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Small bowel obstruction

Mechanical obstruction
Aetiology
Small bowel obstruction accounts for 5% of acute surgical admissions
In UK the commonest causes are:
o Adhesions (60%)
o Strangulated hernia (20%)
o Malignancy (5%)
o Volvulus (5%)
Pathophysiology

Proximal dilatation occurs above obstructing lesion


Results in the accumulation of gas and fluid and reduced reabsorption
Dilation of the gut wall produced mucosal oedema
This impairs venous and then arterial blood flow
Intestinal ischaemia eventually results in infarction and perforation of that
segment of bowel
Ischaemia also results in bacterial and endotoxin translocation
The overall effect is progressive dehydration, electrolyte imbalance and
systemic toxicity
Clinical feature

Colicky central abdominal pain


Vomiting - early in high obstruction
Abdominal distension - extent depends on level of obstruction
Absolute constipation - late feature of small bowel obstruction
Dehydration associated with tachycardia, hypotension and oliguria
Features of peritonism indicate strangulation or perforation

Investigation

Supine abdominal X-ray shows dilated small bowel


May be normal if no air fluid interfaces
Valvulae coniventes differentiate small from large intestine
Erect abdominal film rarely provided additional information

Management
Adequate resuscitation prior to surgery is vital
May require more than 5 litres of intravenous crystalloid
Adequacy of resuscitation should be judged by urine output or central venous
pressure
Surgery in under resuscitated patient is associated with increased mortality
If obstruction presumed to be due to adhesions and there are no features of
peritonism
o Conservative management for up to 48 hours is often safe

o Requires regular clinical review


If features of peritonism or systemic toxicity present
o Need to consider early operation
o Exact procedure will depend on underlying cause
Indications for surgery
Absolute
o Generalised peritonitis
o Localised peritonitis
o Visceral perforation
o Irreducible hernia
Relative
o Palpable mass lesion
o 'Virgin' abdomen
o Failure to improve
Trial of conservatism
o Incomplete obstruction
o Previous surgery
o Advanced malignancy
o Diagnostic doubt - possible ileus

Paralytic ileus

Functional obstruction most commonly seen after abdominal surgery


Also associated with trauma, intestinal ischaemia, sepsis
Small bowel is distended throughout its length
Absorption of fluid, electrolytes and nutrients is impaired
Significant amounts of fluid may be lost from the extracellular compartment

Clinical features

Usually history of recent operation or trauma


Abdominal distension is often apparent
Pain is often not a prominent feature
If no nasogastric tube in-situ vomiting may occur
Large volume aspirates my occur via nasogastric tube
Flatus will not be passed until resolution of the ileus
Auscultation will reveal absence of bowel sounds

Investigation

Plain abdominal x-ray may show dilated loops of small bowel


Gas may be present in the colon
If doubt as to whether there is a mechanical or functional obstruction
Water soluble contrast study may be helpful

Management

Prevention is better than cure


Bowel should be handled as little as possible
Fluid and electrolyte derangements should be corrected
Sources of sepsis should be eradicated
For an established ileus the following will be required
o Nasogastric tube
o Fluid and electrolyte replacement
o No drugs are available to reverse the condition
Usually resolves spontaneously after 4 or 5 days

Bibliography
Coleman M G, Moran B J. Small bowel obstruction. In: Johnson C D, Taylor I eds.
Recent advances in surgery 22. Churchill Livingstone, Edinburgh ,1999; 87-98.
Burke M. Acute intestinal obstruction: diagnosis and management. Hosp Med
2002; 63: 104-107.
Luckey A, Livingstone E, Tache Y. Mechanisms and treatment of postoperative
ileus. Arch Surg 2003; 138: 206-214.

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