INTESTINAL OBSTRUCTION

R.NANDINII
GROUP K1
 OVERVIEW:

•CLASSIFICATION
•COMMON CAUSES OF OBSTRUCTION
•CLINICAL FEATURES
•INVESTIGATION
•TREATMENT
INTRODUCTION
Accounts for 5% of all acute surgical admissions
Patients are often extremely ill requiring prompt
assessment, resuscitation and intensive monitoring

Obstruction
A mechanical blockage arising from a structural abnormality that presents a
physical barrier to the progression of gut contents.

Ileus
is a paralytic or functional variety of obstruction

Obstruction is:
-Partial or complete
-Simple or strangulated
CLASSIFICATION
DYNAMIC OBSTRUCTION
(MECHANICAL)
CAUSES OF I.O (DYNAMIC)
PATHOPHYSIOLOGY:
 OBSTRUCTION BY ADHESIONS

• Peritoneal irritation local fibrin production produces adhesions between apposed surfaces
• As early as 4 weeks post laparotomy. The majority of patients present between 1-5 years
Colorectal Surgery 25%
Gynaecological 20%
Appendectomy 14%
• Prevention: good surgical technique, washing of the peritoneal cavity with saline to remove clots,
etc, minimizing contact w/ gauze, covering anastomosis & raw peritoneal surfaces
 TREATMENT OF ADHESIVE OBSTRUCTION

INITIALLY TREAT CONSERVATIVELY PROVIDED THERE IS

NO SIGNS OF STRANGULATION; SHOULD RARELY
CONTINUE CONSERVATIVE TREATMENT FOR LONGER
THAN 72 HOURS
AT OPERATION, DIVIDE ONLY THE CAUSATIVE ADHESION
AND LIMIT DISSECTION
LAPAROSCOPIC ADHESIOLYSIS IN CASES OF CHRONIC
SUBACUTE OBSTRUCTION
 HERNIA
• ACCOUNTS FOR 20% OF SBO
• COMMONEST 1. FEMORAL HERNIA
2. ID INGUINAL
3. UMBILICAL
4. OTHERS: INCISIONAL
• THE SITE OF OBSTRUCTION IS THE NECK OF HERNIA
• THE COMPROMISED VISCUS IS WITH IN THE SAC.
• ISCHAEMIA OCCURS INITIALLY BY VENOUS OCCLUSION, FOLLOWED BY
OEDEMA AND ARTERIALC OMPROMISE.
• ATTEMPT TO DISTINGUISH THE DIFFERENCE BETWEEN:
• INCARCERATION
• SLIDING
• OBSTRUCTION

• STRANGULATION IS NOTED BY:

• PERSISTENT PAIN
• DISCOLOURATION
• TENDERNESS
• CONSTITUTIONAL SYMPTOMS
 VOLVULUS
A TWISTING OR AXIAL ROTATION OF A Features: palpable tympanic lump
PORTION OF BOWEL ABOUT ITS (sausage shape) in the midline or left
MESENTERY. WHEN COMPLETE IT side of abdomen.
Constipation, abdominal distension
FORMS A CLOSED LOOP (early & progressive)
OBSTRUCTION ISCHEMIA
CAN BE PRIMARY OR SECONDARY:
 1°: CONGENITAL MALFORMATION OF THE GUT
(E.G: VOLVULUS NEONATORUM, CECAL OR
SIGMOID VOLVULUS)
 2°: MORE COMMON, DUE TO ROTATION OF A
PIECE OF BOWEL AROUND AN ACQUIRED
ADHESION OR STOMA

COMMONEST SPONTANEOUS TYPE

IN ADULT IS SIGMOID, CAN BE
RELIEVED BY DECOMPRESSION PER
ANUM
SURGERY IS REQUIRED TO PREVENT
 ACUTE INTUSSUSCEPTION
An intussusception is
OCCURS WHEN ONE PORTION OF composed of three
parts :
THE GUT BECOMES INVAGINATED the entering or inner
WITHIN AN IMMEDIATELY ADJACENT tube;
SEGMENT. the returning or middle
tube;
COMMON IN 1ST YEAR OF LIFE the sheath or outer tube
(intussuscipiens).
COMMON AFTER VIRAL ILLNESS
ENLARGEMENT OF PEYER’S
PATCHES
ILEOCOLIC IS THE COMMONEST
VARIETY IN CHILD.
COLOCOLIC INTUSSUSCEPTION
COMMONEST IN ADULT
CLASSICALLY, A PREVIOUSLY
HEALTHY INFANT PRESENTS WITH
COLICKY PAIN AND VOMITING (MILK
THEN BILE).
BETWEEN EPISODES THE CHILD
INITIALLY APPEARS WELL.
LATER, THEY MAY PASS A
‘REDCURRANT JELLY’ STOOL.

