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INTESTINAL OBSTRUCTION

INTESTINAL OBSTRUCTION

when there is pathological interference with the


normal progration of the intestinal luminal
contents distally, the condition is called
intestinal obstruction.
CLASSIFICATION
• 1, Mechanical obstruction
• obturation obstructoin
• lesions in the intestinal wall
• lesions extrinsic to the bowel.
• 2, Nonmechanical obstruction
• dynamic ileus----->including paralytic ileus/blood ileus
• 3, simple mechanical obstruction
- strangulated obstruction
• - closed loop obstruction
• 4, Acute
-chronic
-Acute on chronic obstruction
Obturation obstructoin
• Meconium
• Hair,fruit and vegetable fibers
• Gall stone
• Polypoid tumour of bowel.
• Interssusception
• Impaction of barium
• worms
lesions in the intestinal wall
• Congenital-Atresia,stenosis,megacolon,Meckle
diverticulum,imperferforete anus etc
• Traumatic-
• Inflammatory-
Chohn’s disease,ulcerative colitis
• Noeplastic-tumoures
• Miscellaneous-
Radiation, post op stenosis
lesions extrinsic to the bowel.

• Adhesive band constriction or angulation by


adhesion.
• External hernia
• Volvulus
• Extrinsic mass-
haematoma,abscess,neoplasms
outside/inside the bowel
Nonmechanical obstruction
• Paralytic ileus-
(failure of transmission of peristalsis wave
due to neuromuscular failure)
Types-Post operative
-peritonitis
-metabolic
reflex–retroperitoneal abscess, # vertebra
simple mechanical obstruction

• Obstruction
• Blood supply remain intact
strangulated obstruction

• Obstruction
• Mesenteric vessels involved.
• Emergency ,required surgery.
• Causes-
1.Adhesive band obstruction
2.Hernia
3.Volvulus
4.intussuception
closed loop obstruction

• When the afferent and efferent loop are obstructed

• Both limb of loop obstructed.


• Neither progression.
• Nor regratation.
• emergency
Acute
• Central abdominal pain
• Early vomiting
• Central abdominal distention
• Constipation later on disention
Chronic
• Obstruction is confined to the large bowel
• Lower abdominal pain
• Absolute constipation later on dist
Acute on chronic obstruction
• Start in large intestine-gradually small
intestine involved.
• Early pain
• Constipation
• Vomiting
• Abdominal distantion.
PATHOPHYSIOLOGY
• Adhesion -40%
• Due to obstructed hernia-12 %
• Inflammatory- 15 %
• Ca-15 %
• Faecal impaction-8%
• Pseudo-obstruction-5%
• Miscellaneous-5%
Bowel motility
• When the intestine is obstructed the part of the intestine above the
obstruction shows vigorous peristalsis to overcome the obstruction
• Duration-2 to 4 days.
• More distal obstruction-more vigorous peristalsis with longer
duration
• If obstruction not relived-
-Intestine ensues
-Peristalsis ceases
-Obstructed intestine flaccid
-paralysis
• For a few hours the intestine below the
obstruction shows normal peristalsis and
absorption
• This empty contain
-Immobile
-Contracted
-Pale.
Distention
• Accumulation of fluid and gas proximal to
the obstruction
• distention.
• (ingested fluid, digestive secretion and
intestinal gas)
• Bacterial proliferation
Fluid and electrolyte imbalance
• Large volume of saliva, gastric secretion, bile and pancreatic juice enter gut daily.
• These are menially absorbed in small intestine
• Distention increases intestinal secretion and decreases absorption.
• Fluid accumulation-proximal to onstruction
various digestive juice-8000 ml /day
saliva--------------------1500ml /day
gastric juice-----------2500 ml /day
pancreatic juice--------1000 ml /day
• Repeated Vomiting
• (vomiting and fluid collection leads to-loss of water,Na,Cl,H,K
ions producing metabolic alkolosis,hypocalamia and
dehydration)
• Dehydration-
-------------Oliguria
------------Reduced cardiac output
-Low CVP
-Hypotension
-Hypovolaemic shock
Intestinal gases
Most of distention caused by accumulation of
1. Swallowed gas
2. Organic gas
(hydrogen sulphied,ammonia,hydrogen and amines)
3. Diffusion from blood (CO2)
4. Bacterial fermentation
(70 % nitrogen,12% O2,CO2-8%,Remaining 10%)
CLINICAL FEATURES
• 1, Abdominal pain
• 2, Vomiting
• 3, constipation
• 4, Distention
Abdominal pain
• First symptom
• Sudden onset
• Cramping in nature
• With 4 to 5 min interval
• Upper abdominal-high obstruction
Umbelicus-ileal obstruction
Lower abdominal-colon obstruction
Perineum-rectisigmoid obstruction
• Poorly localized
• Continuous sever pain without any quiescent period --STRANGULATION
Vomiting
• Early vomiting is reflex-followed by quiescent period
• Interval of vomiting depends on site of Obstruction
• High obstruction-frequent-copious colour-relived by
decompression
• Low small bowel obstruction-less frequient/does not
get relief
• In acute small bowel obstruction character of vomit
alters -initially partly digested food-yellow/green-
finally faeculent
• IN COLON OBSTRUCTION VOMITING IS
ABSENT
constipation

