GIS-K-26

INTESTINAL OBSTRUCTIONSyahbuddin Harahap

Division of Digestive Surgery

Department of Surgery

Faculty of Medicine University of North Sumatera Faculty of Medicine University of North Sumatera

Adam Malik Hospital

DEFINITION

• Bowel /Intestinal obstruction occurs when the normal

propulsion and passage of intestinal contents does not

occur

BO can involve:

– SBO � Small intestine– SBO � Small intestine

– LBO � Large intestine

– Generalized Ileus

via systemic alterations

involving both the small and large intestine

�Etiopathogenesis

- Mechanical obstruction

- Non mechanical (Functional ) obstruction

Mechanical obstruction (Dynamic ) ileus refers to a lack

of passage due to an “obstruction of the bowel”,

which can be located anywhere in the bowelwhich can be located anywhere in the bowel

Non mechanical Obstruction (Paralytic )(adynamic)

(Fungsional) ileus

Paralytic ileus refers to a lack of passage due to

“paralysis of the bowel”

Intestinal /Bowel Obstruction can also be classified according to :

�Time of presentation and duration of obstruction:- Acute- Chronic

�The extent of obstruction-Partial-Complete-Complete

�The type of obstruction-Simple-Closed-loop-Strangulation

Nonmechanical Obstruction�Paralytic (adynamic) (Fungsional) ileus due to :1. After abdominal operations 2. Inflammation �Peritonitis

3. Systemic disorders e.g. sepsis, hyponatremia, hypokalemia,

hypomagnesemia

4. Retroperitoneal disorders e.g. ureter, spine fractures ,

hematoma

5. Thoracic conditions e.g. pneumonia, rib fractures5. Thoracic conditions e.g. pneumonia, rib fractures

6. Drugs e.g opiates, psychotropics , General anesthesie

� Pseudo-ObstructionImbalance in the parasympathetic and sympathetic influences

on Colonic motility.

Acute colonic pseudo-obstruction, also known as Ogilvie

syndrome.

MECHANICAL OBSTRUCTION

at each age group

• Neonate

Congenital atresia

Volvulus neonatum

Meconeum ileus

Hirschsprung”s disease

Imperforate anus

• Middle ageAdhesesion and band

Strangulated Ing.hernia

Strangulated fem.hernia

Imperforate anus

• Infant

Stranggulated inguinal hernia

Intussuception

Complication of Meckel”s diverticulum

Hischsprung”s diseases

• Young adult

Adhesions and bands

Strangulated ing.hernia

Carcinoma colon

Volvulus

• ElderlyAdhesion and bandsStrangulated Ing.herniaStrangulated fem.herniaCarcinoma colonVolvulusImpacted faeces

Incidence Mechanical Obstruction

• May occur at any age

• 70 percent small bowel obstruction (SBO)

• 30 percent large bowel obstruction (LBO)

Common Causes SBO

Adhesion 60%

Neoplasma 20%

Hernia 10%

Crohn 5%

Common Causes of LBO

Colon cancer 65 %

Diverticulitis 20 %

Volvulus 5 %

Miscellaneous 10 %Crohn 5%

Miscellaneus 5%

Miscellaneous 10 %

Etiology?

• Extrinsic (Outside the wall )

• Intrinsic (Inside the wall )• Intrinsic (Inside the wall )

• Inside the lumen

Extrinsic (Outside the wall)

• Adhesions

• Hernia

-- inguinal, femoral, umbilical

• Neoplastic

– extraintestinal neoplasm

• Volvulus (sigmoid, cecal)

Intrinsic (Inside the wall )

• Congenital

– Malrotation

• Neoplastic

– Primary neoplasms

– Metastatic neoplasms– Metastatic neoplasms

• Inflammatory

– Crohn's disease

• Miscellaneous

– Intussusception

– Radiation

Intraluminal (Inside the lumen)

• Gallstone

• Enterolith

• Bezoar

• Foreign body

• Parasit �Bolus Ascaris

Clinical Picture

Mechanical obstruction

The classic quartet

1. Colicky abdominal pain

2. Abdominal distension2. Abdominal distension

3. Nausea and Vomiting

4. Decreased passage of stool or flatus

PathophysiologyDependent upon :

1. Degree of obstruction

2. Duration of obstruction

3. Presence and severity of ischaemia

Result in :

1. Accumulation of fluid and air(Sequestration within the dilated

loop)loop)

Fluid disturbances massive third space losses

8 – 10 L of fluid are secreted

Hypovolumic shock oliguria, hypotension,hemoconcentration

2. Electrolyte depletion3. Bacterial overgrowth �Rapid colonisation

-Maximal by 24 hrs after obstruction

-Bacterial translocation to node and portal system

4. Bowel distension

-Chest compression by pushing up diaghragma muscle

-Decreases the ability mucosa to absorb ,stasis intestinal content

of fluids and electrolytes-Increased intraluminal pressure � oedematous� cyanosis�

intraperitoneal exudation �necrosis �perforation�peritonitis

-ACS � impediment in venous return�arterial insufficiency

5. LBO5. LBO

Ileocaecal valve plays prominent role in pathophysiology of LBO.

