Git6 obstruction

DR S C GAN FMHS/UTAR 12102012 1

GIT6: OBSTRUCTION

DR GAN SENG CHIEWAssociate Professor

FACULTY OF MEDICINE & HEALTH SCIENCESUNIVERSITY TUNKU ABDUL RAHMAN


Intestinal Obstruction

An obstruction may occur anywhere along the small or large intestine and can be partial or complete. The part of the intestine above the obstruction continues to function. This part of the intestine enlarges as it fills with food, fluid, digestive secretions, and gas. The intestinal lining becomes swollen and inflamed. If the condition is not treated, the intestine can rupture, leaking its contents and causing inflammation and infection of the abdominal cavity (peritonitis).


Causes • Birth defect in newborns and babies.• In adults, internal scar tissue from previous

abdominal surgery (adhesions), parts of the intestine bulging through an abnormal opening (hernias), and tumors.

• An obstruction of the duodenum may be caused by cancer of the pancreas; scarring from an ulcer, a previous operation, or Crohn's disease; or adhesions. Rarely, a gallstone, a mass of undigested food, or a collection of parasitic worms may block the intestine.

• An obstruction of the large intestine is commonly caused by cancer, diverticulitis, or a hard lump of stool (fecal impaction). Adhesions and volvulus are less common causes of large intestine obstruction.


What Causes Intestinal Strangulation?

Intestinal strangulation (cutting off of the blood supply to the intestine) usually results from one of three causes.

Strangulation occurs in nearly 25% of people with small-intestinal obstruction. Usually, strangulation results when part of the intestine becomes trapped in an abnormal opening (strangulated hernia); volvulus; or intussusception. Gangrene can develop in as few as 6 hours. With gangrene, the intestinal wall dies, usually causing rupture, which leads to peritonitis, shock, and, if untreated, death.


Symptoms and Diagnosis • Intestinal obstruction usually causes cramping pain

in the abdomen, accompanied by bloating and disinterest in eating (anorexia). Vomiting is common with small-intestinal obstruction but is less common and begins later with large-intestinal obstruction. Complete obstruction causes severe constipation, whereas partial obstruction may cause diarrhea. With strangulation, pain may become severe and steady. A fever is common and is particularly likely if the intestinal wall ruptures.

• When an obstruction occurs, the abdomen is almost always swollen.

• X-rays may show dilated loops of intestine that indicate the location of the obstruction.


Treatment • Usually, a long, thin tube is passed through the

nose and placed in the stomach or intestine. Suction is applied to the tube to remove the material that has accumulated above the blockage. Fluid and electrolytes (sodium, chloride, and potassium) are given intravenously to replace water and salts lost from vomiting or diarrhea.

• Occasionally, an endoscope, which is advanced through the anus, or a barium enema, which inflates the large intestine, may be used, such as in a twisted intestinal segment in the lower part of the large intestine. Most often surgery is performed as soon as possible. In some cases, a colostomy is required.


Acute Gastrointestinal Acute Gastrointestinal EmergenciesEmergencies

DR GAN SENG CHIEW

Associate Professor

FACULTY OF MEDICINE & HEALTH SCIENCES

UNIVERSITY TUNKU ABDUL RAHMAN


Classify By Site

Oesophagus

Acute dysphagia• Perfusion• Bleeding

Stomach/duodenum • Perfusion• Bleeding


Gallbladder/Biliary Tract• Cholecystitis• Cholangitis• Obstructive jaundice

Pancreas• Acute pancreatitis

Small intestine• Intestinal obstruction• Mesenteric Infarct• (Infectious diarrhoea)• Crohn’s Disease• Meckel’s Diverticulum