• There may be one or two natural action of


bowel
• IN FEW CONDITION LIKE RICHTER’S
HERNIA,MESENTRIC VASCULAR
OCCLUSION CONSTIPATION MAY
NOT BE PRESENT.
Distention

• In early small bowel obstruction there may


not be any abdominal distention.
• Distention is less in –high small B.A.
Centrally located - low small B.A.
• Visible peristalsis
• High sound
Physical Examination
• Tachycardia and hypotension indicate sever dehydration and/or
peritonitis.
• Degree of dehydration axamin-skin turgor and moisture of the
mucous membrane
• Fever suggest –strangulation
• GC-POOR-sever illness .
• 1, Inspection :
• peristalsis (long standing obstruction),
• state of nutrition ,
• behavior ,skin color , and turgor ,
• surgical scar,
• Abdominal distention,
• fluid thrill,
• shifting dullness,
• fullness in flank
• All hernial orifices examination
• 2, Palpation :
• demonstrating the sites of the distress, then localizing the anatomic areas
of possible abnormality.
• Garding/rigidity
• Skin temperature (Local site /general body )
• Rebond tenderness
• Mass/lump
• 3,Purcussion
• Tenderness on slight percussion suggest strangulation.
• 3, Auscultation :
• it is of great value. simple one ----noisy and is heard as rushes. During
attacks of colic ,the sounds become loud ,high-pitched and metallic .
• In paralytic ileus no sound will heard.
• 4, Digital examination of the rectum
• 5,sigmoidoscopy examination
Systemic Effects of Obstruction
• 1, water and electrolyte losses
• 2, toxic materials and toxemia
• 3, cardiopulmonary dysfunction
• 4, shock
Laboratory Examination
• 1, complete blood count
normal/slight raised W.B.C.-Simple mechanical obstruction.
Moderate(15000 to 20000) raised W.B.C.-Strangulation.
Very high raised (30000 to 40000).-primary mesenteric vascular
occlusion
• 2, serum electrolytes and amylase determination
• 3, arterial blood gas analysis
• 4, urine specific gravity test
• 5,blood gas analysis
Radiologic Examination
• X-ray is the most important diagnostic procedure. Intestinal
gas often is found. Not so often. Sometimes can display the
intestinal loop.
• Straight X-ray abdomen-AP and lateral
• Lt lateral or decubitus
• Gas-fluid level –highly suggestive of I.O./P.I.
• Houstral fold
• Straight pipe- CHARACTER LESS
• Normally infants under 2 yr of age shows a few fluid level
• Fluid level appears later than gas Shadows.
• No.of fluid level =degree and site of obstruction.
• BARIUM ENEMA
DIAGNOSIS
• 1, Whether obstruction : according to clinical
manifestation ,we can know.
• 2, Mechanical or dynamic one .
• 3, Simple or strangulated one.

• Differentiation :
• 1, continuous rather than intermittent pain .
• 2, the presence of shock and rapid pulse,
elevated temperature and white blood count.
• 3, the presence of peritoneal irritation
• 4, a palpable tender abdominal mass.

• 5, vomitus , gastrointestinal decompression is


bloody.
• 6, active non operative treatment is no use.
• 7, X-ray examination show isolated. large
intestinal loop.
TREATMENT
Nonoperative Treatment
• Basic treatment :
• 1, redress water , electrolyte and acid-base balance
2, gastrointestinal decompression .
. 3, antibiotic treatment.
• Fluid and electrolyte therapy-
• 18 no venous catheter
• Site –Superior vena cava
• Urine catheterization
• RL,D-5%,
• Potassium
• In sever dehydration-3.5 lit/day
• And later on 2.5 lit/day + nasogastric aspirated
fluid
• Rate-according to CVP
gastrointestinal decompression

• Short tube (Levin)


• Long tube (Miller-Abott)
Surgical Treatment
• 1, principle of operation (when to operate)
For strangulation and closed-loop obstruction
the operation is required as soon as possible.
2, For simple one ,if the non operative method is no
use ,the operation is needed.
• Within 24 hr.
• A period of preparation is required except in
strangulation, closed loop obstruction
• Type of anaesthesia- G.A.
• Incision-midline vertical
• After opening –presence or absence of fluid noted
with colour
• Straw colour-simple obstruction
• Bloodly-strangulation
• Caecum has to be searched
• If Caecum grossly distended-obstruction is in colon.
• And if collapsed-small bowel
Whether the affected segment is
viable or not
• Colour
• Motility
• Arterial pulsation
The Procedure of Operation
• Procedures not requiting opening of bowel
• Enterotomy for removal of obturation obstruction
• Resection of the obstructing lesion or strangulated
bowel with primary anastomosis.
• Bypass anastomosis around an obstruction.
• The selection depend on the etiological causes.
colostomy
• If obstruction in Right colon-
Right colectomy with ileotransverse
colostomy.
If obstruction in Left colon-
3 stage –
proximal defunctioning colostomy
anastomosis
closer of colostomy
Postoperative Care
• The principles are :
fluid and electrolyte management ,
antibiotics and
gastrointestinal decompression.
Common Types of Intestinal
Obstruction
Peritoneal Adhesions and Bands

• Congenital : less
• Acquired : more usual. Most are due to injure
,operation and infection.
Diagnosis
• 1, History of operation, injure ,infection.
• 2, Clinical manifestation .
• 3, maybe no manifestation in long time ,
suddenly the symptoms appears ,and the pain is
severe.
PROPHYLAXIS
• 1, Avoiding any unnecessary trauma ,strangulation
of tissue and contamination during operative
procedures.
• 2, All debris should be removed and any
unnecessary foreign material, excessive suture
material and mass ligation in the wound should be
avoided.
TREATMENT
• 1, Intestinal decompression by nasogastric
incubation.
• 2, operation : sewing the intestine to itself so that the
loops of intestine are arranged in an orderly ,ladder
like fashion.
VOLVULUS
• Volvulus is a twisting or rotation of bowel upon its
mesentery , often resulting in intestinal obstruction.
Circulatory impairment may follow , particularly
when the twist is more than 180 degree .
• Common site-
• 90 % sigmoid colon-Sigmoid –anticlockwise
rotates.

• Occasionally 10% in caecum-clockwise rotates.

• In transverse colon extremely rare


DIAGNOSIS
• 1, Sigmoid volvulus :
• 1,common in the elderly with chronic
constipation,neurologic disease indivuduals
• 2, cramping abdominal pain is a constant complaint.
• 3, nausea and vomiting are inconstant symptoms. And
tend to occur late
• 4, there is an enormous gas -filled loop of the large
intestine.
• 2, Small bowel volvulus :
• 1, common in the young person.
• 2, presents following labor activity after eating.
• 3, sudden onset of severe abdominal pain
,nausea, vomiting and distention.
• 4, shock in the early stage with the necrosis of a
large segment or entire small intestine.
• 5, not easy differentiated from other types of
mechanical intestinal obstruction until laparotomy.
TREATMENT

• 1, Sigmoidoscopic reduction with a large rectal


tube or fiber optic colonoscopic reduction.
• 2, The most volvulus should be approached by
transabdominal operation , and the surgeon
should choose the necessary procedure.
INTUSSUSCEPTION
• 1, An intussusception is an invagination of part of
the intestinal tract into the lumen of the adjacent
intestine.
• 2, 80% of intussusception occur in children under 2
years. In adults ,in contrast to children, the cause is
usually related to intestinal tumors.
• Proximal to distal is commonly seen
• When it is distal it proximal it is called
retrograde intussception
• Compound type
• AETIOLOGY
• Primary –no definite cause
• Secondary –polyp,ca,submucous
lipama,stump of appendix
TREATMENT
• 1,Hydrostatic pressure
• 2, use barium enema
• 3, resection of the involved bowel including the
leading point with end-to-end anastomosis.
Pseudo-Obstruction of The Colon
• 1, Cause : surgical or blunt trauma but may be related
to other extracolonic or extraabdominal disease.
• 2, Signs: massive dilatation of the cecum and
ascending and transverse colon with no vomiting and
no peritoneal signs. No air in distal portion of colon.
• 3, Treatment: conservative methods. If conservative
methods fail ,and cecum is greater than 12cm,
laparotomy is indicated. And if signs of acute
abdomen. Usually cecostomy is the choice.