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Definition:
mechanical or functional obstruction of the
intestines, preventing the normal transit of
the products of digestion.
It is a medical emergency. Although many
cases are not treated surgically, it is a
surgical problem.
Frequency:
Approximately 20% of patients admitted to
the hospital with an acute abdomen have
an intestinal obstruction
(most common surgical disorder of small
bowel)).
Mortality/Morbidity
Mortality and morbidity are dependent on the etiology, the early
recognition and correct diagnosis of obstruction.
Aetiology:
can be classified into 3 main groups
'extraluminal' extrinsic (eg, adhesions, hernias, volvulus)
intramural lesions in the bowel wall (eg, Crohn disease ,
tuberculosis, primary and secondary neoplasia, potassium
strictures, radiation strictures, complications of surgical
anastomosis)
Intraluminal (eg, foreign bodies, bezoars, food bolus)
Neoplasms 20 % ( intrinsic 3%
extrinsic 17% )
Pathophysiology:
Obstruction of the small bowel leads to proximal dilatation of
the intestine due to accumulation of GI secretions and
swallowed air.
Swallowed air major source of gaseous distension (early)
nitrogen is not well absorbed by the mucosa.
Bacterial fermentation (later )other gases are produced
partial pressure of nitrogen in the lumen are lowered; gradient
of diffusion of nitrogen from blood to lumen.
Large quantities of fluid from the extracellular space are lost
into the gut ; and from the serosa into the peritoneal cavity.
fluid fills the the lumen proximal to the obstruction;
net secretion is enhanced
mediators substances (endotoxin, prostaglandins) released
from the luminal baceria are responsible.
Reflexely induced vomiting accentuates the fluid and
electrolytes deficit.
Hypovolemia leads to multi-organ system failure and is the
cause of death with non-strangulating obstruction.
History
partial or complete VS simple or strangulated.
Abdominal pain (characteristic with most patients)
Nausea
Vomiting, which is associated more with proximal obstructions
In distal obstruction, (vomiting late,feaculent)
Diarrhea (an early finding)
Constipation (a late finding) as evidenced by the absence of flatus or
bowel movements
Fever and tachycardia - Occur late and may be associated with
strangulation
Virgin abdomen Previous abdominal or pelvic surgery, previous
radiation therapy, or both (may be part of patient's medical history)
History of malignancy (particularly ovarian and colonic)
Examination:
Vital signs: normal (early)
Tachycardia, hypotension (late)
Temperature: normal (simple)
elevated (strangulation)
Abdominal Ex: distension (more in distal).
Mild tenderness
Visible peristalsis
Bowel sounds: hyperactive (early)
hypoactive (late)
Silent (peritonitis)
Ex of hernias (incarcerated)
In strangulation: shock
fever
Cramping abd pain become
severe continuos pain
Abd. Tenderness and rigidity
Silent abd
Incarcerated hernia,
abd. Mass
(intussusceptum)
Gross or occult blood
Leukocytosis.
acidosis
note: no historical , physical or lab works
entirely excludes the possibility of
strangulation in complete SBO.
investigation:
Essential laboratory tests
Serum chemistries: Results are usually normal or mildly elevated.
BUN level: If the BUN level is increased, this may indicate
decreased volume state (eg, dehydration).
Imaging studies:
Plain radiography:
Obtain plain radiographs first for patients in whom SBO is
suspected.
At least 2, supine or flat and upright, are required
Ladder-like pattern Dilated small-bowel loops with air fluid levels
(>6)
Ladder-like pattern
Dilated S.B.
S.B.O. + P.U.H.(incarcerated)
Strangulated L.I.H.
Midgut volvolus
Cecal volvolus
Computed Tomography
CT scans clearly demonstrate abnormalities of the bowel
wall, the mesentery, the mesenteric vessels, and the
peritoneum.
useful in making an early diagnosis of strangulated obstruction
particularly when clinical and radiographic findings are
inconclusive.
proved useful etiologies of SBO extrinsic causes such as
adhesions and hernia from intrinsic causes such as neoplasms or
Crohn
disease. It also differentiates the above from intraluminal
causes such as bezoars.
about 90% sensitive and specific in detecting SBO.
is the study of choice if the patient has fever, tachycardia,
localized abdominal pain, and/or leukocytosis.
It is capable of revealing abscess, inflammatory process,
extraluminal pathology resulting in obstruction, and mesenteric
Ischemia.
does not require oral contrast for the diagnosis of SBO because
the retained intraluminal fluid serves as a natural contrast agent.
Ultrasonography
Management:
Absolute
Relative
Generalised peritonitis
Localised peritonitis
Visceral perforation
Irreducible hernia
Trial of conservatism
Incomplete obstruction
Previous surgery
Advanced malignancy
Diagnostic doubt - possible ileus
Complications
Sepsis
Intra-abdominal abscess
Wound dehiscence
Aspiration
Short-bowel syndrome (as a result of multiple surgeries)
Death (secondary to delayed treatment)
Prognosis:
With proper diagnosis and treatment of the
obstruction, prognosis is good. Complete
obstructions treated successfully nonoperatively
have a higher incidence of recurrence than those
treated surgically.
Mortality and morbidity are dependent on the etiology,
the early recognition and correct diagnosis of
obstruction.
Paralytic ileus
Background
After abdominal surgery, a normal physiological
ileus occurs.
spontaneously resolves within 2-3 days
the terms postoperative adynamic ileus or paralytic
ileus are defined as ileus of the gut persisting for
more than 3 days following surgery.
Ileus occurs from hypomotility of the gastrointestinal
tract in the absence of a mechanical bowel
obstruction.
This suggests that the muscle of the bowel wall is
transiently impaired and fails to transport intestinal
contents.
This lack of coordinated propulsive action leads to
the accumulation of both gas and fluids within the
bowel.
The stomach regains activity in 1-2 days, and the colon regains
activity in 3-5 days.and the small bowe within 24-48 hours
Sepsis
Drugs (eg, opioids, antacids, coumarin, amitriptyline,
chlorpromazine)
Metabolic (eg, low potassium, magnesium, or sodium levels;
anemia; hyposmolality)
Myocardial infarction
Pneumonia
Trauma (eg, fractured ribs, fractured spine)
Biliary and renal colic
Head injury and neurosurgical procedures
Intra-abdominal inflammation and peritonitis
Retroperitoneal hematomas
Clinical
History
Hx previous operation
Physical
may be tender.
Pseudo-obstruction
Mechanical Obstruction
(Simple)
Borborygmi, tympanic,
peristaltic waves,
hypoactive or hyperactive
bowel sounds, distension,
localized tenderness
Borborygmi, peristaltic
waves, high-pitched bowel
sounds, rushes, distension,
localized tenderness
Plain
Radio
graph
s
Ileus
Workup
Laboratory Studies
Laboratory studies and blood work should focus on evaluations for
infectious, electrolytic, and metabolic derangements.
Imaging Studies
On plain abdominal radiographs, ileus appears as copious gas
dilatation of the small intestine and colon.
With enteroclysis, the contrast medium in patients with paralytic ileus
should reach the cecum within 4 hours; if it remains stationary for
longer than 4 hours, mechanical obstruction is suggested.
Management:
Diet
Activity
Medication
Notes:
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