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Pathology of Intestinal Obstruction Major Causes of Intestinal Obstruction Mechanical Obstruction Hernias (internal, external) Intestinal adhesions Intussusception

Volvulus Intestinal Obstruction Single Obstruction Mechanical obstruction Without occlusion of blood supply

Other Less Frequent Conditions Tumours Inflammatory strictures Obstructive gallstones, fecaliths Congenital strictures, atresia Congenital bands Meconium in cystic fibrosis Imperforate anus

Strangulation Interfere mesenteric blood supply (most serious complication) Blood supply compromised Disruption of tips of intestinal villi Obstruction of venous outflow Venous thrombosis

Etiology of Intestinal Obstruction Luminal Atresia Malrotation Inflammatory bowel disease Intussusception Medication (KCl, NSAIDs) Gall stone ileus Foreign bodies Meckel s diverticulum Hypertrophic pyloric stenosis Strictures Neoplasms Constipation Enteroliths Bezoars Intestinal Obstruction Herniation

Extraluminal Adhesions Hernias Volvulus Carcinomatosis Pancreatitis Retroperitoneal haematoma Abscess, sepsis Enteric neuropathy Aganglionosis Hirschprung disease

Blood extravasate into bowel wall, mesentery Luminal bacteria invades submucosa Intestinal wall Peritoneal cavity Endotoxin Macrophage IL1 Shock

Adhesions

Intussusceptions

Volvulus

Inguinal Direct, Indirect Reducible swelling, irreducible swelling Strangulated (blood supply)(gangrene) Femoral Female Umbilical Birth weight infants Internal Mesenteric Diaphragmatic Epigastric (extraperitoneal) Cardinal Signs (Intestinal Obstruction) Pain Abdominal Intermittent, severe, colicky Poorly localised around umbilicus Distention Accumulation of gas, liquid Upper small bowel stomach distended, vomiting Lower small bowel central abdomen distended Vomiting High Small Bowel Obstruction Lower Small Bowel Obstruction Vomiting early, frequent, copious, Vomiting delayed, less frequent colicky, minimal distention (large absorptive surface above obstruction, fluid slowly collects) Dehydration Semidigested food Faeculent vomiting Mucoid gastric juice (bacterial growth) Yellowish bile Large Bowel Obstruction Vomit delayed 2-3 days Becomes faeculent soon (faecal) Signs of dehydration uncommon Absolute Constipation No faeces, No flatus 1 or 2 evacuation may occur after obstruction (contents distal to obstruction) After that, absolute constipation

Intussusceptions Children Common 80% Ileo-ileal Peyer patches

Adult Tumours y Benign y Malignant Infraction

Twisting of bowel upon itself Location y Small intestine (most common) y Sigmoid colon (2nd common) y Caecum (3rd common) Segments with long mesenteric attachment

Distention Occur proximal to site of obstruction Normal peristalsis, evacuation continues distally Later, empty intestine becomes immobile Composition Gaseous swallowed air 68% Diffusion from blood 22% Bacterial, digestion product 10% Amount of air from all sources/ day 7-10L Expelled in flatus 0.5L Amount of fluid ingested + secretions 8-10L/D Intestinal secretions alone 7.5-8L/D Absorption of fluid Occur in distal jejunum, ileum In high small bowel obstruction Mucosal surface area distal to obstruction not available for reabsorption Fluid continues to accumulate proximally (distention, vomited) Multiple fluid levels Pockets of gas trapped above pools of liquid (in loops of bowel) Multiple fluid levels erect X-ray of abdomen

Circulatory Changes in Intestinal Obstruction Simple Obstruction Intraluminal pressure in bowel lumen Affect blood flow, Intramural circulation Venous return is impeded Mucosa congested Capillary rupture Haemorrhage All layers of intestine involved Mucosal anoxia Necrosis, perforation (antimesenteric border) Hasten the process Thrombosis of intramural, mesenteric veins Intraluminal Fluid Accumulation (due to) Osmolality (from enzymatic breakdown of intestinal contents) Alteration in blood supply Digestive secretions Inability to absorb H2O, electrolytes at normal rate Prostaglandins ( fluid secretion) Failure of fluid, electrolyte absorption y Progressive contraction of extracellular fluid, vomiting y Fluid depletion, visceral vascular volume y Hypovolaemic shock

Closed Loop Obstruction Intraluminal pressure All circulatory changes in simple obstruction (accelerated) Example Stenosing carcinoma of distal colon Pressure (in closed loop) Ulceration, Gangrene Perforate caecum (pressure is highest)

Strangulation Major arterial supply occluded Loop Dusky Black (gangrene)

Pseudo-Obstruction Adynamic ileus y Paralytic ileus (functional) y Abdominal operation y Trauma y Peritonitis y Ischaemia y Spinal cord injury y Systemic infection Secondary pseudo-obstruction y Affect smooth muscle scleroderma y Affecting neural Hirschprung disease, Chaga s disease, Amyloidosis y Endocrine DM, hypothyroidism y Pharmacological agents y Irradiation, jejuno-ileal bypass, infarct Ileus Cessation of normal intestinal motility Causes Post-operative ileus (POI) Sympathetic nervous sytem (mediate POI) Component Threshold Threshold Spinal reflex Prevertebral gangionectomy (abolished by splanchnectomy) Large Bowel Obstruction Obstruction often gradual > 40 y/o Pain minimal, absent (unless there is peritonitis) Progressive constipation LOA, LOW Nausea, vomiting Most common causes y Volvulus y Acute diverticulitis y Colorectal carcinomas Examination Abdomen distended Abdomen non-tended (unless peritonitis supervenes)