Intestinal obstruction

Dr nawin kumar

1. Dynamic- mechanical

obstruction

2. Adynamic- – Peristalsis –absent – Peristalsis -non-

propulsive form

Pathology

Proximal to obstruction– Altered mobility

– Distension

Distal to obstruction

– Normal peristalsis

– Absorption

Pathology

Proximal to obstruction – Altered mobility

– Distension

– Dilates

– flaccid

– Paralysis

• Exhaustion

• to prevent Viability

Distension

Gas– Swallowed air– Diffusion from blood– Products of digestion and bacterial activity– O2 & CO2 reabsorbed– Nitrogen 90% and H2S

Fluid– Digestive juice

– No absorption of food

• Electrolyte imbalance– Reduced intake– Defective intestinal absorption– Vomitintg– sequestration

• Distal to obstruction

– Normal peristalsis

– Absorption

– Empty and contracted

– immobile

• Veins compressed first - Edema

and hemorrhages

• Arterial compression –

Haemorrhagic infarction

• Translocation of bacteria, toxins

and systemic absorption

Strangulation External Internal

• Smaller absorptive surface

• Short segment – Less blood and fluid loss

• Larger absorptive surface

• Large segment – More blood and fluid loss - shock

Closed loop obstruction

• Obstruction both at proximal

and distal point

– Strangulated loops

– Colonic obstruction with a

competent ileocecal valve

Special types

• Internal hernia

• Entric stricture

• Bolus obstruction

• Adhesion and bands

• Intussusception

• volvulus

Clinical features

• Classical qurtet

1. Pain

2. Vomiting

3. Distension

4. Constipation

pain

• Colicky

• Mild constant diffuse

• severe

vomiting

• Proximal- more vomiting

• With time– Undigested food to faeculant

distension

• More distal- more distension

constipation

• Absolute

• Relative

• Absent in– Richter’s hernia– Gall stone obstruction– Mesentric vascular obstruction– obstruction with pelvic abscess– Partial obstruction- faecolith, neoplasm

Levels

• Small bowel obstruction– High– low

• Large bowel obstruction

Levels

• Small bowel obstruction- High– Early vomiting– Rapid dehydration– Minimal distension– X ray -fluid level ?

Levels

• Small bowel obstruction- low– Pain- prominent– Late vomiting– Central distension– X ray -fluid level - multiple

Levels

• Large bowel obstruction– Early distension, severe– Late vomiting, dehydration– Pain mild– X ray –caecum , ascending colon distended

Nature of presentation

• Acute- SB, sudden onset of pain• Chronic- LB, constipation,

distension• Acute on Chronic- recurrant• Subacute- constipation?

Other features

• Dehydration

• Hypokalemia

• Pyrexia –

Ischemia/perforation/Inflammatory obs.

• Hypothermia

• Abdominal tenderness

Type of presentation

• Simple – Intact blood supply

• Strangulated – Compromised blood supply

Signs of strangulation

• Continous pain

• Localised tenderness, rigidity,

rebound tenderness

• Shock

• Does not respond to conservative

management

Radiology

• X – ray abdomen ErectAir fluid levels

• X – ray abdomen SupineDistended bowel

Small bowel

• Central and transverse lie

• Jejunum – Valvulae conniventes

(concertina / Stack of coins)

• Ileum – Characterless

• Colon – Haustral folds

Treatment

• Gastrointestinal drainage

• Fluid and electrolyte replacement

• Relief of obstruction

Timing of surgery• Emergent

Obstructed/strangulated Ext hernia

Internal intestinal strangulation

Acute obstruction

• Other cases

Atleast within 24 hrs

• Adhesions

upto 72hrs

Principles of Surgical intervention

• Mt. of the segment at the site of

obstruction

• The distended proximal bowel

• Underlying cause of obstruction

assessment

• Site of obstruction

• Nature of obstruction

• Viability of gut

Site of obstruction

Caecum

Dilated Not dilated

Large bowel Small bowel

Trace distally Trace proximally

Nature of obstruction

Viability of bowelViable

Dark color – Light Dark persists

Mesentery bleeds on pricking

No bleeding

Peritoneum – Shiny Dull & Lustreless

Int Musc – Firm, Peristalsis seen

Flabby, thin, friable

Non viable

Mesenteric pulsation + Absent

Doubtful – Resected ends as stomas

No resection / Multiple ischaemic areas (Mesenteric Vasc Occlusion)

