By

Prof. Dr. Prof. Dr. ISMAIL TANTAWY ISMAIL TANTAWY

Learning objectives to understand

The pathophysiology of The pathophysiology of dynamic and adynamic dynamic and adynamic

intestinal obstructionintestinal obstruction

The causes, clinical The causes, clinical Pictures and complications Pictures and complications

of intestinal obstructionof intestinal obstruction..

The indications and contraindications of either surgical or The indications and contraindications of either surgical or conservative treatment of intestinal obstruction.conservative treatment of intestinal obstruction.

Definition:Definition:Failure of propulsion of intestinal contents. Failure of propulsion of intestinal contents. Due to either mechanical occlusion of the lumen Due to either mechanical occlusion of the lumen

((dynamic obstructiondynamic obstruction) or failure of the propulsive ) or failure of the propulsive movement (movement (adynamic obstructionadynamic obstruction). ).

AetiologyAetiology

Mechanical (Mechanical (DynamicDynamic) ) Obstruction Obstruction

Functional (Functional (adynamicadynamic) )

Due to occluded lumen Patent lumen

Mechanical (Dynamic) ObstructionMechanical (Dynamic) Obstruction

In the lumen In the lumen In the wall In the wall Outside the wall Outside the wall

Meconium ileusMeconium ileus Gall stone ileus and Gall stone ileus and

bolus obstructionbolus obstruction Ascaris mass Ascaris mass Faecal impaction, F.B., Faecal impaction, F.B.,

or enterolith or enterolith

Congenital atresia. Congenital atresia. Inflammatory stricture. e.g. Inflammatory stricture. e.g.

T.B. Crohn’s, ulcerative T.B. Crohn’s, ulcerative colitis, diverticulitis. colitis, diverticulitis.

Malignancy: cancer colon, Malignancy: cancer colon, and rectum.and rectum.

Bands and adhesions (the Bands and adhesions (the commonest cause).commonest cause).

Tight rings of hernia sacTight rings of hernia sacTumours and enlarged LNs.Tumours and enlarged LNs.

Functional (adynamic)Functional (adynamic)

Paralytic ileus Paralytic ileus Spastic ileusSpastic ileus: Hirschsprung's : Hirschsprung's disease is a good example disease is a good example

Mesentric vascular Mesentric vascular occlusion (occlusion (MVOMVO) )

PathologyPathology

Types of intestinal obstructionTypes of intestinal obstruction

Simple Simple obstruction obstruction

Strangulated Strangulated obstruction obstruction

Occluded lumen without Occluded lumen without interference with blood supply interference with blood supply

Obstruction with interference with blood supply of the Obstruction with interference with blood supply of the affected loop:affected loop:

Strangulated hernia Strangulated hernia Volvolus Volvolus Intussusception Intussusception

Adhesive obstruction (some Adhesive obstruction (some cases e.g. internal herniation)cases e.g. internal herniation)

Mesentric vascular Mesentric vascular occlusion.occlusion.

Patho-pathologyPatho-pathologyLocal effectsLocal effects

Proximal to the site of obstruction Proximal to the site of obstruction At the site of obstruction At the site of obstruction Distal to obstruction Distal to obstruction

Proximal to the site of obstruction: Proximal to the site of obstruction:

The proximal loop passes through the following phases:The proximal loop passes through the following phases:

(A) Proximal to the site of obstruction: (A) Proximal to the site of obstruction:

The proximal loop passes through the following phases:The proximal loop passes through the following phases:Hyperperistaltic with antiperistaltic waves: occurs early in Hyperperistaltic with antiperistaltic waves: occurs early in

trial to overcome the obstruction . trial to overcome the obstruction . Stage of dilatation (due to exhaustion and paralysis) & The Stage of dilatation (due to exhaustion and paralysis) & The

loop becomes distended with:loop becomes distended with:

FluidsFluids LateLate GasesGases

1000-1500 ml saliva 1500 - 2500 ml gastric juice 1000 ml bile 1500 ml pancreatic secretion. 3000 ml intestinal secretion

Swallowed, secreted Swallowed, secreted & diffused from & diffused from bloodblood ( (The secreted The secreted part alone is more part alone is more than 8 liters per daythan 8 liters per day).).