If competent valve = Closed loop obstruction

In 10 – 20 % of individual ICV incompetentCaecal around 10 – 12 cm � the risk of perforation

Clinical Manifestations

Altered mental state

Vital Sign

Hypovolumic shock

TachicardiaTachicardia

Hypotension

Tachipnoe

Fever

Oliguria

Abdominal Examination

Patient �Supine position with the legs flexed at the hip

Abdominal Colicky pain The periodicity of pain:

3 to 4 minutes pain from proximal intestinal obstruction

15 to 20 minutes pain from distal small bowel or colon

On Inspection

Abdominal distensionAbdominal distension

Proximal obstructions may cause little or no distention

Distended small bowel loops usually occupy the central

abdomen Distended large bowel loops are typically seen

around the periphery .

Visible peristalsis which are indicative of acute small bowel

obstructionAbdominal Scars � Adhesion

On AuscultationPerformed for at least 3 to 4 minutes

�Metallic sound

�Borborygmi

�The absence of bowel tones :

Is typical of intestinal paralysis .

Late�Quiet abdomen (may also indicate Late�Quiet abdomen (may also indicate

intestinal fatigue from long-standing

obstruction).

On PalpationInguinal ,Femoral , Umbilical ,Incisional HerniasPalpable mass Abdominal asymmetry or a protruding mass

suggests an underlying malignancy, an abscess, or closed-loop

obstruction.

Peritoneal irritation

On PercussDull � Fluid or MassDull � Fluid or Mass

Tympanic � Air (Intraluminal or not )

Peritoneal irritation

DRE (Digital Rectal Examination )

For Mass , Impacted faeces

Vomiting – NG Aspirates

Consists� food and gastric chyme� bile �faeculent

�GOO � Clear , food and gastric chyme�Mid to distal SBO � Bilious/Bile�Distal SBO to LBO � Feculent

Mechanical Obstruction Nonmechanical Obstruction

Abdominal

Pain

colicky pain severity may decrease over time as a

result of bowel fatigue and atony.

3 to 4 minutes from proximal SBO

15 to 20 minutes distal SBO or LBO

Diffuse , usually mild

Inspection Abdominal distension

Visible peristalsis

Abdominal distension

Auscultation Metalic Sound Quiet abdomen

Borborygme

Late � Quiet Abdomen

Abd.X Ray

Erect

Supine

Large small intestinal loops

gas less in colon

Step ladder A/F levels

Gas diffusely through

intestine, incl. colon

May have large diffuse A/F

levels

Barium

Enema

Obvious transition point on contrast study No obvious transition point

on contrast study

Exudate No peritoneal exudate Peritoneal exudate if

peritonitis

Fluid resuscitation

HYPOVOLEMIC SHOCK <-> ARF

ACUTE RENAL FAILURE

• PRERENAL

• INTRARENAL

• POSTRENAL

ARF : OLIGURIA < 500 ML/d

SERUM CREATININ > 3MG/dL

TREATMENT PRE RENAL ARF

• INITIAL FLUID THERAPY

� RESPON TO URINARY OUTPUT � 0,5 – 1 cc /kg bw

� Return of normal vital sign but NO RESPON TO URINARY OUTPUT � OLIGURIA

CVP ------CVP 8-12 cm of water (or 10-15 cm of water in mechanically

ventilated patients).ventilated patients).

VC RENAL VASCULATURE

TREATMENT

• DIURESIS --� FUROSEMIDE 80-200 MG IV/TWD

• INOTROPIC AGENTS �LOW DOSE DOPAMIN /DOBUTAMIN 0,5 -3 ug/kg bw/min

VD RENAL VASCULATURE

INCREASE MYOCARDIAL CONTRACTILITY

EVALUATION OF FLUID RESUSCITATION

• RETURN OF NORMAL VITAL SIGNS

• MENTAL STATUS

• URINARY OUTPUT

• ACID/BASE BALANCE• ACID/BASE BALANCE

• CVP

Diagnoctic Studies

�Laboratory test• Fecal Occult Blood Test

• CBC

• Serum electrolyte concentrations

• The serum creatinine concentration / BUN• The serum creatinine concentration / BUN

• The coagulation profile

• Urinalysis should be done to check for hematuria

• Liver function profile

�Sigmoidoscopy

Exclude a rectal or distal sigmoid obstruction.

�Imaging / X ray examination

�Chest x-ray Exclude a pneumonic process To look for subdiaphragmatic air.

�Plain abdominal X ray Erect and lying down � routinely

�Water soluble enema to exclude �Water soluble enema to exclude colonic obstruction.

Colonic pseudo obstuctionLBO + incompetent ileocecal thereby mimicking small bowel obstruction.

Barium enema X ray transition point on contrast study

bent inner tube = Coffe bean” appearance “Bird Beak “

SIGMOID VOLVULUS

Management of Bowel Obstruction

Principles• Fluid resuscitation

Requirements = Deficit + Maintenance + Ongoing losses

• Close monitoring hemodinamic

– Foley catheter� urine output

– CVP

• Electrolyte, acid-base correction

• NGT decompression

• Antibiotics

• Diagnostic study

• Informed concent

• Exploratory laporotomy