INTESTINAL

OBSTRUCTION
MSU Medical Students.
Batch 2.
Group 2.
 CONTENTS
• Definition
• Introduction
• Etiologies
• Categories
• Pathophysiologiy
• Clinical Manifestation
• Investigations
• Treatment
• Complication
 Definition
• Intestinal obstruction is a partial or complete
blockage of the bowel caused by whether
mechanical or functional obstruction of the
intestines that results in the failure of the
intestinal contents to pass through.
 Introduction
• Mechanical obstruction is divided into:
a)Obstruction of the small bowel (including the
duodenum) and
b)Obstruction of the large bowel.
• Obstruction may be partial or complete.
a)About 85% of partial small-bowel obstructions
resolve with non-operative treatment,
whereas
b)About 85% of complete small-bowel
obstructions require operation.
 Etiologies
• Overall, the most common causes of
mechanical obstruction are adhesions,
hernias, and tumors.
• Other general causes are diverticulitis, foreign
bodies (including gallstones), volvulus
(twisting of bowel on its mesentery),
intussusception (telescoping of one segment
of bowel into another and fecal impaction.
• Specific segments of the intestine are affected
differently.
 Aetiologies
LOCATION CAUSES
Colon •Tumors (usually in left colon)
•Diverticulitis (usually sigmoid)
•Volvulus (sigmoid or cecum)
•Fecal impaction
•Hirschprung's disease

Duodenum Adult •Cancer of duodenum

•Cancer of head of pancreas
•Ulcer disease

Neonates •Atresia
•Volvulus
•Bands
•Annular pancreas
 LOCATION CAUSES
Jejunum and Ileum Adult •Hernias
•Adhesions (common)
•Tumors
•Foreign body
•Meckel's diverticulum
•Crohn's disease (uncommon)
•Ascaris infestation
•Midgut volvulus
•Intussusception by tumor (rare)
Neonates •Meconium ileus
•Volvulus of malrotated gut
•Atresia
•Intussusceptiom
 Categories
• Complete or Partial
• Mechanical versus Functional
• Small versus Large intestine
• Acute, Sub-Acute, Chronic
 Mechanical vs. Functional
A. Mechanical
1.Extraluminal: adhesions (bands of scar tissue),
hernias, volvulus (twisted bowel), tumours.
2.Intramural: tumors, IBD (e.g Crohn’s),
strictures, paralytic, intussusception
(telescoping bowel)
3.Intraluminal (partial or complete): foreign
bodies, fecal impaction, gallstones, bezoars,
worms
 Mechanical vs. Functional
B. Functional – Paralytic Ileus
• Failure of peristalsis to move intestinal contents:
adynamic ileus (paralytic ileus, ileus) due to neurologic or
muscular impairment
• Accounts for most bowel obstructions
• Causes include
a. Post gastrointestinal surgery
b. Tissue anoxia or peritoneal irritation from hemorrhage,
peritonitis, or perforation
c. Hypokalemia
d. Medications: narcotics, anticholinergic drugs,
antidiarrheal medications
e. Spinal cord injuries, uremia, alterations in electrolytes
 Pathophysiology
1) In simple MECHANICAL obstruction, blockage occurs without
vascular compromise.
2) Ingested fluid and food, digestive secretions, and gas
accumulate above the obstruction.
3) The proximal bowel distends, and the distal segment
collapses.
4) The normal secretory and absorptive functions of the mucosa
are depressed, and the bowel wall becomes edematous and
congested.
5) Severe intestinal distention is self-perpetuating and
progressive, intensifying the peristaltic and secretory
derangements and increasing the risks of dehydration and
progression to strangulating obstruction.
6) Strangulating obstruction is obstruction with
compromised blood flow; it occurs in nearly 25% of
patients with small-bowel obstruction.
7) It is usually associated with hernia, volvulus, and
intussusception.
8) Strangulating obstruction can progress to infarction and
gangrene in as little as 6 h.
9) Venous obstruction occurs first, followed by arterial
occlusion, resulting in rapid ischemia of the bowel wall.
10) The ischemic bowel becomes edematous and infarcts,
leading to gangrene and perforation.
11) In large-bowel obstruction, strangulation is rare (except
with volvulus).
12) Perforation may occur in an ischemic segment (typically
small bowel) or when marked dilation occurs.
13) The risk is high if the cecum is dilated to a diameter ≥
13 cm.
14) Perforation of a tumor or a diverticulum may also occur
at the obstruction site.
 Pathophysiology
• COLICKY PAIN due to excessive contraction
• PROXIMAL DISTENSION due to accumulation
of fluid, gas
• Impaired absorption of fluid and electrolyte
-DEHYDRATION
• SEPSIS - bacterial overgrowth due to stasis
• Impairment of venous & arterial flow -
STRANGULATION, INFARCTION,
PERFORATION
 Clinical Features
• Colicky low abdominal
pain
• Vomiting
• Abdominal distension
• Absolute constipation
• Others - dehydration,
fever, tachycardia,
oliguria, hypotension,
peritonism
Manifestations Small Bowel Obstruction
a. Vary depend on level of obstruction and speed of
development
b. Cramping or colicky abdominal pain, intermittent,
intensifying
c. Vomiting
1. Proximal intestinal distention stimulates vomiting center
2. Distal obstruction vomiting may become feculent
d. Bowel sounds
1. Early in course of mechanical obstruction: borborygmi
and high-pitched tinkling, may have visible peristaltic
waves
2. Later silent; with paralytic ileus, diminished or absent
bowel sounds throughout
e. Signs of dehydration
Manifestation Large Bowel Obstruction
a. Only accounts for 15% of obstructions
b.Causes include cancer of bowel, volvulus,
diverticular disease, inflammatory disorders,
fecal impaction
c. Manifestations: deep, cramping pain; severe,
continuous pain signals bowel ischemia and
possible perforation; localized tenderness or
palpable mass may be noted
 Investigation
• FBC
• Electrolytes and Urea
• Plain supine AXR - dilated SB, central, valvulae
coniventes, air fluid level
• Contrast X-rays – barium/gastrograffin follow-
through/enema
• CT scan with oral contrast
 Treatment 1 - Resuscitation