Either swallowed Either swallowed ((70%70%), diffused ), diffused from blood (from blood (20%20%) ) or produced from or produced from putrefaction of putrefaction of food (food (10%10%).).

Bacterial proliferation with Bacterial proliferation with breakdown of retained breakdown of retained intestinal contents intestinal contents produces toxins that produces toxins that accumulate in the stagnant accumulate in the stagnant fluid and do not pass to the fluid and do not pass to the circulation except after circulation except after release of obstruction, release of obstruction, which may lead to which may lead to toxaemia which may be toxaemia which may be fatal. fatal.

Distal to obstructionDistal to obstruction

Normal peristalsis to evacuate Normal peristalsis to evacuate the residual content.the residual content.

The distal segment is empty, collapsed, The distal segment is empty, collapsed, contracted and immobile.contracted and immobile.

EarlyEarly LateLate

At the site of obstruction At the site of obstruction

Simple Simple obstruction obstruction

StrangulatedStrangulated obstruction obstruction

The strangulated loop The strangulated loop becomes distended becomes distended with gas & fluid with gas & fluid

At first, the venous flow is occluded (being of low pressure) leading to At first, the venous flow is occluded (being of low pressure) leading to oedema and congestion.oedema and congestion.

Arterial flow is then occluded leading to ischaemia and gangrene. Arterial flow is then occluded leading to ischaemia and gangrene. The devitalized wall of the intestine permits passage of toxins & The devitalized wall of the intestine permits passage of toxins &

bacteria to the peritoneal cavity & circulation causing toxaemia. bacteria to the peritoneal cavity & circulation causing toxaemia. Lastly, perforation leads to peritonitis.Lastly, perforation leads to peritonitis.

Complications (Complications (general effectsgeneral effects) )

Hypovolaemic shock:Hypovolaemic shock: due to fluid loss by vomiting, due to fluid loss by vomiting, sequestration of fluids in the third space (dilated sequestration of fluids in the third space (dilated loops). loops).

In strangulated obstruction:In strangulated obstruction: shock is more marked shock is more marked due to additional blood loss into the strangulated due to additional blood loss into the strangulated loop. loop.

Dehydration & electrolytes imbalance:Dehydration & electrolytes imbalance: hyponatraemia & hypokalaemia.hyponatraemia & hypokalaemia.

Toxaemia:Toxaemia: in strangulated obstruction. in strangulated obstruction. Perforation & peritonitis.Perforation & peritonitis.

Clinical pictureClinical picture

SymptomsSymptoms

Pain Pain Vomiting Vomiting Constipation Constipation DistensionDistension

Simple obstSimple obstruction:ruction: colicky pain in attacks colicky pain in attacks with long free intervals.with long free intervals.

Strangulated obstructionStrangulated obstruction:: colicky pain with short colicky pain with short intervals with constant intervals with constant dull aching pain between dull aching pain between the attacks of colics. the attacks of colics.

Paralytic ileus:Paralytic ileus: No colic. No colic.

The higher the The higher the obstruction, obstruction, the earlier the the earlier the vomiting.vomiting.

Absolute constipation to Absolute constipation to both faeces and flatus.both faeces and flatus.

The lower the The lower the obstruction, the earlier obstruction, the earlier the constipation.the constipation.

The lower the The lower the obstruction obstruction the more is the more is distension.distension.

SignsSigns

General General Local Local

Signs of dehydration, Signs of dehydration, shock or toxaemia.shock or toxaemia.

General signs of the General signs of the cause e.g. distant cause e.g. distant metastasis of GIT metastasis of GIT cancer.cancer.

InspectionInspection Palpation Palpation Percussion Percussion

Auscultation Auscultation Per-rectal examination Per-rectal examination (PR exam.) (PR exam.)

Abdominal Abdominal distention.distention.Visible Visible peristalsis on the peristalsis on the abdominal wall.abdominal wall.

