Intestinal Obstruction

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Intestinal Obstruction

• Dr Bina Ravi
• Associate Professor and Consultant
• Department of Surgery

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Abdomen- Bowel sound

• Present- Mechanical obstruction
• Not present-
• Adynamic obstruction
• (no gas under diaphragm)
• Perforation
• (gas under diaphragm)

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Objectives

• Pathophysiology dynamic, adynamic
• Cardinal features history, examination
• Causes small, large gut obstruction
• Indications contraindications for conservative
  Mx

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Obstruction

• Dynamic peristalsis, mechanical obstruction
• Adynamic- paralytic ileus, non propulsive
  Mesenteric vascular obstruction or, pseudo
  obstruction

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Dynamic Obstruction

• Pain, distention, vomiting, absolute constipation
• Two- small gut high , low
• Large gut
• Acute , chronic, acute on chronic or, sub-acute
• Simple intact vascularity
• Strangulated compromised vascularity

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Intestinal obstruction Causes
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Causes Dynamic obstruction

• Intra-luminal impaction, FB, Bezoars, gallstones
• Intramural- strictures, malignancy
• Extra-luminal- bands/adhesions, hernia, volvulus,
  intussusception

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Adynamic obstruction-causes

• Paralytic ileus
• Mesenteric vascular occlusion
• Pseudo obstruction

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Pathophysiology

• Proximal gut dilates- altered motility
• Below the obstruction normal motility, immobile
• Proximal increased peristalsis, dilates,
  reduced peristalsis, flaccid
• Gas- bacteria. Aerobic/anaerobic, 90 N2
• Fluid- dig. Juices,

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Pathophysiology

• Dehydration and electrolyte imbalance
• Reduced intake
• Defective absorption
• Vomiting
• Sequestration in gut

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Strangulation

• Blood supply compromised
• Venous return first affected, arterial
• Hemorrhagic infarction
• Translocation and systemic exposure to microbes/
  toxins
• Morbidity/ mortality- age, extent, Peripheral
  vascular failure

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Closed loop obstruction

• Strangulation
• Distention
• Necrosis
• perforation

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Acute Intestinal Obstruction-CP

• Location, age of obstruction, pathology, ischemia
• Pain
• Vomiting
• Distension
• Constipation
• Dehydration, Hypokalemia, fever, abdomen
  tenderness

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• Pain severe, colicky, umbilical, lower abdomen
• Increases with peristalsis, later reduces
• Severe pain - strangulation

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Vomiting

• High obstruction- violent
• Low obstruction- slow onset nausea/vomit
• Gradually digestive food changes to feculent
  material

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Distension

• Greater if distal obstruction
• Visible peristalsis
• Peristalsis delayed in colonic obstruction
• Absent in Mesenteric vascular obstruction

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Constipation

• Absolute
• Relative
• Absent in Richters hernia, gallstone, MVO,
  Pelvic abscess, partial obstruction

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Dehydration

• Vomiting, fluid sequestration
• Dry skin, poor venous filling, sunken eyes,
  oliguria
• Raised blood urea, Hb, - secondary polycythemia

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Hypokalemia

• K, amylase, LDH strangulation, raised TLC or,
  leucopenia
• Fever indicates ischemia, perforation,
  inflammation
• Hypothermia septic shock

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Abdomen tenderness

• Localized ischemia
• Peritonitis infarction or, perforation

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Strangulation

• Diagnosis is clinical
• Features of obstruction
• Persistent pain, Shock, local tenderness
• Non-responsive to conservative Mx
• Hernia strangulation tender, irreducible,
  absent cough impulse, recent increase in size

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Radiology

• Supine/ erect plain abdomen films
• Small gut- central, transverse, no gas-colon
• Jejunum- valvulae connivantes
• Ileum- featureless
• Cecum- round gas in RIF
• Large gut- haustral folds

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Supine
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Sigmoid volvulus

• Dilated, no haustral pattern
• Small gut- air and fluid levels
• More the fluid levels, more distal the lesion

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Inv

• Plain x ray- impacted foreign body
• Fluid levels non obstructing conditions
  inflammatory bowel disease, acute pancreatitis,
  abdominal sepsis

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Treatment

• 3 measures
• Intestinal drainage
• Fluid and electrolyte replacement
• Relief of obstruction

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Surgical Mx

• Mx of segment at the site of obstruction
• The distended proximal bowel
• Underlying cause of obstruction

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Supportive

• NG tube drainage
• Na , water replacement
• Antibiotics

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Large gut

• Ca or diverticular disease
• Contrast study pseudo-obstruction
• Caecal perforation- caecostomy, ileostomy

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Adhesions/bands

• Commonest
• Fibrin adhesions-fibrinous, fibrous
• Appendectomy , gynaecological op.
• Bands- congenital, bacterial peritonitis, greater
  omentum causing band
• Mx- conservative 72 hrs lap adhesiolysis

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Special obstructions

• Int. hernia foramen of Winslow, hole in the
  mesentery, hole in transverse colon, defects in
  broad ligament, cong diaphragmatic hernia,
  paraduodenal fossae, intraperitoneal fossae
• Mx- release the ring, reduction of hernia

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Enteric strictures

• TB, Crohns, Ca, lymphomas, stricturoplasty
• Bolus obstruction food, gall stone,
  trichobezoars, phytobezoars, stercoliths, worms

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Ac Intussusception

• Proximal gut enters distal gut
• Adults lead point, polyp, submucosal lipoma,
  tumor,
• Colo-colic adults
• Pathology- inner tube, outer tube, returning of
  middle tube
• Strangulating obstruction- ileoileal, ileocaecal,
  ileocolic

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Clinical picture

• Severe attacks of pain lasts few minutes
• Later - red currant jelly stool
• Exam between episodes-50-60 sausage shaped lump
  empty RIF Sign de Dance
• P/R blood stained finger
• Later vomit, distension

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Radiology

• Plain film absent caecal gas
• Ba enema- claw sign
• CT scan
• Mx- Hydrostatic reduction with enema
• Operative reduction
• Recurrent 5- anchorage of ileum to ascending
  colon

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Differential diagnosis

• Acute enterocolitis
• Henoch Schoenlein perpura
• Rectal prolapse

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Volvulus

• Axial rotation of bowel at its mesentery
• Congenital or secondary
• Small intestine, caecum, sigmoid-common
• Small gut- spontaneous, vegetable consumption
  untwist
• Caecal clockwise- females- lap . Untwist,
  resection if gangrene

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Sigmoid

• Anticlockwise
• Bands, overloaded colon, large mesocolon, narrow
  pelvic mesocolic attachment

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Treatment

• Flexible sigmoidoscopy/ rigid
• Laparotomy- untwisting
• Viable fixing to retroperitoneum
• Resection Paul Mickulikz- gangrene
• Sigmoid colectomy/ Hartmanns procedure later
  re-anastomosis

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Compound volvulus

• Rare, ile-osigmoid knotting
• Gangrene
• Laparotomy - Decompression, resection and
  anastomosis

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Thanks
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