PATHOPHYSIOLOGY

INTRODUCTION

Prevention of intestinal contents from moving distally.

CLASSIFICATION
A.

B.

Dynamic Adynamic

DYNAMIC OBSTRUCTION

Peristalsis has to work against a mechanical obstruction Mechanism

Volvulus

Incarceration
Obstruction Intussusception

ADYNAMIC OBSTRUCTION
Peristalsis is either abscent( e.g. paralytic ileus) Peristalsis may be present in nonpropulsive form ( e.g. mesenteric vascular occlusion or pseudo-obstruction) Mechanical element absent in both types.

CAUSES
A.

Dynamic obstruction

Intraluminal

Impaction Foreign bodies Bezoars Gallstones

Intramural

Stricture Malignancy

CAUSES (contd.)
A.

Dynamic obstruction

Extraluminal

Bands/ adhesions Hernia Volvulus Intussusception

B.

Adynamic obstruction

Paralytic ileus Mesenteric vascular occlusion Pseudo-obstruct

causes of dynamic osbtruction

obstructed hernia 12% inflammatory 15% adhesion 40%

carcinoma 15%

faecal impaction 8%

pseudo obstruct 5%

miscellaneous 5%

adhesion faecal impaction obstructed hernia

miscellaneous carcinoma

pseudo -obstruct inflammatory

PATHOPHYSIOLOGY
In dynamic obstruction proximal bowel dilates and develops altered motility. Below obstruction : normal peristalsis and absorption Later distal bowel contracts and becomes immobile. Initially proximal peristalsis increases to overcome obstruction. In obstruction not relieved bowel dilation reduction in peristaltic strength flaccidity and paralysis

PATHOPHYSIOLOGY(contd.)

Distention produced by 2 factors:

Gas Fluid

Gas
Growth of aerobic and anaerobic organisms gas production Majority : nitrogen (90%) and hydrogen sulphide

Fluid

Composed of digestive juices

PATHOPHYSIOLOGY(contd.)

Fluid

Obstruction Fluid accumulation in bowel wall Excess secreted into lumen Dehydration and electrolyte loss due to:

Reduced oral intake Defective intestinal absorption Vomitting Suquestration in the bowel lumen

STRANGULATION
Compromises blood supply Viability of the bowel is threatened Causes

External
Hernial

orifices Adhesions and bands

Interrupted blood flow

Volvulus Intussusception

STRANGULATION (contd.)

Causes

Increased intraluminal pressure

Closed

loop obstruction infraction

Primary
Mesenteric

Strangulation Venous compression Congestion and edema Impairment of arterial supply Gangrene Proliferation of bacteria Toxins and transmigration Peritoneal cavity Septic shock

CLOSED LOOP OBSTRUCTION

Obstruction at both proximal and distal points. Distention on both sides of the strangulated segments Seen in presence of the malignant stricture of the right colon with a competent ileocaecal valve.

Carcinomatous stricture

INTERNAL HERNIA

Occurs when a portion of the small intestine becomes entrapped in one of the retroperitoneal fossae or in a congenital mesenteric defect. Sites

The foramen of Winslow A hole in the mesentery A hole in the broad ligament Defects in the broad ligament Congenital or acquired diaphragmatic hernia Duodenal retroperitoneal fossae Caecal/ appendiceal retroperitoneal fossae Intersigmoind fossa

ENTERIC STRICTURES
Formed secondary to tuberculosis or Crohns disease Malignant strictures are associated with lymphoma

BOLUS OBSTRUCTION

a)

Due to food , gallstones, trichobezoar, phytobezoar, stercoliths and worms. Gallstones

Occur in elderly Secondary to erosion of the large gallstone through the gallbladder to the duodenum May be recurrent

BOLUS OBSTRUCTION (contd.)

b)

Food
Occur in patients with partial or complete gastrectomy Unchewed articles pass into the small intestine Fruits and vegetables implicated.

BOLUS OBSTRUCTION (contd.)

c)

Trichobezoar
Firm masses of undigested hair balls Due to persistent hair chewing or sucking May be associated with psychiatric abnormality.

BOLUS OBSTRUCTION (contd.)

d)

Phytobezoar
Firm masses of fruit/vegetables Predisposing factors

High fiber intake Inadequate chewing Previous gastric surgery Hypochlorhydria Loss of gastric acid pump mechanism

BOLUS OBSTRUCTION (contd.)

e)

Stercoliths
Masses of dried compressed faeces Found in small intestine in association with a jejunal diverticulum or ileal stricture

BOLUS OBSTRUCTION (contd.)

f)

Worms
Ascaris lumbricoides can cause bowel osbtruction.

OBSTRUCTION BY ADHESIONS AND BANDS

1.

Frequent in western countries Adhesions

Causes Ischaemic areas sites of anastomoses, retroperitonealisation of raw areas. trauma, vascular occlusions Talc, starch, gauze Peritonitis, TB Crohns disease

Foreign material Infection Inflammation Radiation enteritis

OBSTRUCTION BY ADHESIONS AND BANDS (contd.)

2.

Bands
Usually only one band culpable May be ;

Congenital e.g. obliterated vitalointestinal duct A string band following previous bacterial peritonitis A portion of greater omentum, usually adherent to the parietes.

INTUSSUSCEPTION
One portion of gut becomes invaginated into immediately adjacent segment. Mostly in children ( 5 to 10 months) 90% idiopathic Weaning, loss of maternal acquired immunity and common viral pathogen implicated. Initiating event: hyperplasia of Peyers patches

INTUSSUSCEPTION (contd.)

Associated pathological conditions in children

Merkels diverticulum polyp Duplication Henoch-Scholein purpura

Associated pathogical conditions in adults

Polyp ( e.g. Putez Jeghers syndrome) A submucosal lipoma Other tumors

INTUSSUSCEPTION (contd.)

Pathology

Composed of 3 parts
The

entering or inner tube The returning or middle tube The sheath or outer tube

The part that advances is the apex, the mass is the intussusception and the junction of the entering layer with the mass is the neck Usually the blood supply of the inner layer impaired.

VOLVULUS

Twisting or axial rotation of a portion of bowel about its mesentery. If complete forms closed loop obstruction May be primary or secondary Primary occurs secondary to congenital malrotation of gut , abnormal mensenteric attachments or congenital bands E.g. volvulus neonatarum
caecal volvulus sigmoid volvulus

Secondary is due to rotation of a piece of bowel around an acquired adhesion or stoma.