Simple obstruction: mild Simple obstruction: mild tenderness over the distended tenderness over the distended loops maximum over the site of loops maximum over the site of the obstruction.the obstruction.Strangulated obstruction: Strangulated obstruction: tenderness & rebound tenderness tenderness & rebound tenderness over the strangulated loop. over the strangulated loop.

Hyper-resonance Hyper-resonance over the distended over the distended loops loops

Loud exaggerated intestinal sounds in Loud exaggerated intestinal sounds in the hyperperistaltic stage (the hyperperistaltic stage (earlyearly).).Dead silent abdomen in paralytic ileus Dead silent abdomen in paralytic ileus and during the stage of dilatation (and during the stage of dilatation (latelate).).

Empty rectum supports the diagnosis.Empty rectum supports the diagnosis.It may reveal anorectal carcinoma or It may reveal anorectal carcinoma or red currant jelly stool in intussusception.red currant jelly stool in intussusception.

How to suspect the level of obstruction clinically? How to suspect the level of obstruction clinically?

Items Items High small bowelHigh small bowel Low small bowelLow small bowel Large bowelLarge bowel

1-Pain1-Pain above the above the umbilicusumbilicus

Around & below Around & below itit

Lower Lower abdominalabdominal

2-Vomiting 2-Vomiting -Very early (with -Very early (with

pain)pain)-Copious-Copious

-1-2h after pain-1-2h after pain-moderate-moderate

1-2 day after 1-2 day after painpainmildmild

3-Constipation 3-Constipation LateLate IntermediateIntermediate EarlyEarly

4-Abd. distension 4-Abd. distension -Mild or absent-Mild or absent-central-central

-Inter mediate-Inter mediate-central-central

-Marked-Marked-peripheral-peripheral

5-Dehydration 5-Dehydration Marked earlyMarked early IntermediateIntermediate Mild & lateMild & late

Differences between Simple, strangulated and functional obstruction (P. ileus)Differences between Simple, strangulated and functional obstruction (P. ileus)

ItemItem Simple obst.Simple obst. Strangulated. Obst.Strangulated. Obst. Paralytic ileusParalytic ileus

1-Pain 1-Pain

Intermittent Intermittent colicky pain with colicky pain with long free intervals. long free intervals.

Attacks of colicky Attacks of colicky pain with short pain with short intervals of constant intervals of constant dull aching pain. dull aching pain.

Mild dull aching Mild dull aching pain of distension or pain of distension or no pain no pain

2-Shock2-Shock Mild.Mild. Severe.Severe. Moderate.Moderate.

3-Palpation 3-Palpation Tenderness Tenderness especially over the especially over the site of obstruction.site of obstruction.

Tenderness and Tenderness and rebound tenderness. rebound tenderness.

Very mild Very mild tenderness.tenderness.

4-Auscultation 4-Auscultation Hyperperistalsis Hyperperistalsis then silent then silent abdomen. abdomen.

Hyperperistalsis Hyperperistalsis then silent abdomen.then silent abdomen.

Dead silent Dead silent abdomen.abdomen.

5-N/G suction5-N/G suction It relieves pain in It relieves pain in hours.hours.

It does not relieve It does not relieve pain. pain.

It relieves distention. It relieves distention.

6- Leucocytic count6- Leucocytic countNot increasedNot increased IncreasedIncreased Not increased except Not increased except

in cases secondary to in cases secondary to sepsissepsis

InvestigationsInvestigations

Double enema test: Double enema test: Two enemas are given one hour apart. Two enemas are given one hour apart. If the second enema comes without If the second enema comes without 3F3F ( (Faeces FlatusFaeces Flatus or or ForceForce), ),

intestinal obstruction is proved.intestinal obstruction is proved.

Radiological investigations: Radiological investigations:

**Plain X. ray abdomen erect position: Plain X. ray abdomen erect position: It reveals distended loops with multiple fluid It reveals distended loops with multiple fluid levels in levels in stepladder patternstepladder pattern..

