction, a rapid proliferation of bacterial organisms occurs consisting predominantly of fecal-type organisms. reaching a plateau of 1091010 colonies/mL after 1248 hours of an established obstruction.

Bacterial toxins have an important role in the mucosal response to bowel obstruction.

Diagnosis

History and Physical ExaminationHistory

Physical Examination

Laboratory

RadiologicFlat & upright (supine) abdominal radiographs

Computed Tomography

CT findings diagnostic of bowel obstruction include intestinal loops greater than 25 mm in diameter and a transition zone between dilated and collapsed bowel loops.

Ultrasonographythe intestinal loops measure more that 25 mm in diameter and the distal ileum is found to be collapsed. US is less accurate than CT, except in cases of intraluminal obstructions.

ManagementSmall Bowel

NON-OPERATIVEFor uncomplicated small bowel obstruction

Contraindications:suspected ischemia, large bowel obstruction, closed-loop obstruction, strangulated hernia, and perforation

When to convert into operative management?Uncomplicated obstruction turns into complicated obstruction.

SIGNSfever, tachycardia, leukocytosis, localized tenderness, continuous abdominal pain, and peritonitis.

OPERATIVE

Large BowelRequire prompt surgical intervention and should not undergo a trial of nonoperative management

Resuscitate aggressively with an isotonic crystalloid solutionElectrolyte correctionNasogastric decompression

to decrease the amount of air and gastric contents delivered to the bowel.

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