Textbook Discussion

INTESTINAL OBSTRUCTION
Intestinal obstruction exists when blockage prevents the normal ow of intestinal
contents through the intestinal tract. Two types of processes can impede this ow:
Mechanical obstruction: An intraluminal obstruction or a mural obstruction from
pressure on the intestinal wall occurs. Examples are intussusception, polypoid tumors and
neoplasms, stenosis, strictures, adhesions, hernias, and abscesses.
Functional obstruction: The intestinal musculature cannot propel the contents along the
bowel. Examples are amyloidosis, muscular dystrophy, endocrine disorders such as
diabetes mellitus, or neurologic disorders such as Parkinsons disease. The blockage also
can be temporary and the result of the manipulation of the bowel during surgery.
The obstruction can be partial or complete. Its severity depends on the region of
bowel affected, the degree to which the lumen is occluded, and especially the degree to
which the vascular supply to the bowel wall is disturbed. Most bowel obstructions occur
in the small intestine. Adhesions are the most common cause of small bowel obstruction,
followed by hernias and neoplasms. Other causes include intussusception, volvulus (ie,
twisting of the bowel), and paralytic ileus. Most obstructions in the large bowel occur in
the sigmoid colon. The most common causes are carcinoma, diverticulitis, inammatory
bowel disorders, and benign tumors.

Mechanical causes of intestinal obstruction

Cause Course of Events Result

Adhesions Loops of intestine become adherent to After surgery, adhesions

areas that heal slowly or scar after produce a kinking of an
abdominal surgery; occurs most intestinal or loop
commonly in small intestine.
Intussusception One part of the intestine slips into The intestinal lumen
another part located below it (like a becomes narrowed and
telescope shortening); occurs more blood supply becomes
commonly in infants than adults strangulated

Volvulus Bowel twists and turns on itself and Intestinal lumen becomes
occludes the blood supply obstructed. Gas and uid
accumulate in the trapped
bowel.
Hernia Protrusion of intestine through a Intestinal ow may be
weakened area in the abdominal muscle completely obstructed.
or wall. Blood ow to the area may
be obstructed as well.
Tumor A tumor that exists within the wall of the
intestine extends into the intestinal Intestinal lumen
lumen or a tumor outside the intestine becomes partially
causes pressure on the wall of the obstructed; if the tumor into
intestine. Most common type is colorectal the intestinal lumen, is not
adenocarcinoma. removed, complete
obstruction results.

Small Bowel Obstruction

Pathophysiology
 Intestinal contents, uid, and gas
accumulate above the intestinal obstruction. The
abdominal distention and retention of uid
reduce the absorption of uids and stimulate
more gastric secretion. With increasing
distention, pressure within the intestinal lumen
increases, causing a decrease in venous and
arteriolar capillary pressure. This causes edema,
congestion, necrosis, and eventual rupture or
perforation of the intestinal wall, with resultant
peritonitis. Reflux vomiting may be caused by
abdominal distention. Vomiting results in loss of
hydrogen ions and potassium from the stomach,
leading to reduction of chlorides and potassium
in the blood and to metabolic alkalosis.
Dehydration and acidosis develop from loss of
water and sodium. With acute uid losses,
hypovolemic shock may occur
Clinical Manifestations
The initial symptom is usually crampy pain that is wavelike and colicky. The patient
may pass blood and mucus but no fecal matter and no atus. Vomiting occurs. If the
obstruction is complete, the peristaltic waves initially become extremely vigorous and
eventually assume a reverse direction, with the intestinal contents propelled toward the
mouth instead of toward the rectum. If the obstruction is in the ileum, fecal vomiting
takes place. First, the patient vomits the stomach contents, then the bile stained contents
of the duodenum and the jejunum, and nally, with each paroxysm of pain, the darker,
fecal-like contents of the ileum. The signs of dehydration become evident: intense thirst,
drowsiness, generalized malaise, aching, and a parched tongue and mucous membranes.
The abdomen becomes distended. The lower the obstruction is in the GI tract, the more
marked the abdominal distention. If the obstruction continues uncorrected, hypovolemic
shock occurs from dehydration and loss of plasma volume.
Assessment and Diagnostic Findings
Diagnosis is based on the symptoms described previously and on imaging studies.
Abdominal x-ray and CT ndings include abnormal quantities of gas, uid, or both in the
intestines. Laboratory studies (ie, electrolyte studies and a complete blood cell count)
reveal a picture of dehydration, loss of plasma volume, and possible infection.
Large Bowel Obstruction
Pathophysiology
As in small bowel obstruction, large bowel
obstruction results in an accumulation of intestinal
contents, uid, and gas proximal to the obstruction.
It can lead to severe distention and perforation
unless some gas and uid can ow back through the
ileal valve. Large bowel obstruction, even if
complete, may be undramatic if the blood supply to
the colon is not disturbed. However, if the blood
supply is cut off, intestinal strangulation and
necrosis occur; this condition is life-threatening. In
the large intestine, dehydration occurs more slowly
than in the small intestine because the colon can absorb its uid contents and can distend
to a size considerably beyond its normal full capacity. Adeno carcinoid tumors account
for the majority of large bowel obstructions. Most tumors occur beyond the splenic
exure, making them accessible with a exible sigmoidoscope.
Clinical Manifestations
Large bowel obstruction differs clinically from small bowel obstruction in that the
symptoms develop and progress relatively slowly. In patients with obstruction in the
sigmoid colon or the rectum, constipation may be the only symptom for months. The
shape of the stool is altered as it passes the obstruction that is gradually increasing in
size. Blood loss in the stool may result in iron deciency anemia. The patient may
experience weakness, weight loss, and anorexia. Eventually, the abdomen becomes
markedly distended, loops of large bowel become visibly outlined through the abdominal
wall, and the patient has crampy lower abdominal pain. Finally, fecal vomiting develops.
Symptoms of shock may occur.
Assessment and Diagnostic Findings
Diagnosis is based on symptoms and on imaging studies. Abdominal x-ray and abdominal
CT or MRI ndings reveal a distended colon and pinpoint the site of the obstruction.
Barium studies are contraindicated.
Adhesions
An adhesion is a band of scar tissue
that binds 2 parts of your tissue that are
not normally joined together. Adhesions
may appear as thin sheets of tissue like
plastic wrap or as thick fibrous bands. The
tissue develops when the body's repair
mechanisms respond to any tissue
disturbance, such as surgery, infection,
trauma, or radiation. Although adhesions
can occur anywhere, the most common
locations are within the stomach, the
pelvis, and the heart.
Abdominal adhesions: Abdominal
adhesions are a common complication of
surgery, occurring in up to 93% of people
who undergo abdominal or pelvic surgery. Abdominal adhesions also occur in about 10%
of people who have never had surgery. Most adhesions are painless and do not cause
complications. However, adhesions cause about 60% of small bowel obstructions in
adults and are believed to contribute to the development of chronic pelvic pain. Adhesions
typically begin to form within the first few days after surgery, but they may not produce
symptoms for months or even years. As scar tissue begins to restrict motion of the small
intestines, passing food through the digestive system becomes progressively more
difficult. The bowel may become blocked. In extreme cases, adhesions may form fibrous
bands around a segment of an intestine. This constricts blood flow and leads to tissue
death.
Adhesions Causes
Adhesions develop as the body attempts to repair itself. This normal response can
occur after surgery, infection, trauma, or radiation. Repair cells within the body cannot
tell the difference between one organ and another. If an organ undergoes repair and
meets another part of itself, or another organ, scar tissue may form to connect the 2
surfaces.

