What is Intestinal Obstruction?

Intestinal obstruction is blockage of the inside of the intestines by an actual mechanical obstruction.
Some causes include adhesions (scar tissue), foreign bodies, intussusception, ischemia (decreased
blood supply), hernias, volvulus (twisting) or tumors. As blockage occurs gas and air distend the
bowel proximal (closest) to the blockage. As the process continues, gastric (stomach), bilious (bile
from the liver used in digestion) and pancreatic secretions (secretions from the pancreas used for
digestion) begin to form a pool. Water, electrolytes and proteins accumulate in the area. This
pooling and bowel distention decrease the circulating blood volume and the blood supply to the
bowel tissue. Strangulation of a bowel segment may cause necrosis (death of the tissue),
perforation (a hole), and loss of fluid and blood. Since intestinal contents cant go downstream from
the stomach, nausea and vomiting occur in most patients.
Examples of Causes of Intestinal Obstruction

Obstruction due to hernia

Obstruction due to
intussusception

Obstruction due to mesenteric

occlusion

Obstruction due to volvulus

Obstruction due to tumor

Obstruction due to adhesions

What is Ileus?
Ileus is a functional rather than mechanical obstruction of the bowel. It is a lack of propulsive
peristalsis (wave-like movement) of the bowel. It stops the movement of bowel contents downward.
There is abdominal distention and an absence of bowel sounds. Ileus may be the result of
anesthesia, interruption of nerve supply to the bowel, intestinal ischemia (obstruction of circulation),
abdominal wound infections, electrolyte imbalance (loss of potassium leads to lack of intestinal
peristalsis) or metabolic diseases. The result of ileus is the distention of the bowel with gas and
fluid. The process is similar to obstruction. Your nurse or pediatric surgeon will be happy to answer
any of your questions.

Etiology

Common causes of mechanical obstruction are adhesions, hernias, tumors, foreign bodies
(including gallstones), inflammatory bowel disease (Crohn's disease), Hirschsprung's
disease, fecal impaction, and volvulus.
Obstruction of the small bowel: Small-bowel (jejunoileal) obstruction is commonly
caused by incarceration in hernias or by adhesions and is less commonly caused by tumors
(primary or metastatic), obturation by foreign bodies, a Meckel's diverticulum, or Crohn's
disease. Ascaris infestation is rare in the USA but occurs in some tropical countries.
Volvulus of the midgut is rare. Intussusception in adolescents and adults is almost always
caused by tumors. In infants, it is usually caused by meconium ileus, volvulus of a
malrotated gut, atresia, and intussusception
Obstruction of the duodenum: Duodenal obstruction is usually caused by cancer,
primarily in the duodenum or head of the pancreas. In neonates, duodenal obstruction is
most commonly caused by atresia, volvulus, bands, congenital esophageal webs, and
annular pancreas. In rare instances, congenital webs persist into adult life and lead to
deformities (eg, the so-called intraluminal diverticula associated with obstruction).
Obstruction of the large bowel: Large-bowel obstruction is caused by tumors,
diverticulitis, volvulus, and fecal impaction. Tumors include cancer that blocks the lumen
and rare benign lesions (eg, lipomas, large polyps) that can lead to intussusception.
Obstructing cancer occurs most often at the splenic and sigmoid flexures, diverticulitis
usually obstructs in the sigmoid, and volvulus is most common in the sigmoid or cecum

Pathophysiology
In simple mechanical obstruction, blockage occurs without vascular or neurologic
compromise. Ingested fluid and food, digestive secretions, and gas accumulate in excessive
amounts if obstruction is complete. The proximal bowel distends, and the distal segment
collapses. The normal secretory and absorptive functions of the mucous membrane are
depressed, and the bowel wall becomes edematous and congested. Severe intestinal
distention is self-perpetuating and progressive, intensifying the peristaltic and secretory
derangements and increasing the risks of dehydration, ischemia, necrosis, perforation,
peritonitis, and death.
In strangulating obstruction, infarction of the bowel is most commonly associated with
hernia, volvulus, intussusception, and vascular occlusion. Strangulation usually begins with
venous obstruction, which may be followed by arterial occlusion, resulting in rapid
ischemia of the bowel wall. The bowel becomes edematous and infarcted, leading to
gangrene and perforation.

Symptoms, Signs, and Diagnosis

Obstruction of the small bowel: Diagnosis of simple obstruction is based on a triad of