JejunumJejunum:: shows circular folds called shows circular folds called ""valvulaevalvulae conniventsconnivents" giving " giving concertina concertina appearanceappearance

IleumIleum:: shows shapeless characterless tubes. shows shapeless characterless tubes. Colon:Colon: typical haustrations of the colon.typical haustrations of the colon. Multiple fluid levelsMultiple fluid levels

**Barium enema:Barium enema:

When colonic obstruction is suspected. When colonic obstruction is suspected.

**Upper GIT series:Upper GIT series:Barium or Gastrograffin meal with follow-through to detect Barium or Gastrograffin meal with follow-through to detect upper small intestinal obstruction in neonates and infants.upper small intestinal obstruction in neonates and infants.

Laboratory investigations:Laboratory investigations:Total leucocytic countTotal leucocytic count:: markedly rises in cases of strangulation.markedly rises in cases of strangulation.Serum electrolytes:Serum electrolytes: decreased sodium and potassium levels.decreased sodium and potassium levels.

Differential Diagnosis:Differential Diagnosis:

From other causes of acute abdomen.From other causes of acute abdomen.

Treatment:Treatment:

Conservative treatment:Conservative treatment: Correction of fluid & electrolytes imbalance i.e. Correction of fluid & electrolytes imbalance i.e. I.V.I.V. fluids fluids

according to the deficit. according to the deficit. Fluid chart is mandatory. Fluid chart is mandatory. Nasogastric suction through Ryle's tube for:Nasogastric suction through Ryle's tube for:

**Preoperative benefits:Preoperative benefits: It relieves distension, which may cause cardiac & It relieves distension, which may cause cardiac &

respiratory embarrassment. respiratory embarrassment. It relieves congestion & oedema of the intestines and helps It relieves congestion & oedema of the intestines and helps

return of tone & peristalsis. return of tone & peristalsis.

**Operative benefits:Operative benefits: For anaesthesiaFor anaesthesia: : it prevents vomiting & aspiration it prevents vomiting & aspiration

pneumonia.pneumonia. For surgeon:For surgeon: it deflates the intestine providing easy it deflates the intestine providing easy

manipulation & easy closure of the abdomen.manipulation & easy closure of the abdomen.

**Postoperative benefits:Postoperative benefits: It prevents massive toxic absorption after release of obstruction.It prevents massive toxic absorption after release of obstruction. It reduces the incidence of postoperative paralytic ileus It reduces the incidence of postoperative paralytic ileus

(distention and vomiting).(distention and vomiting). Antibiotics:Antibiotics: to guard against respiratory infection, peritonitis & to guard against respiratory infection, peritonitis &

septicemia.septicemia. Repeated enemata are used to break faecal impaction and stimulate Repeated enemata are used to break faecal impaction and stimulate

colonic motility.colonic motility.

Surgical treatment:Surgical treatment:

A part from few cases, in which the previous A part from few cases, in which the previous conservative measures may be curative, most cases need conservative measures may be curative, most cases need emergency exploration.emergency exploration.

Exploration: Exploration: In adults, midline incision is preferred.In adults, midline incision is preferred.

Deliver the caecum Deliver the caecum and examineand examine

Decompress the bowels if Decompress the bowels if greatly distended by greatly distended by

Deal with Deal with the cause the cause

If collapsed, it is If collapsed, it is small intestinal small intestinal obstruction obstruction →→ follow follow the ileum to the the ileum to the distended loops. distended loops.

If distended, it is If distended, it is large intestinal large intestinal obstruction obstruction →→ follow follow the colon to the the colon to the collapsed part.collapsed part.

By this way you can By this way you can reach the site of the reach the site of the obstruction .obstruction .

Threading a long Threading a long nasogastric tube through nasogastric tube through the intestine down to the the intestine down to the site of obstruction. site of obstruction.

Decompression through Decompression through a small stab in the bowel a small stab in the bowel and introduction of wide and introduction of wide bore catheter connected bore catheter connected to a sucker then close the to a sucker then close the stab with sutures.stab with sutures.

