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INTESTINAL OBSTRUCTION

Definition
Is a partial or complete blockage of the bowel
(small or large intestine) that prevent the feces and
gas from passing distally

Frequency
Among patients who are admitted to the hospital for
severe abdominal pain, 20% have an intestinal
obstruction
INTESTINAL OBSTRUCTION
Frequency
Bowel obstruction can affect individuals of any age

Different conditions occur at higher rates in


certain age groups
►Children under the age of two, for example,
are more likely to present with:
intussusceptions or
congenital defects

►Elderly patients, on the other hand, have a


higher rate of colon cancer
INTESTINAL OBSTRUCTION
Morbidity and mortality rates
The mortality rate of small bowel obstruction ranges from
:
2% for a simple obstruction to
25% for a strangulation obstruction that:
compromises the blood supply and
is treated after a lapse of 36 hours

Large bowel obstruction carries a mortality rate of:


2% for volvulus to
40% if part of the bowel is gangrenous
INTESTINAL OBSTRUCTION

Etiology
There are two types of intestinal obstructions:
mechanical and
non-mechanical, called paralytic ileus

Mechanical obstructions occur because the


bowel is physically blocked

Unlike mechanical obstruction, non-mechanical


obstruction, occurs because peristalsis stops
INTESTINAL OBSTRUCTION
Etiology
Mechanical Obstruction
Three types of abnormalities may produce
mechanical obstruction
I) Obstruction of intestinal lumen
may be caused by several kinds of diseases,
such as:

► Intussusception
Is an invagination of the bowel lumen, with
invaginated portion (the intussusceptum) passing
distally into the ensheathing outer portion (the
intussuscipiens) by peristalsis
Illustration
• Intussusception
INTESTINAL OBSTRUCTION

Etiology
Mechanical Obstruction
► Intussusception
Unrelieved intussusception can occlude the
blood supply of the intussusceptum

In adults, intussusception is usually caused


by an abnormality of the bowel wall, such as:
tumor or
Meckel’s diverticulum
INTESTINAL OBSTRUCTION
Etiology
Mechanical Obstruction
► Intussusception
In infants and children, intussusception may
occur without apparent anatomic cause

► Large gallstone (biliary ileus)


Can enter the intestinal lumen via a
cholecystoenteric fistula, can cause obstruction
to produce a rare condition called gallstone
ileus
Illustration

Large gallstone (biliary ileus)


INTESTINAL OBSTRUCTION
Etiology
Mechanical Obstruction
► feces
meconium or
bezoars
may obstruct the intestine
Bezoars occur more frequently in:
children
the mentally retarded and
the toothless, and in
patients after gastrectomy
INTESTINAL OBSTRUCTION
Etiology
Mechanical Obstruction
2) Intrinsic bowel lesion
Producing intestinal obstruction are often
congenital such as:
Atresia
Stenosis
Duplication
They occur most commonly in:
infant and
children
INTESTINAL OBSTRUCTION
Etiology
Mechanical Obstruction
2) Intrinsic bowel lesion
Neoplasm
carcinoma of the sigmoid colon
Inflammation
Chrohn’s disease
INTESTINAL OBSTRUCTION
Etiology
Mechanical Obstruction
3) Lesions extrinsic to the bowel cause intestinal
obstruction
► Adhesion of the intestine by adhesions from:
previous operations or
inflammation
is the leading cause of small intestinal
obstruction

► External hernias
Are the second most common cause of mechanical
small intestinal obstruction
Illustration
Small bowel obstruction by
adhesion
INTESTINAL OBSTRUCTION
Etiology
Mechanical Obstruction
► Internal hernia due:
to congenital abnormalities of the
mesentery or
to surgical defects in the mesentery
cause bowel obstruction

►Extrinsic masses such as:


neoplasms and
abscesses
may cause mechanical bowel obstruction
Illustration
Internal hernia
INTESTINAL OBSTRUCTION
Etiology
Mechanical Obstruction
► A volvulus
Is an extrinsic abnormality in which a portion of the
alimentary canal rotates or twists about itself

The twist usually involves the blood supply of the


twisted portion of the bowel
Illustration
• Volvulus:
INTESTINAL OBSTRUCTION
Etiology
Mechanical Obstruction
► A volvulus
A volvulus usually accompanies an underlying abnormality:
midgut volvulus is caused by mesenteric abnormality of
malrotation

Cecal volvulus occurs when the cecum or right colon is on a


mesentery rather than being retroperitoneal
Etiology
Mechanical Obstruction
► A volvulus
Sigmoid volvulus develops when the
sigmoid is abnormally long

Another type of volvulus occurs when


adhesion fix the intestinal to a point that
acts as a pivot for the volvulus
INTESTINAL OBSTRUCTION

Etiology
Mechanical Obstruction
► A volvulus
The most common causes of intestinal obstruction in
adults are adhesions, usually from previous
operations:
hernias and
neoplasms

Neoplasms are the most common cause of colon


obstruction
Illustration
Neoplasm
Etiology
Paralytic Ileus (or non-mechanical obstruction)
It is a common disorder, occurs to some extent in most
patients undergoing abdominal operations

Several neural, humoral, and metabolic factors cause this


abnormality; such as:
►Intestinointestinal reflex, result from prolonged
intestinal distention

*Distenstion of other organs, such as the ureter, can


inhibit intestinal motility
*Spine fracture, retroperitoneal hemorrhage, or
trauma can also produce paralytic’s ileus
INTESTINAL OBSTRUCTION
Etiology
Paralytic Ileus (or non-mechanical obstruction)
►Clinically, peritonitis causes paralytic ileus