symptoms: (1) Abdominal cramps are centered around the umbilicus or in the epigastrium;
if cramps become severe and steady, strangulation probably has occurred. (2) Vomiting
starts early with small-bowel and late with large-bowel obstruction. (3) Obstipation occurs
with complete obstruction, but diarrhea may be present with partial obstruction.
Strangulating obstruction occurs in nearly 25% of cases of small-bowel obstruction and
can progress to gangrene in as little as 6 h; it is manifested by steady, severe abdominal
pain from the outset or beginning a few hours after the onset of crampy pain.
In the absence of strangulation, the abdomen is not tender. Hyperactive, high-pitched
peristalsis with rushes coinciding with cramps is typical. In strangulation, distention
increases, the abdomen becomes tender, and auscultation reveals a silent abdomen or
minimal peristalsis. Sometimes, a mass is palpable. However, only laparotomy can
definitively diagnose strangulation. Shock and oliguria are serious signs that indicate either
late simple obstruction or strangulation and must be treated promptly. If the site of
obstruction is unclear, colonoscopy sometimes can supplement rectal and pelvic
examinations.
Abdominal x-ray in both the supine and upright positions usually confirms diagnosis. A
ladderlike series of small-bowel loops usually is typical but also occurs with an obstructing
lesion of the right colon. Fluid levels in the bowel can be seen in upright views. Distended
loops may be absent with an obstruction of the upper jejunum. With closed-loop
strangulating obstructions (as may occur with volvulus), the radiologist may find no
distended loops but may find a mass suggesting infarcted bowel. A barium enema can
usually rule out colonic lesions. In questionable cases of small-bowel obstruction, oral
barium can be given but is contraindicated if obstruction is believed to be in the colon.
Obstruction of the large bowel: Symptoms usually develop more gradually than with
small-bowel obstruction. Increasing constipation leads to obstipation and abdominal
distention. If the ileocecal valve is competent, there may be no vomiting; if it allows reflux
of colonic contents into the ileum, vomiting may occur (usually several hours after onset of
symptoms). Lower abdominal cramps unproductive of feces are present.
Physical examination typically shows a distended abdomen with loud borborygmi. There is
no tenderness, and the rectum is usually empty. A mass corresponding to the site of the
obstructing tumor may be palpable. Unlike in small-bowel obstruction, adhesions rarely
obstruct the colon. Strangulation (except with volvulus) is rare. However, obstruction may
lead to marked distention and cecal rupture. Perforation of a tumor or of a diverticulum also
may occur at the obstruction site. Systemic symptoms with large-bowel obstruction are far
less serious than with small-bowel obstruction; fluid and electrolyte deficits are uncommon.
If the obstructing lesion is cancer or diverticulitis, abdominal x-ray shows distention of the
colon proximal to the lesion. If the cecum is dilated to a diameter of 13 cm, the danger of
rupture is high and immediate operation is indicated. Preliminary endoscopy or barium
enema should be performed for precise location of the obstruction. If used, endoscopy

should precede barium studies.

Volvulus often has an abrupt onset. Potential strangulation of blood supply and gangrene
are always present. Cecal volvulus can be diagnosed on abdominal x-ray by a large gas
bubble in the midabdomen or the left upper quadrant. Sigmoidal volvulus usually occurs in
the elderly. With both cecal and sigmoidal volvulus, a barium enema shows the site of
obstruction by a typical bird-beak deformity at the site of the twist.

Treatment
Every patient with possible intestinal obstruction should be hospitalized. Treatment of acute
intestinal obstruction must proceed simultaneously with diagnosis. Therapy must be based
on the fact that surgery is necessary to definitively diagnose strangulating obstruction.
Obstruction of the small bowel: A nasogastric tube is inserted and placed on suction.
Simple intubation with a long intestinal tube, rather than surgery, may be attempted in
treating early postoperative obstruction or repeated obstruction caused by adhesions in the
absence of peritoneal signs. Most surgeons favor early laparotomy, although often it is
delayed 2 or 3 h to improve the status and obtain a urine output in a very ill, dehydrated
patient.
An inlying bladder catheter helps monitor urinary output. IV fluids (preferably lactated
Ringer's solution) and electrolytes are started. In cases of repeated vomiting, serum Na and
K are likely to be depleted and must be replaced. Fluid balance charts must be maintained
continuously, and serum electrolytes should be determined at least daily. In dehydrated
patients, a central venous pressure line is helpful. Surgery removes the offending lesion
whenever possible. Procedures to prevent recurrence should be performed, including repair
of hernias, removal of foreign bodies, and complete lysis of adhesions.
Obstructing gallstones are removed by lithotomy; cholecystectomy can be performed
either simultaneously or later. Bezoars, another cause of obturation, can be removed
endoscopically. More often, these are removed by enterotomy at laparotomy. Disseminated
intraperitoneal cancer involving the small bowel is a major cause of death from intestinal
obstruction in adults. Any attempt to bypass an obstruction is likely to help only briefly.
Treatment of obstruction of the duodenum in adults consists of resection or, if the lesion
cannot be removed, palliative gastrojejunostomy
Obstruction of the large bowel: Treatment is essentially the same as for small-bowel
obstruction. Nasogastric suction, IV fluids and electrolytes, and a urinary catheter are
needed before emergency operation.
Obstructing cancers of the colon can often be treated by a single-stage resection and
anastomosis. Other options include a diverting colostomy and anastomosis. Rarely,
diverting colostomy with delayed resection is required. When diverticulitis causes

obstruction, it may be associated with perforation. Removal of the involved area may be
very difficult but is indicated if perforation and general peritonitis are present. Resection
and a colostomy are performed, and anastomosis is postponed. Fecal impaction usually
occurs in the rectum and can be removed digitally. However, a fecal concretion alone or a
mixture with barium or antacids that produces complete obstruction (usually in the sigmoid)
requires laparotomy.
Treatment of cecal volvulus consists of either resection and anastomosis of the involved
segment or fixation of the cecum in its normal position by cecostomy. In sigmoidal
volvulus, a typical distended loop of the sigmoid can be seen on the abdominal x-ray. The
endoscope or a long rectal tube can usually decompress the loop, and resection and
anastomosis may be deferred for a few days. Without a resection, recurrence is almost
inevitable.