Simple obstruction:Simple obstruction: Remove the cause if Remove the cause if possible or do bypass or possible or do bypass or colostomy.colostomy.

Strangulated Strangulated obstruction:obstruction: Remove the Remove the cause of strangulation cause of strangulation and examine the and examine the viability of the loop. viability of the loop.

ItemItem Viable loopViable loop Gangrenous loopGangrenous loop

-Inspection-Inspection-luster-luster-colour-colour-peristalsis-peristalsis

Present (shining)Present (shining)Red (light)Red (light)SeenSeen

Absent (dull) Absent (dull) Dark or black Dark or black Absent Absent

-Palpation-Palpation -tone-tone-Pulsation -Pulsation

Present (firm)Present (firm)Felt in the mesenteryFelt in the mesentery

Absent (flabby) Absent (flabby) Absent Absent

-Operative Doppler U/S-Operative Doppler U/S + ve+ ve -ve-ve

If the viability of a loop is questionable, If the viability of a loop is questionable, try to improve it bytry to improve it by

Wrapping the loops with Wrapping the loops with hot fomentations. hot fomentations.

Increase oxygenation Increase oxygenation for for 1010 minutes. minutes.

If not improved or proved gangrenous, If not improved or proved gangrenous, resection of gangrenous loop is indicated. resection of gangrenous loop is indicated.

If it isIf it is ::

Small intestine or right Small intestine or right colon then do primary colon then do primary resection anastomosis. resection anastomosis.

Left colon then either resection Left colon then either resection ended by colostomy or recently ended by colostomy or recently primary resection anastomosis primary resection anastomosis after on table colonic lavage after on table colonic lavage ((Dudely lavageDudely lavage) is done. ) is done.

Common causes of obstruction in Common causes of obstruction in different age groupsdifferent age groups

Newborn (first month): (Newborn (first month): (see the chapter of pediatric surgery )see the chapter of pediatric surgery )Jejuno ileal atresia or stenosis (Jejuno ileal atresia or stenosis (the commonest causethe commonest cause).).Malrotation or volvolus neonatorum.Malrotation or volvolus neonatorum.Congenital duodenal obstruction (Congenital duodenal obstruction (atresiaatresia).).Duplication of the intestineDuplication of the intestineHirchsprung's diseaseHirchsprung's diseaseImperforate anus.Imperforate anus.Meconium ileusMeconium ileus

InfancyInfancy ( (1 month – 2 years1 month – 2 years) & ) & ChildhoodChildhood ( (2y-12y2y-12y): ):

IntussusceptionIntussusception ( (the commonest cause in infantsthe commonest cause in infants).).Strangulated external herniaStrangulated external hernia ( (the commonest cause in childrenthe commonest cause in children) .) .Ascaris mass obstruction.Ascaris mass obstruction.

Young adult and middle age:Young adult and middle age:

Adhesive intestinal obstruction (Adhesive intestinal obstruction (the commonest causethe commonest cause).).Strangulated hernia. (Strangulated hernia. (see the chapter of herniassee the chapter of hernias) ) Paralytic ileus.Paralytic ileus.Stricture obstruction e.g. Stricture obstruction e.g. T.BT.B. . Gall stone obstruction. Gall stone obstruction.

Old age:Old age:

Malignant obstruction (Malignant obstruction (the commonestthe commonest).).Volvolus sigmoid.Volvolus sigmoid.Faecal impaction.Faecal impaction.

The commonest causes of intestinal The commonest causes of intestinal obstruction as a whole areobstruction as a whole are

Strangulated externalStrangulated external herniahernia

Adhesive intestinal Adhesive intestinal obstruction obstruction

Paralytic ileusParalytic ileus Malignant obstructionMalignant obstruction

AetiologyAetiologyPeritoneal irritation leading to fibrinous exudate that Peritoneal irritation leading to fibrinous exudate that causes fibrinous adhesions between adjacent intestinal causes fibrinous adhesions between adjacent intestinal

loops. loops. They may resolve or change into mature permanent They may resolve or change into mature permanent

fibrous tissue causing fibrous adhesions.fibrous tissue causing fibrous adhesions.

