intestinal obstruction bs

7/27/2019 intestinal obstruction bs

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Intestinalobstruction


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Intestinalobstruction

Mechanicalobstruction

Paralytic

Ileus


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Paralytic Ileus

After abdominal surgery (laparotomy) Electrolyte imbalances (hypokalemia)

Abdominal thrauma

Spine fracture

Retroperitoneal hemorrhage Ureter distensionAcute pancreatitis

Ischemia of the intestine

Drugs (Narcotics, Psychotropics)

Peritonitis (ex. Gangrenous cholecystitis)

Diabetic coma

Extra abdominal infections (Lung)Sepsis

IBD (ulcerative colitis)


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Intestinalmechanicalobstruction

Pathogenesis

Stenosis

Obstruction

Compression Invagination

Torsion

Angulation

Strangulation


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IntestinalobstructionPattern in Africa

40%

16%

14%

14%

10%

3% 3%

Adhesions

Hernia

Small Intest volvolus

Intussusception

Sigmoid volvolus

Ascaris

Large bowel tumor

70 % of the patients were below the age of 15 years

80% with gangrenous bowel segments


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Large gallstones -- cholecystoenteric fistulagallstoneileus

Bezoars (children, mentally retarded, toothless, aftergastrectomy)

Congenital lesions (atresia, stenosis, duplication) Neoplasms of small bowelperitoneal carcinosis

Inflammation (Chrons disease- diverticulitis- BK-endometriois)

Fecal impaction (bedridden old patient) Meconium

Foreign bodies

Iatrogenic strictures (intest. Anastomosis o RT)

Intestinal

mechanicalobstruction

Etiology


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http://www-cdu.dc.med.unipi.it/Archives/photogallery/SmallBowelInfarction/images/Diapositiva03_JPG.jpg


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Accumulation of fluids and gas proximal to the

obstruction

Simple mechanicalobstructionPATHOGENESIS

Distention of the intestine (self perpetuating)

Increase intestinal secretion

Losses of water, Na, Cl, K, H

Dehydratation, ipokalemia, hypochloremia

Metabolic alkalosis


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Circultory changes

Low central venous pressure

Reduced cardiac output

Hypotention

Hypovolemic shock

Rapid proliferation of intestinal bacteria

Toxiemia

Simple mechanicalobstructionPATHOGENESIS


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Paralytic Ileus

Mechanical

obstruction
http://www.filebuzz.com/software_screenshot/full/34734-7art_fluorescent_clock_screensaver.jpg


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Ischemia of the bowel

Strangulation obstructionPATHOGENESIS

Loss of blood and plasma into the strangulatedsegment

Gangrene Perforation

Peritonitis

Sistemic absorption of toxic materia


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Intestinal obstruction

Clinical aspects

Abdominal pain

Vomiting

Obstipation

Abdominal distention

Failure to pass flatus

Fever

Dehydratation

Hypotentionhypovolemic shock


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Pain

Typical crampy pain in paroxysm at 4 to 5

minute intervals in proximal obstruction

Less frequently in distal occlusion

After a long period of mechanical obstruction

the crampy pain may subside

A strangulation should be suspected whencontinuus severe pain replace crampy pain


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Vomiting

Proximal obstruction produce profuse

vomiting and little abdominal distension

Distal obstruction is less frequent but feculent

Initial phase byliary aspect

Late phase feculent

BUT


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Intestinal obstruction - LevelHIGH LOW

PAIN Crampy pain in paroxism Less intensity

VOMITING Early, profuse, biliary Late, feculent may be

absent

METEORISM + +++

BEGINNING Acute Slow, insidious

ABDOMINAL

DISTENTION

Moderate, upper

quadrant

Early, intense

GENERAL CONDIT Early compromission preserved

ELECTOLYTES Cl, K, Na rapid loss Late hydro electrolytic

imbalance


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Intestinal obstruction Clinical examination

Palpation abdominal masses can suggest neoplasms,intussusception, abscess

Incarcerated hernias may be obscure (obese)

Surgical scars can suggest adhesions Abdominal auscultation period of increasing separated by

periods of quite bowel sounds (high pitched, tinkling or

musical) in mechanical obstruction

Rectal examination to seek luminal masses. Blood in the

feces suggest mucosal lesion (cancer, intussusception,

infarction)

Key points


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Intestinal obstruction Clinical examination

Young children and babies

Atresia

Volvolus

Anal imperforation Meconial ileus

Intestinal Duplication

Malrotation Intussusception

Ascaris infestation

Hernia

Patient age and sex

Adults

Hernia

Adhesions

Neoplasm

Inflammation

RT

Endometriosis

Gynecological

pathology


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Gas abnormally large quantities of gas in the bowel

Multiple gas-fluid levels in the upright or lateral decubitusposition

Abdominal direct X ray

exhamination


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Multiple gas-fluid levels does not always mean intestinal

obstruction

Abdominal pain and diarrhea can be found in

gastroenteritis (cytomegalovirus infection as well as

salmonellosis) expecially if profuse watery for 12 or morehours.

Abdominal direct X ray exhamination

Remember


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Identify the distended tract

Small bowel Colon

Both plus stomach

Radiological examination

What can we see


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Gas in the small bowel

outlines the

valvulae

conniventes, which

usually occupy the

entire trasverse

diameter of the

bowel image


Small bowel


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Colonic haustral

marking occupy

only a portion of

the transverse

diameter of the

bowel


large bowel


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Intestinal obstructionRadiological examination

Typical the small bowel pattern occupies themore central portion of the abdomen, the

colon shadow is on the periphery of the

abdominal film or in the pelvis


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Intestinal obstructionRadiological examination

Duringparalytic ileus gaseous distention

occurs somewhat uniformly in the stomach,

small intestine and colon


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Helpful in distal occlusion may be

operative in intussusception

Barium Enema


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Is sensitive for diagnosing complete

obstruction of the small bowel and

determining the localization and causeof obstruction

CT scan


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Proximal

obstruction

Distal

obstruction
http://radiographics.rsnajnls.org/content/vol26/issue3/images/large/g06ma02g12c.jpeghttp://radiographics.rsnajnls.org/content/vol26/issue3/images/large/g06ma02g12b.jpeg


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Hematocrit

WBC Electrolytes

PCR (C reactive protein)

AST -ALTGGT- LDH

Laboratory test


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Fluid and electrolytes therapy

Intestinal decompression (NG tube) Diuresys monitoring

Correct surgical timing for relief of

obstruction

Treatment


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Duration of obstruction

Severity of fluid, electrolyte and acidbase abnormalities

Opportunity to improve vital organ

function Consideration of the risk of

strangulation

Timing of operation depends

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