Red currant jelly

stools
 LARGE BOWEL OBSTRUCTION
• DISTINGUISHING ILEUS FROM MECHANICAL OBSTRUCTION IS CHALLENGING
• ACCORDING TO LAPLACE’S LAW: MAXIMUM PRESSURE IS AT THE MAXIMUM DIAMETER AREA
CAECUM IS AT THE GREATEST RISK OF PERFORATION
• PERFORATION RESULTS IN THE RELEASE OF FORMED FEACES WITH HEAVY BACTERIAL
CONTAMINATION

AETIOLOGY:
1. CARCINOMA:
THE COMMONEST CAUSE, 18% OF COLONIC CA. PRESENT WITH OBSTRUCTION
2. BENIGN STRICTURE:
DUE TO DIVERTICULAR DISEASE, ISCHEMIA, INFLAMMATORY BOWEL DISEASE.
3. VOLVULUS:
-SIGMOID VOLVULUS/CAECAL VOLVULUS
4. HERNIA.
5. CONGENITAL : HIRSCHPRUNG, ANAL STENOSIS AND AGENESIS
 CLINICAL FEATURES
HIGH SMALL BOWEL OBSTRUCTION CARDINAL
FEATURES:
VOMITING OCCURS EARLY AND IS PROFUSE WITH
RAPID DEHYDRATION.
Colicky pain
Vomiting
DISTENSION IS MINIMAL WITH LITTLE EVIDENCE OF
FLUID LEVELS ON ABDOMINAL RADIOGRAPHY
Abd distention
Constipation
LOW SMALL BOWEL OBSTRUCTION
PAIN IS PREDOMINANT WITH CENTRAL DISTENSION.
VOMITING IS DELAYED.
OTHER FEATURES:
Dehydration
MULTIPLE CENTRAL FLUID LEVELS ARE SEEN ON
RADIOGRAPHY
Hypokalaemia
Pyrexia
LARGE BOWEL OBSTRUCTION Abd tenderness
DISTENSION IS EARLY AND PRONOUNCED.
PAIN IS MILD AND VOMITING AND DEHYDRATION ARE
LATE.
THE PROXIMAL COLON AND CAECUM ARE DISTENDED
ON ABDOMINAL RADIOGRAPHY
 PHYSICAL EXAMINATION
INSPECTION
ABDOMINAL DISTENTION, SCARS, VISIBLE
PERISTALSIS.
PALPATION
MASS, TENDERNESS, GUARDING
PERCUSSION
TYMPHANIC, DULLNESS
AUSCULTATION
BOWEL SOUND ARE HIGH PITCH AND INCREASE IN
 INVESTIGATIONS:
• LAB:
• FBC (LEUKOCYTOSIS, ANAEMIA, HEMATOCRIT, PLATELETS)
• CLOTTING PROFILE
• ARTERIAL BLOOD GASSES
• U& CRT, NA, K, AMYLASE, LFT AND GLUCOSE, LDH
• GROUP AND SAVE (X-MATCH IF NEEDED)
• OPTIONAL (ESR, CRP, HEPATITIS PROFILE)

• RADIOLOGICAL:
• PLAIN ABDOMINAL XRAYS
• USS ( FREE FLUID, MASSES, MUCOSAL FOLDS, PATTERN OF PARISTALSIS,
DOPPLER OF MESENTERIC VASULATURE, SOLID ORGANS)
• OTHER ADVANCED STUDIES (CT, MRI, CONTRAST STUDIES)

Fluid levels with gas above;
‘stepladder pattern’. Ileal
obstruction by adhesions; patient
erect.
 Figure 3. Lateral decubitus view
of the abdomen, showing air-fluid
 Supine radiograph from a patient with levels consistent with intestinal
complete small bowel obstruction obstruction (a rro ws ).
shows distended small bowel loops in
the central abdomen with prominent
valvulae conniventes (small white
arrow)
THE DIFFERENCE BETWEEN SMALL AND
LARGE BOWEL OBSTRUCTION
Large bowel Small Bowel
•Peripheral ( diameter 6 cm •Central ( diameter 3 cm max)
max) •Vulvulae coniventae
•Presence of haustration •Ileum: may appear tubeless
 ROLE OF CT
• USED WITH IV CONTRAST, ORAL AND RECTAL CONTRAST
(TRIPLE CONTRAST).

• ABLE TO DEMONSTRATE ABNORMALITY IN THE BOWEL

WALL, MESENTERY, MESENTERIC VESSELS AND
PERITONEUM.