Exams and Tests

Doctors typically diagnose adhesions during a surgical procedure such
as laparoscopy(putting a camera through a small hole into the stomach to visualize the
organs). If they find adhesions, doctors usually can release them during the same surgery.
Studies such as blood tests, x-rays, and CT scans may be useful to determine the extent of
an adhesion-related problem. However, a diagnosis of adhesions usually is made only
during surgery. A physician, for example, can diagnose small bowel obstruction but cannot
determine if adhesions are the cause without surgery.

B. Signs and symptoms

Found in textbook Found in patient
Crampy abdominal pain (+) September 24, 2017
Pass blood and mucus (+) September 25, 2017
Vomiting (+)September 24, 2017
Fecal vomiting (-)
Intense thirst (-)
drowsiness (-)
Generalized malaise (+) September 23,2017
aching (+) September 23,2017
Parched tongue and mucous membranes (-)
Abdominal distention (-)
constipation (-)
hematuria (+) September 25, 2017
weakness (+) September 23,2017
Weight loss (-)
anorexia (-)
pain due to obstruction during exercise or (+) 2016
when stretching.

C. Nursing Management
maintaining the function of the nasogastric tube
assessing and measuring the nasogastric output
assessing for fluid and electrolyte imbalance
monitoring nutritional status and assessing improvement (eg, return of normal
bowel sounds, decreased abdominal distention, subjective improvement in
abdominal pain and tenderness, passage of atus or stool)
The nurse reports discrepancies in intake and output, worsening of pain or
abdominal distention, and increased nasogastric output.
The nurses role is to monitor the patient for symptoms that indicate that the
intestinal obstruction is worsening
provide emotional support and comfort
The nurse administers IV uids and electrolytes as prescribed
D. Medical Management/Surgical Mangement
Decompression of the bowel through a nasogastric tube is successful in
most cases. When the bowel is completely obstructed, the possibility of
strangulation and tissue necrosis (ie, tissue death) warrants surgical
intervention. Before surgery, IV uids are necessary to replace the depleted
water, sodium, chloride, and potassium. The surgical treatment of intestinal
obstruction depends on the cause of the obstruction. For the most common
causes of obstruction, such as hernia and adhesions, the surgical procedure
involves repairing the hernia or dividing the adhesion to which the intestine
is attached. In some instances, the portion of affected bowel may be
removed and an anastomosis performed. The complexity of the surgical
 procedure depends on the duration of the intestinal obstruction and the
condition of the intestine.
Restoration of intravascular volume, correction of electrolyte abnormalities,
and nasogastric aspiration and decompression are instituted immediately.
A colonoscopy may be performed to untwist and decompress the bowel. A
cecostomy, in which a surgical opening is made into the cecum, may be
performed in patients who are poor surgical risks and urgently need relief
from the obstruction. The procedure provides an outlet for releasing gas
and a small amount of drainage. A rectal tube may be used to decompress
an area that is lower in the bowel. However, the usual treatment is surgical
resection to remove the obstructing lesion. A temporary or permanent
colostomy may be necessary. An ileoanal anastomosis may be performed if
removal of the entire large bowel is necessary.