The irritating causes may be (theories)The irritating causes may be (theories)

Mechanical or Mechanical or thermal e.g. thermal e.g.

diathermy or hot diathermy or hot fomentations fomentations

InfectionInfection ForeignForeign bodiesbodies TraumaTrauma VascularVascular

Peritonitis Peritonitis & TB.& TB.

Talk powder Talk powder (over surgical (over surgical gloves) & silk gloves) & silk

suturessutures

Ischaemia or Ischaemia or congestion.congestion.

Pathology:Pathology:Types:Types:

Occurs early, which is easily Occurs early, which is easily broken by blunt dissection broken by blunt dissection

Fibrinous Fibrinous adhesions adhesions

Which is firm and needs sharp Which is firm and needs sharp dissection (dissection (adhesolysisadhesolysis).).

Fibrous Fibrous adhesions adhesions

Clinical pictureClinical picture

There is a history of previous operation There is a history of previous operation e.g. appendicectomy or gynecological e.g. appendicectomy or gynecological operations or past history of peritonitis operations or past history of peritonitis

Fibrinous Fibrinous adhesions adhesions

Picture of simple obstruction but the adhesions Picture of simple obstruction but the adhesions may compress the blood supply and cause may compress the blood supply and cause strangulated intestinal obstruction strangulated intestinal obstruction

Fibrous Fibrous adhesions adhesions

TreatmentTreatment

ConservativeConservative Surgical Surgical

ConservativeConservative

Should be tried first even for few days so long as there is no Should be tried first even for few days so long as there is no Suspicion of strangulation. Suspicion of strangulation.

I.V. fluidsI.V. fluids, , N/GN/G suction may be beneficial and the intestinal suction may be beneficial and the intestinal movement may break down fibrinous adhesions.movement may break down fibrinous adhesions.

Surgical Surgical

Exploration and division of Exploration and division of the offending adhesions. the offending adhesions.

Prevention of recurrence Prevention of recurrence

Exploration and division of the offending adhesions:Exploration and division of the offending adhesions:

If adhesions are extensive If adhesions are extensive →→ bypass by lateral anastomosis. bypass by lateral anastomosis.

Prevention of recurrence:Prevention of recurrence:

Instillation of different substances:Instillation of different substances: to reduce the fibrous tissue to reduce the fibrous tissue formation e.g. hyaluronidase, heparin, steroids, fibrinolysin, formation e.g. hyaluronidase, heparin, steroids, fibrinolysin, dextran…etc. is usually useless.dextran…etc. is usually useless.

Noble's plicationNoble's plication:: The adjacent loops are sutured along their anti- The adjacent loops are sutured along their anti-mesenteric border in ordered fashion.mesenteric border in ordered fashion.

Charle-Phillip's transmesenteric plicationCharle-Phillip's transmesenteric plication:: In which placation is In which placation is done in the mesentery few centimeters from the bowel that looks done in the mesentery few centimeters from the bowel that looks like a pouch of sausagelike a pouch of sausage

Baker's tube:Baker's tube: intraluminal tube splinting the loops gentle curves. intraluminal tube splinting the loops gentle curves. This tube is removed 12 days later. This tube is removed 12 days later.

Aetiology:Aetiology:

Obstruction of the terminal ileum by aggregation of Obstruction of the terminal ileum by aggregation of Ascaris Ascaris lumbricoideslumbricoides worms forming a mass, usually following worms forming a mass, usually following antihelminthic treatment.antihelminthic treatment.

Incidence:Incidence:Rarely seen nowadays.Rarely seen nowadays.Common in children below Common in children below 10 years10 years in tropics. in tropics.

Clinical picture:Clinical picture:

History of Ascaris infestation or intake of antihelminthics may History of Ascaris infestation or intake of antihelminthics may be positive.be positive.

The vomitus may contain worms. The vomitus may contain worms. Picture of simple intestinal obstruction.Picture of simple intestinal obstruction.

Investigations:Investigations:Leucocytic count may show marked esinophilia.Leucocytic count may show marked esinophilia.