• IT CAN DEFINE:
• THE LEVEL OF OBSTRUCTION
• THE DEGREE OF OBSTRUCTION
• THE CAUSE: VOLVULUS, HERNIA, LUMINAL AND MURAL
CAUSES
• THE DEGREE OF ISCHAEMIA
• FREE FLUID AND GAS
• FIGURE: AXIAL COMPUTED TOMOGRAPHY SCAN
SHOWING DILATED, CONTRAST-FILLED LOOPS OF BOWEL
• ENSURE: PATIENT VITALLY STABLE WITH NO RENAL ON THE PATIENT’S LEFT (YELLO W ARRO WS), WITH
DECOMPRESSED DISTAL SMALL BOWEL ON THE
FAILURE AND NO PREVIOUS ALERGY TO IODINE PATIENT’S RIGHT (RED ARRO WS). THE CAUSE OF
OBSTRUCTION, AN INCARCERATED UMBILICAL HERNIA,
CAN ALSO BE SEEN (G REENARRO W), WITH PROXIMALLY
DILATED BOWEL ENTERING THE HERNIA AND
DECOMPRESSED
Source: Jackson, PG. & Raiji M., Evaluation and Management of Intestinal Obstruction, BOWEL EXITING
January 2011, American THEofHERNIA.
Academy Family Physicians
ROLE OF BARIUM GASTROGRAFIN STUDIES
Barium should not be used in
a patient with peritonitis

• AS: FOLLOW THROUGH, ENEMA

• LIMITED USE IN THE ACUTE SETTING
• GASTROGRAFIN IS USED IN ACUTE
ABDOMEN BUT IS DILUTED
• USEFUL IN RECURRENT AND CHRONIC
OBSTRUCTION
• MAY ABLE TO DEFINE THE LEVEL AND
MURAL CAUSES.
• CAN BE USED TO DISTINGUISH ADYNAMIC
AND MECHANICAL OBSTRUCTION
Source: Jackson, PG. & Raiji M., Evaluation and Management of Intestinal Obstruction, January 2011, American Academy of Family Physicians
Source: Jackson, PG. & Raiji M., Evaluation and Management of Intestinal Obstruction, January 2011, American Academy of Family Physicians
 TREATMENT OF INTESTINAL OBSTRUCTION
• SUPPORTIVE
1. RESUSCITATION
2. RYLE TUBE FREE FLOW WITH 4 HOURLY ASPIRATION
-DECOMPRESSION OF PROXIMAL TO THE OBSTRUCTION, REDUCE SUBSEQUENT
ASPIRATION DURING INDUCTION OF ANESTHESIA AND POST EXTUBATION.
3. IV DRIP NORMAL SALINE / HARTMANN (SODIUM & WATER LOSS DURING IO)
4. BROAD SPECTRUM ANTIBIOTIC (NOT MANDATORY BUT NEED IN ALL PATIENT
UNDERGOING SURGERY.
• SURGICAL
IND: OBSTRUCTED /STRANGULATED EXTERNAL HERNIA, INTERNAL INTESTINAL
STRANGULATION AND ACUTE OBSTRUCTION
1.MIDLINE INCISION USUALLY LOOK ON CAECUM
2.OPERATIVE DECOMPRESSION
3.LOOK AT VIABILITY OF INTESTINE
4.LARGE BOWEL OBSTRUCTION: COLOSTOMY
 INDICATIONS FOR SURGERY
• ABSOLUTE
• GENERALISED PERITONITIS
• LOCALISED PERITONITIS
• VISCERAL PERFORATION
• IRREDUCIBLE HERNIA

• RELATIVE
• PALPABLE MASS LESION
• 'VIRGIN' ABDOMEN
• FAILURE TO IMPROVE

• TRIAL OF CONSERVATISM
• INCOMPLETE OBSTRUCTION
• PREVIOUS SURGERY
• ADVANCED MALIGNANCY
• DIAGNOSTIC DOUBT - POSSIBLE ILEUS

Source: http: Surgical Tutor.co.uk

 MANAGEMENT FOR LARGE BOWEL
All patients require
OBSTRUCTION
•Adequate resuscitation
•Prophylactic antibiotics
•Consenting and marking for potential stoma formation

•At operation
•Full laparotomy should be performed
•Liver should be palpated for metastases
•Colon should be inspected for synchronous tumours

•Appropriate operations include:

•Right sided lesions – right hemicolectomy
•Transverse colonic lesion – extended right hemicolectomy
•Left sided lesions – various options
Source: http: Surgical Tutor.co.uk
Three-staged procedure
•Defunctioning colostomy
•Resection and anastomosis
•Closure of colostomy

Two-staged procedure
•Hartmann’s procedure
•Closure of colostomy

One-stage procedure
•Resection, on-table lavage and primary anastomosis
•Three stage procedure will involve 3 operations!
•Associated with prolonged total hospital stay
•Transverse loop colostomy can be difficult to manage
•With two-staged procedure only 60% of stomas are ever reversed
•With one-stage procedure stoma is avoided
•Anastomotic leak rate of less than 4% have been reported
•Irrespective of option total perioperative mortality is about 10%