Large Bowel (+ App)• Acute Appendicitis• Acute Diverticulitis• Lower GI bleeding• Perforation• Intestinal obstruction• Uncontrolled

ulcerative colitis

Perintoneal cavity• Peritonitis• Intra-abdominal

abscess


Oesophagus - BleedingOesophagus - Bleeding

Oesophagitis, Mallroy Weiss, Varices

• Variceal bleeding – can be catastrophic

• Treatment - varices– Sengstaken

tube– Somatostatin

injection


Oesophagus – Acute Oesophagus – Acute DysphagiaDysphagia

• Presentation – cannot swallow– May have benign stricture or cancer

– Triggered by food bolus or tablet

– Treatment - – remove bolus– deal with

underlying • oesophageal disease


Oesophagus – PerforationOesophagus – Perforation

High mortality

May follow endoscopy

Presentation – acute

chest/abdominal pain

Air in mediastinum and

soft tissues

Treatment -

surgery - benign

intubation - malignant


Stomach/duodenum – Perforation

Presentation – • abdominal pain• rigidity• peritonism, shock • Air under diaphragm

on X-ray

Treatment -• antibiotics,

resuscitate• repair


Stomach/duodenum – Stomach/duodenum – BleedingBleedingPresentation – • Haematemesis +/-• Melaena• Severity• Increased PR>90• Fall BP<100

Causes • DU, erosions, GU

Treatment – • ransfusion• inject DU


Gall bladder/Bil iary TractGall bladder/Bil iary Tract

Obstructive Jaundice • Yellow skin, sclerae• Pale stools, dark urine• +/- Pain• +/- Courvoisier’s sign• CT – dilated bile ducts• Establish diagnosis• Gallstones• Ca Head of Pancreas• Appropriate

treatment


Gall bladder/Bil iary TractGall bladder/Bil iary Tract

Acute Cholecystitis • Presentation• Acute RUQ pain• +/- Pyrexia• +/- Rigors• Diagnosis – FBC,

WBCC, USS• Treatment –

Antibiotics,• analgesics• Early surgery


PancreasPancreasAcute pancreatitis • Constant pain,

vomiting,• ShockCauses• Gallstones, or• AlcoholDiagnosis• Serum amylase• elevation, USS• complications• pseudocyst,

phlegmon• abcess


Small IntestineSmall Intestine

Meckel’s Diverticulum

• rare• diverticulum of

terminal ileum• can be lined by

gastric epithelium • can perforate • can present like

appendicitis


Small IntestineSmall IntestineIntestinal obstruction • May arise due to • adhesions, hernia,

tumour

Presentation• colicky abdominal

pain,• vomiting,

constipation• Treatment• resuscitate/operate


Small IntestineSmall Intestine

Mesenteric infarct • Sudden occlusion of

small• bowel arterial supply• Sudden onset of

abdominal pain, shock

• Peritonitis

Treatment• resuscitate/operate


Large bowelLarge bowelAcute diverticulitis • Maximal in (L) colon• Presentation LIF

pain,• fever, tenderness,• leukocytosis• Middle aged or

elderly

Treatment – • conservative• antibiotics, fluids,

bed rest


Large bowelLarge bowel

Lower GI bleeding • Diverticulum, colitis,• Crohn’s tumour• Present with Fresh

Red Blood P/R• Tendency to be more

conservative than with upper GI

• Resuscitate, transfusion


Large bowelLarge bowelPerforation • Diverticulum,

colitis,• sudden severe

abdominal pain,• rigidity• Faecal peritonitis• Pyrexia, shock• Free gas on X-ray

Treatment• resuscitate, operate


Inflammatory Bowel DiseaseInflammatory Bowel Disease

• Recurrent regeneration

• Increased risk of tumour formation

• 14.8 X


Large BowelLarge Bowel

Ulcerative colitis• Presents – bloody• diarrhoea, pyrexia• leukocytosis• may develop toxic

megacolon

Treatment – • steroids• Surgery on failure


Peritoneal cavityPeritoneal cavity

Acute peritonitis• any perforation,• pancreatitis• abdominal pain,

tenderness• guarding, silent

abdomen• shock

Treatment –

underlying condition

Git6 obstruction

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