TreatmentTreatment

ConservativeConservative Exploration Exploration

(N/G suction + (N/G suction + IV. Fluids) may IV. Fluids) may

succeed. succeed.

The mass is identified and trial is done to knead it The mass is identified and trial is done to knead it along the ileum to the colon without opening the along the ileum to the colon without opening the

bowel. bowel. If kneading fails, remove the mass through If kneading fails, remove the mass through

transverse incision in the bowel. transverse incision in the bowel. The bowel incision should be sutured with The bowel incision should be sutured with silk suturessilk sutures

because the worms tend to eat the catgut sutures and because the worms tend to eat the catgut sutures and re-open the sutured wound of the intestine, through re-open the sutured wound of the intestine, through

their way to the peritoneum.their way to the peritoneum.

Aetiology:Aetiology:

Incidence:Incidence:

Clinical picture:Clinical picture:

Obstruction of the distal colon and rectum by inspissated faeces Obstruction of the distal colon and rectum by inspissated faeces ((forming a massforming a mass). ).

It is common in elderly bed ridden patients with chronic constipation.It is common in elderly bed ridden patients with chronic constipation.

Clinical picture of simple distal intestinal obstruction.Clinical picture of simple distal intestinal obstruction.Indentible mass may be felt in the Lt. iliac fossa and the faecal mass is Indentible mass may be felt in the Lt. iliac fossa and the faecal mass is

felt per-rectumfelt per-rectum

Treatment:Treatment: Conservative measures + repeated enemata may succeed to loosen the Conservative measures + repeated enemata may succeed to loosen the

mass and relieve obstruction.mass and relieve obstruction. If failed, anal dilatation under anaesthesia and manual removal of the If failed, anal dilatation under anaesthesia and manual removal of the

mass is done.mass is done.

Aetiology:Aetiology:

Incidence:Incidence:

Clinical picture:Clinical picture:

Obstruction of the terminal ileum by large gall stone (Obstruction of the terminal ileum by large gall stone (2.5 cm or more 2.5 cm or more in diameterin diameter) which had ulcerated through the gall bladder wall into ) which had ulcerated through the gall bladder wall into the duodenum.the duodenum.

It passes down to be impacted usually It passes down to be impacted usually 2 feet2 feet from the ileocaecal valve from the ileocaecal valve causing simple intestinal obstruction.causing simple intestinal obstruction.

It is a rare condition, common in old obese multiparous females with It is a rare condition, common in old obese multiparous females with long history of dyspepsia.long history of dyspepsia.

Clinical picture of simple intestinal obstruction:Clinical picture of simple intestinal obstruction: Usually there is a long history of chronic cholecystitis with recent Usually there is a long history of chronic cholecystitis with recent

exacerbation.exacerbation. The diagnosis is usually delayed because it's clinical pictures The diagnosis is usually delayed because it's clinical pictures

resemble exacerbation attacks of gall bladder disease.resemble exacerbation attacks of gall bladder disease.

Investigations:Investigations:

Plain X ray of abdomen in erect position: It may show:Plain X ray of abdomen in erect position: It may show:

The classic multiple fluid level but the stone is rarely seen. The classic multiple fluid level but the stone is rarely seen. Gas in the gall bladder or biliary tree (Gas in the gall bladder or biliary tree (pneumobiliapneumobilia) is diagnostic.) is diagnostic.

Treatment “Treatment “SurgicalSurgical”:”:

Exploration after good preoperative preparation:Exploration after good preoperative preparation: Try to crush the stone between fingers without opening the Try to crush the stone between fingers without opening the

bowel.bowel. If failed, open the ileum above the stone, and remove it then If failed, open the ileum above the stone, and remove it then

close the incision transversely close the incision transversely Avoid any manipulation in the region of the gall bladder, which Avoid any manipulation in the region of the gall bladder, which

may break down the cholecyto-enteric fistula and results in may break down the cholecyto-enteric fistula and results in external duodenal or biliary fistula.external duodenal or biliary fistula.