2nd look laparotomy after 24-48hrs

Surgical procedure

• Adhesiolysis

• Excision / Resection

• Bypass / Proximal decompression

Operative decompression

• Compromise of Exposure / Viability / Closure

• Septic complications of spillage

• Savage’s decompressor / NG tube

• Replace fluid

Large bowel obstruction

Caecum to Prox trans colon

– Rt. Hemicolectomy, if resectable

– Ileotransverse bypass if not

resectable

Splenic flexure

– Extended Rt.Hemicolectomy

Left colon / Rectosigmoid

• Decompression proximal colostomy

• Resection with – Anastamosis with covering colostomy– Paul Mikulicz procedure– Hartmann’s procedure

Thank youThank you

SPECIAL TYPES

• internal hernia• Enteric Stricture• Bolus obstruction

– Gallstone – Food– Bezoars

• Adhesion and bands• Intussusception• volvulus

INTERNAL HERNIA

• Internal hernia– Retroperitoneal fossa

• Duodenal fossa-– Left– right

• Caecal/appendicaeal fossa– Superior– Inferior– retrocaecal

• Intersigmoid fossa

– Congenital peritoneal defect• Foramen of winslow• Hole in mesentry, mesocolon, broad ligament

– Diaphragmatic hernia

• Duodenal fossa-

– Left– right

• Caecal/appendicaeal fossa

– Superior

• Caecal/appendicaeal fossa

– Inferior

• Retrocaecal fossa

intersigmoid

Foramen of winslow

• Release the constriction agent by division

• Donot-• Duodenal fossa-

• Foramen of winslow

• Hole in mesentry, mesocolon, broad ligament

• Decompress and reduce

Enteric Stricture

• Benign– TB– Chrohn’s

• Malignant– Lymphoma– Ca – sar

Enteric Stricture

• t/t– RA– stricturoplasty

bolus

• Gall stone

• Food

• Bezoars

• Stercolith

• worms

Gall stone

• Fistula

• 60 cm proximal to IC

• Ball valve effect

• t/t– Crush– Milk– Enterotomy– Faceted stone

food

• Post gastrectomy

• t/t– same

bezoars

• Trychobezoars

• Phytobezoars

stercolith

• Diverticula

• Stricture

worms

• Ascariasis

• Follow anti helminthic therapy

• perforation

• X ray- medusa head

• t/t

Adhesions

• Most common cause

• Difficult to differentiate from paralytic ileus

Causes• Ischaemic areas

• Foreign material

– Talc

– Starch

– gauze

– silk

• Infection – Peritonotis

– TB

• Inflammatory conditions-

• Radiation enteritis

• Drugs – Practolol

Peritoneal irritation

Local fibrin production

Adhesion between apposed surfaces

Early fibrinous adhesions Late fibrous adhesions

Prevention

• Good Surgical technique

• Peritoneal wash

• Minimizing contact with gauze

• Covering anastamosis & raw

peritoneal surfaces

Classification

• Early / Flimsy

• Late/ Dense

Bands

• Congenital

• Acquired

– Peritonitis

– Greater omentum adherent to

parietes

Treatment

• Conservative

– NPO

– RT aspiration

– IV fluids

– Vital signs & Abd. girth monitoring

– Signs of strangulation

– Maximum 72hrs

Surgery

• Adhesiolysis

– Only those causing obstruction

– Covering with omental grafts

– Constriction sites

Recurrent adhesive obstruction

• Repeat Adhesiolysis

• Noble’s plication procedure

• Charles phillip Transmesenteric plication

• Intestinal intubation

intussusception

• Telescoping

• Proximal to distal

• Children- 5-10 yr

• follow URTI

• weaning

Lead point

Inner tubeMiddleouter

types

• Strangulating

• t/t

• Radiological reduction

• Sx

volvulus

• Primary– Volvulus neonatorum– Sigmoid– Caecal– Gastric– midgut

• Secondary

Sigmoid volvulus

• Anticlockwise

• BONE

• X-ray

• Inner tube

• Cofee bean

• t/t

• Endoscopic reduction

• Sx

Caecal volvulus

• mobile

Compound volvulus

• Ileosigmoid knotting