Source: http: Surgical Tutor.co.uk

 COMPLICATIONS ASSOCIATED WITH
INTESTINAL OBSTRUCTION REPAIR
• INCLUDE EXCESSIVE BLEEDING
• INFECTION
• FORMATION OF ABSCESSES (POCKETS OF PUS)
• LEAKAGE OF STOOL FROM AN ANASTOMOSIS
• ADHESION FORMATION
• PARALYTIC ILEUS (TEMPORARY PARALYSIS OF THE INTESTINES)
• REOCCURRENCE OF THE OBSTRUCTION.

Source: http://www.surgeryencyclopedia.com/Fi-La/Intestinal-Obstruction-Repair.html
 PARALYTIC ILEUS

A STATE IN WHICH THERE IS A FAILURE OF TRANSMISSION OF

PERISTALTIC WAVES 2° TO NEUROMUSCULAR FAILURE ( IN
AUERBACH’S AND MEISSNER’S PLEXUSES)
STASIS  LEADS TO ACCUMULATION OF FLUID AND GAS WITHIN
BOWEL A/W DISTENSION, VOMITING, ABSENCE OF BOWEL SOUND
AND ABSOLUTE CONSTIPATION
VARIETIES FACTORS: POSTOPERATIVE, INFECTION, REFLEX ILEUS
AND METABOLIC
RADIOLOGICAL: GAS FILLED LOOPS OF INTESTINES WITH
MULTIPLE FLUID LEVELS
MANAGEMENT:
ESSENCE OF TREATMENT PREVENTION WITH USE OF
NASOGASTRIC SUCTION AND RESTRICTION OF ORAL INTAKE
UNTIL BOWEL SOUND AND PASSAGE OF FLATUS RETURN
MAINTAIN ELECTROLYTE BALANCE
SPECIFIC TREATMENT:
• REMOVED PRIMARY CAUSE
• DECOMPRESSED GI DISTENSION
• IF PROLONG PARALYTIC ILEUS , CONSIDER LAPAROTOMY EXCLUDE
HIDDEN CAUSE AND FACILITATE BOWEL DECOMPRESSION
 PSEUDO-OBSTRUCTION
OBSTRUCTION USUALLY COLON- OCCUR IN THE
ABSENCE OF MECHANICAL CAUSE OR ACUTE
INTRA-ABDOMINAL DISEASE.
ASSOCIATED WITH A VARIETY OF SYNDROMES IN
WHICH THERE IS UNDERLYING NEUROPATHY
AND/OR A RANGE OF OTHER FACTORS

IDIOPATHIC SEPTICAEMIA
Metabolic Retroperitoneal irritation
Severe trauma at lumbar area Drugs
Shock Secondary GI involvement
Small intestinal pseudo-obstruction
This condition may be primary (i.e.
idiopathic or associated with
familial visceral myopathy) or secondary.
The clinical picture consists of recurrent
subacute obstruction.
 The diagnosis is made by the exclusion
of a mechanical cause.
Treatment consists of
initial correction of any underlying disorder.
Metoclopramide and
erythromycin may be of use.
Colonic pseudo-obstruction (Ogilvie’s
syndrome, )
This may occur in an acute or a chronic
form.
presents as acute large bowel
obstruction.
Abdominal radiographs show evidence of
colonic obstruction, with marked caecal
distension being a common
feature.
AXR shows colonic obstruction with
marked caecal distension
Confirmation of absence mechanical
cause by colonoscopy or single contrast
water soluble barium enema or CT.
Once confirmed, treated by colonoscopic
decompression
 ACUTE MESENTERIC OCCLUSION
• ACUTE ISCHEMIC OF MESENTERIC VESSEL. COMMONLY SMA
• CAUSES: AF, MURAL THROMBOSIS, ATHEROMATOUS PLAQUE FROM AORTIC
ANEURYSM AND VALAVE VEGETATION FROM ENDOCARDITIS
• FEATURES: -SUDDEN ONSET OF SEVERE ABD. PAIN IN PT WITH AF AND
ATHEROSCLEROSIS
-PERSISTENT VOMITING AND DEFECATION THEN PASSAGE OF ALTERED
BLOOD
-HYPOVOLUMIC SHOCK
• INVESTIGATIONS: - NEUTROPHIL LEUKOCYTOSIS
- ABD XRAY: ABSENCE OF GAS IN THICKENED SMALL INTESTINES
• TREATMENT: - ANTI-COAGULANT
- EMBOLECTOMY
- REVASCULARIZATION