CASE PRESENTATION INTESTINAL OBSTRUCTION

INTERN DEEPAK PAUDEL

GMCTH

DEPARTMENT OF SURGERY

68yr/M from Armala ,Ex Army by profession was admitted through GMC ER on 27th of Asad 2073( @ 10:20 PM) with chief complaints of:

• pain abdomen for 3 days• Dyspepsia for 3 days• Abdominal distention for 3 days

HOPI

• Pain - in RIF gradual on onset burning sensation

continuous started in the morning non radiating no known aggravating factor relieved by shifting position

Pain is associated with abdominal distention

water brash nausea burning micturation H/O loss of appetite

• H/O passage of hard stool• No H/O fever ,headache ,trauma• No H/0 cough ,weight loss • No H/0 vomiting.

PAST HISTORY

• H/0 appendectomy 40 yrs ago• From than ,he started to develop abdominal

pain of similar nature .• According to him, he experiences similar

problem once in every year.• Last time on Bhadra 2072 he was admitted to

GMCTH for abdominal pain ,admitted ,treated conservatively and relieved.

FAMILY HISTORY

• No such H/O in the family• no H/O of HTN, DM, TB

PERSONAL HISTORY

• Consumes alcohol occasionally.• Non vegeterian • Doesn’t smoke• But has a habit of chewing tobacco.

ALLERGIC HISTORY

• No known allergic history of any drug

• GENERAL EXAMINATION

Pt .was concious, well oriented to T,P,P lying comfortably in supine position with cannula fitted in the left hand

- Vitals R/R:-25/min

BP:- 110/70 mm of Hg in rt brachial Artery. Pulse-84beats/min Temp 98 F

• Pallor• Icterus • Lymphadenopathy nil• Clubbing• Cyanosis• Oedema nil• Dehydration

GI EXAMINATION

Inspection -umbilicus centrally placed and abdomen is

distended. -visible scar in rt iliac fossa -all quadrants move equally with respiration -no visible pulsation and peristalsis -hernial sites intact -ext. genitilia-normal

Palpation -Abdominal girth :90 cm(01) -86 cm(02) -72 cm

(04/04) -local temprature normal -tenderness on lower abdominal region -no palpable mass -no organomegaly -hernial sites intact and normal ext. genital

Percussion – resonant note - tender RIF -shifting dullness –ve

auscultation – normal bowel sound heard -no vascular bruits heard P/R exm- no mass, no blood, faeces present.

• Respiratory exmn-normal• CVS exmn- normal• CNS exmn –normal

Provisional diagnosis

• Intestinal obstruction: For abdominal pain Constipation Abdominal distention

Differential DiagnosisD/d For AgainstMeckels Diverticulitis

Pain abdomen No antecedent h/o of lower GI bleeding

Rt. Ureteric colic Abdominal PainAggravated on movement

No history of hematuriano radiation to loin

D/D For AgainstPerforated peptic ulcer

Severe pain in RIF history of dyspepsia

pain is not related to food intake.

Crohns diseases Pain abdomen No diarrhoea and wt loss

Investigation

• CBC:-WBC -10,000/mm3• Na+ 141 ,k+ 4.0• USG impression : slightly prominent bowel loop. • Plain abdominal X-ray

Treatment

• Under liquid diet.• IV fluids• Analgesics:inj tramadol ,buscopan,• Antibiotics :levoflox,inj xone • Soap water enema.

Intestinal obstruction

Definition:

• Intestinal Obstruction(IO) is a condition in which there is a sudden stoppage of the onward passage of intestinal contents-i.e. Gas, digestive juices and food

Intestine

CLASSIFICATIONAccording to: Aetiopathology

Onset Level Nature

Peristalsis is working against a mechanical obstruction

DYNAMIC(MECHANICAL)

Result from atony of the intestine with loss of normal peristalsis, in the absence of a mechanical cause.

or it may be present in a non-propulsive form (e.g. mesenteric vascular occlusion or pseudo-obstruction)

ADYNAMIC(FUNCTIONAL)

Small or Large bowel

High (Proximal) or Low (Distal) small bowel

According to LEVEL

High IO- near the ampulla- jejunum and proximal ileum.

Low IO- distal to the ampulla- distal ileum and colon.

According to nature of Obstruction:

1. Simple Obstruction- the bowel lumen is occluded ,blood supply remains intact. The source of obstruction is usually intra-abdominal. ( Eg. Intra-abdominal adhesions, very rarely gallstones, ball of worms, bezoars).

2. Strangulation- the bowel lumen together with its blood supply is cut-off. Eg. Strangulated inguinal hernias. Pure strangulation without bowel luminal narrowing is usually due to mesenteric embolism/thrombosis.

3. Closed loop obstruction- The bowel is obstructed both proximally and distally. Here the blood supply may be impaired.A classic example is seen in an obstruction of the colon with a competent ileo-caecal valve.NB: All the 3 types spoken about can occur at the same time for example in a strangulated inguinal hernia.

Closed loop obstruction

According to onset:

-Chronic Obstruction-Usually seen in large bowel obstruction. The symptoms may arise from the cause and the subsequent obstruction.-Acute on Chronic Obstruction- sudden obstruction in a previously incomplete obstruction.Sub-acute Obstruction- There is a partial obstruction.

Causes Dynamic obstructrion

Intraluminal• Impaction• Foreign bodies• Bezoars• Gallstone

Intramural• Congenital atresia• Stricture• Malignancy(15%)

Extramural• Bands/

adhesion(40%)• Hernia (12%)• Volvulus• Intussusception• Tumor-benign/

malignant

BANDS

Ball of Ascaris worms

Adynamic cause of Obstruction

• Paralytic ileus• Electrolyte imbalance• Spinal injury• Diabetis mellitus• Renal surgeries• Mesenteric ischemia

PathophysiologyProximal

bowel dilated

& develops altered motility dilate

reduce

peristaltic

strength

flaccidity &

paralysis (prev.

vascular damage due to

inc. intralum

inal pressure

Distal to obs. Bowel

exhibits normal peristal

sis & absorbtion becom

e empty

contrac

t & becom

e immobi

le

Distention is by gas & fluid-Gas:

aerobic &

anaerobic

growth-Fluid:

Digestive juices

& retarde

d absorp

tion

Dehydration &

electrolytes loss: Reduced

oral intake,

defective

intestinal

absorption, loses

from vomiting

& sequestration in

bowel of lumen.

Clinical presentation

The clinical presentation varies according to;- The location of the obstruction- The age of the obstruction- Underlying pathology- Presence or absence of intestinal ischaemia.

Clinical features• Abdominal pain• Vomiting• Distension• Constipation• Dehydration• Feature of toxemia and septicemia• Feature of strangulation• Temperature• Bowel sound• Per rectal examination

Small vs large bowel obstruction

Investigation

• CBC• Electrolyte Na/K• Plan X-ray abdomen erect and supine• CT scan

A. Investigations(i) Supportive- FBC, BU+Cr. Other investigations may be requested on the basis of clinical suspicion. (ii)Diagnostic -Plain abdominal x-rays Erect and supine -CXR-Enema-Endoscopic techniques

ManagmenetI.V fluids and electrolytes rescusitation N.G tube if repeated vomitingAntibiotics Exploratory laparatomyHernia operationAdhesions AdhesiolysisObstruction removeVolvulus derotate and or operateMesenteric ischemia operateAbscess or peritonitis drain and treatIntussusception pneumatic or barium reduction or

operate

• SRB’s Manual of surgery, 4E• Bailey & Love’s Short practice of surgery, 25th

Edition• Principles of surgery • Internet

REFRENCES: