Intestinal Obstruction

Prepared by Ahmad Zaki and

Zurina
Supervisor : Dr Viknes

Outlines
Definition
Classifications
Pathophysiology
Causes
How to diagnose
Management
Take home messages

Definition
Intestinal obstruction is a partial or
complete blockage of the bowel that
prevents the contents of the intestine
frompassing through.

Classification

Mechanical and functional

Partial and complete
Simple and strangulated
Acute and subacute

Pathophysiology
Obstruction

Obstruction
Proximal

for Mechanical IO

Below/distal
Dilates
Proximal
peristalsis will
increase to
overcome the
obstruction

Exhibition normal
peristalsis and
absorption

it will continue
to dilates

Until it become
empty

reduction of
peristaltic
strength
resulting in
flacidity and
paralysis

collapses

abdominal
pain,
distention,
vomiting
and
absolute
constipatio
n.

Varieties
underlying
causes

Pathophysiology
for Functional IO

Activation of
inhibitory spinal
reflex arcs

Systemic generation of
endocrine and
inflammatory mediators

Failure of
transmission of
peristaltic wave
Stasis
Accumulation
of fluid and gas

Abdominal
Distension,
vomiting,
absence of bowel
sound and
absolute
constipation

Causes
INTESTINAL
OBTRUCTIO
N

FUNCTIONA
L

Paralytic Ileus
Pseudo- obstruction

MECHANICAL

INTRALUMINAL
- Faecal
impaction
- Foreign bodies
- Bezoars
- Gallstones

INTRAMURAL
- Volvulus
- Intussusception
- Malignancy
- Stricture

EXTRAMURAL
- Bands /
adhesions
- Hernia

 ELDERLY carcinoma, diverticulitis,

sigmoid volvulus
ADULT hernia, adhesion, carcinoma
PAEDIATRICS intussusception, congenital
hypertrophic pyloric stenosis, atresia
(duodenum, ileum), meconium obstruction,
volvulus neonatorum

How to diagnose?
Thorough history and clinical
examination
Investigations
Biochemical test
Radiology

History
4 cardinal symptoms

Abdominal pain
Vomiting and nausea
Abdominal distention
Absolute constipation

Others: dehydrations, hypokalaemia,

pyrexia, abdominal tenderness, high
pitched bowel sound.

1) Pain
first symptom, occurs suddenly and usually severe.
Nature : colicky, coincide with peristalsis
constant, diffuse as distension increases.
severe pain indicative of strangulation.
2) Vomiting
The more distal the obstruction, the longer interval
between the onset of symptoms and
nausea/vomiting.
As obstruction progresses the character of the
vomitus alters (digested food faeculent material;
as a result of the presence of enteric bacterial
overgrowth)

3) Distension
Small bowel: dependent on the site of the
obstruction and is greater the more distal the lesion.
Colonic obstruction: delayed distension
Visible peristalsis may be present.
4) Constipation
Absolute or relative.
Absolute constipation COMPLETE intestinal obstruction.

The rule that constipation is present in intestinal

obstruction does not apply in:
Richters hernia; gallstone obturation; mesenteric
vascular occlusion; obstruction associated with pelvic
abscess; partial obstruction (faecal impaction/colonic
neoplasm) ~diarrhoea may often occur.

The clinical features vary according to:

the location of the obstruction
the age of the obstruction
the underlying pathology
the presence or absence of intestinal ischaemia.
In high small bowel obstruction,
vomiting occurs early and is profuse with rapid
dehydration. Distension is minimal
In low small bowel obstruction,
Vomiting is delayed. pain is predominant with central
distension.
In large bowel obstruction,
distension is early and pronounced. Pain is mild and
vomiting and dehydration are late.

Physical examination
Inspection
Visible scar

Palpation
hernial orifices

-band
-adhesion

-incarcerated
-strangulated hernia
large, slightly tender, - torsion
mobile
- intussusception
mass changes its
-mass of Ascaris worms
position with colicky
pain
- intraperitoneal
tender indurated
abscess
mass
- fecaloma
hard impacted

Percussion

- tympanic sound

Auscultation

-runs of borborygmi
-tinkling high pitched
musical sounds

Rectal examination
fresh blood and
mucus
hard mass of faeces
hard mass in the
rectovesical pouch

-strangulating lesion
-carcinoma of large gut
-intussusception
- constipation
-extraintestinal tumour

Investigations
Biochemical test

FBC

- high Hb and hematocrit

- leukocytosis
- Anaemia

BUSE

- electrolytes depletion
(hypokalemia,
hyponatreamia)

Arterial blood gasses

Clotting profile
Optional (ESR, CRP,
Hepatitis profile,
tumour markers)

-- acidosis

Radiology
X-RAYS

-Gas pattern
-Fluid level
-Masses shadow
-Fecal pattern

ULTRASOUND

-free fluid
-masses
-mucosal folds
-pattern of paristalsis

CT, MRI, Contrast

studies

-level of obstruction
-partial or complete
-cause of the obstruction

Large Bowel:
Peripheral
Presence of haustration,
diameter >8 cm
distended caecum a
rounded gas shadow in the
right iliac fossa. >10cm
diameter.

Small Bowel:
Central
jejunum valvulae
conniventes
Ileum featureless
Diameter >5 cm
No gas is seen in the colon

Multiple air fluid levels located

centrally-small bowel obstruction

Small bowel volvuluscoffee bean appearance.

Management
Early management
Conservative
Operative

Early management
Resuscitation
Oxygen therapy (if necessary)
Correct dehydration and electrolytes
IV antibiotics-IV cefobid 1gm bd, IV flagyl 500
mg tds
Close monitoring
Temperature,Pulse,BP,Urine output, Central
venous pressure
Regular re-evaluation
Keep nil by mouth
Nasogastric tube- 4hourly aspirate and free flow
Appropriate analgesia

Conservative
If obstruction presumed to be due to adhesions and there are
no features of peritonism, conservative management may
be consider.
Nasogastric tube
to help decompress the dilated bowel
CBD
To monitor urine output
IV fluid
Normal saline or Hartmans for intravascular volume
depletion
Electrolytes correction
Guided by test results
Analgesic
Opioidpain relievers may be used for patients with severe
pain
Antibiotic

Operative
Principles of surgical intervention for
obstruction
Management of:
The segment at the site of obstruction
The distended proximal bowel
The underlying cause of obstruction

Indications for surgery

Immediate intervention:

Evidence of strangulation (eg:hernia)

Signs of peritonitis resulting from perforation
or ischemia

In the next 24-48 hours

Clear indication of no resolution of obstruction

( Clinical, radiological).
Diagnosis is unclear in a virgin abdomen

Take home messages

The 4 main Cardical signs of intestinal
obstruction are Abdominal pain, Abdominal
distention, Vomiting and Constipation.
Always examine for hernia orifice.
Request for Supine, Erect and CXR.
Provide adequate resusitation to the patient.
Be attentive of signs of peritonitis resulting
from perforation or ischemia of bowel.