• NBM
• Fluid replacement - IV fluid
• IV antibiotic
• Correction of electrolyte imbalance
• Nasogastric suction
• Monitoring - vital signs, fluid balance
• Adequate analgesia
 Treatment 2 - Surgery
Indications
• Non-resolving or failure of conservative treatment
• Perforation / peritonitis
• Underlying disease e.g hernia, crohns, tumour

 Avoid in obstruction due to adhesions

 High mortality in poorly resuscitated patients
 Treatment 3
• Resuscitation
• Surgery
a. Laparotomy
b. Hemicolectomy- Right / extended right / left
c. Sigmoid colectomy
d. Anterior resection
e. Abdominoperineal resection
f. Hartmann’s procedure
g. Colostomy

• Staged laparotomy
1, 2 or 3-stage procedures
Complications
a. Hypovolemia and hypovolemic shock can
result in multiple organ dysfunction (acute
renal failure, impaired ventilation, death)
b.Strangulated bowel can result in gangrene,
perforation, peritonitis, possible septic shock
c. Delay in surgical intervention leads to higher
mortality rate
SBO
SBO
SBO
Intussusception Volvulus
 Large-bowel obstruction. This
chest radiograph demonstrates
Abdominal (KUB) film of a patient
free air under the diaphragm,
with obstipation. Dilation of the
indicating bowel perforation.
colon is associated with large-bowel
obstruction.
 Large-bowel obstruction.
Large-bowel obstruction. Contrast
Gastrografin study in a patient
study demonstrates colonic
with obstipation reveals
obstruction at the level of the splenic
colonic obstruction at the
flexure, in this case due to carcinoma.
rectosigmoid level.
 Large-bowel obstruction.
Abdominal (KUB) radiograph
depicting massive dilation of
the colon due to a cecal
volvulus.
Large-bowel obstruction.
Contrast study of patient with
cecal volvulus. The column of
contrast ends in a "bird's beak"
at the level of the volvulus.
Large-bowel obstruction.
Massive dilation of the
colon due to a sigmoid
volvulus.
 References
1. Merck Manual Professional
2. eMedicine (http://emedicine.medscape.com)
3. MedlinePlus (http://medlineplus.gov)