►Electrolyte imbalance, particularly hypokalemia, contribute to


paralytic ileus by interfering with the normal ionic movements
during smooth muscle contraction

► Finally, ischemia of the intestine rapidly inhibits motility


INTESTINAL OBSTRUCTION
Etiology
Idiopathic Intestinal Pseudo-Obstruction (IIPO)
IIPO is a chronic illness characterized by symptoms of
recurrent intestinal obstruction without demonstrable
mechanical occlusion of bowel

The patients with this disease have:


* impaired motor response to intestinal distension
* duodenal and colonic slow waves may be normal
* some patients have aperistalsis of the esophagus
INTESTINAL OBSTRUCTION
Etiology
Idiopathic Intestinal Pseudo-Obstruction (IIPO)
In IIPO, the heredity plays a role in this disorder

The symptom IIPO include:


Cramping abdominal pain
Vomiting
Distension
Diarrhea
Steatorrea
INTESTINAL OBSTRUCTION
Etiology
Idiopathic Intestinal Pseudo-Obstruction (IIPO)
Physical examination reveals abdominal distension

IIPO is distinguished from mechanical intestinal


obstruction by the absence of the radiological findings
of mechanical obstruction

Surgery treatment for IIPO should be avoid

Intravenous hyperalimentation may help manage


these patients
Pathogenesis
Intestinal Obstruction
Mechanical obstruction of the intestine causes
accumulation of the fluid and gas proximal to the
obstruction producing distention of the
intestine

Ingested fluid, digestive secretions and intestinal


gas
initiate the distension

Large volume of saliva, gastric secretion, bile, and


pancreatic juice enter the gut daily

The stomach has a very small capacity for absorbing


fluid
Pathogenesis
Intestinal Obstruction
Obstruction of the bowel leads to proximal
dilatation of the intestine due to accumulation
of GI secretions and swallowed air

This bowel dilatation stimulates cell secretory


activity
resulting in more fluid accumulation

This leads to increased peristalsis both above


and below the obstruction with frequent:
loose stools and
flatus early in its course
Pathogenesis (Intestinal Obstruction)
* Vomiting occurs if the level of obstruction is proximal
*Increasing bowel distention leads to increased
intraluminal pressures

This can cause compression of mucosal lymphatics


leading to bowel wall lymphedema

With even higher intraluminal hydrostatic pressures,


increased hydrostatic pressure in the capillary beds
results in massive third spacing of fluid, electrolytes,
and proteins into the intestinal lumen
Pathogenesis
Intestinal Obstruction
The fluid loss and dehydration that ensue may be severe and
contribute to increased:
morbidity and
mortality

Strangulated bowels are most commonly associated with


adhesions and occur when a loop of distended bowel twists
on its mesenteric pedicle
Pathogenesis
Intestinal Obstruction
Bacteria in the gut proliferate proximal to the obstruction
Microvascular changes in the bowel wall allow bacterial
translocation to the mesenteric lymph nodes ►►► ►
cystemic toxicity
dehydration and
electrolytes abnormalities
Pathogenesis
Intestinal Obstruction
The arterial occlusion leads to bowel:
ischemia and
necrosis
If left untreated, this progresses to:
perforation
peritonitis and
fecal soilage of peritoneal cavity

if left untreated ► death


Clinical
Small bowel
History
Abdominal pain (characteristic with most patients)

Pain, often described as:


crampy and
intermittent
is more prevalent in simple obstruction

Often, the presentation may provide clues to the


approximate: (1) location and (2) nature of the
obstruction
Clinical
Small bowel
History
Usually, pain that occurs for:
a shorter duration of time and
is colicky and
accompanied by bilious vomiting
may be more proximal bowel obstruction

Pain may last as many as several days


Progressive in nature and with abdominal distention
►► this may be typical of more distal bowel
obstruction
Clinical (Small bowel)
History
Pain may be changed in the character:
►Example: constant pain, this may indicate
the development of a more serious complication
(strangulation, or ischemic bowel)

Nausea
Vomiting, which is associated more with
proximal obstructions
Diarrhea (an early finding)
INTESTINAL OBSTRUCTION
Clinical
Small bowel
History
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
INTESTINAL OBSTRUCTION
Clinical
Small bowel
History
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)


Physical Examination:
Small bowel
Abdominal distention

Duodenal or proximal small bowel has less


distention when obstructed than the distal bowel has
when obstructed

Hyperactive bowel sounds occur early as GI contents


attempt to overcome the obstruction

Hypoactive bowel sounds occur late


Physical Examination:

Small bowel

Exclude incarcerated hernias of the groin,


femoral triangle, and obturator foramina

Proper genitourinary and pelvic examinations


are essential

►Look for the following during rectal examination


* Gross or
* Occult blood
which suggests: late strangulation or malignancy
INTESTINAL OBSTRUCTION

Physical Examination:
Small bowel
Check for symptoms commonly believed to be
more diagnostic of intestinal ischemia, including
the following:
Fever (temperature >100°F)
Tachycardia (>100 beats/min)
Peritoneal signs
INTESTINAL OBSTRUCTION

Differential Diagnosis
Small bowel
Appendicitis, Acute
Cholangitis
Cholecystitis and Biliary Colic
Cholelithiasis
Constipation
Diverticular Disease
Foreign Bodies, Gastrointestinal
Gastroenteritis
Inflammatory Bowel Disease
Differential Diagnosis
Small bowel
Obstruction, Large Bowel
Ovarian Torsion
Pancreatitis
Pediatrics, Appendicitis
Pediatrics, Gastroenteritis
Pediatrics, Intussusception
Pelvic Inflammatory Disease
Urinary Tract Infection
Lab Study
Small bowel
1) 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 (e.g.,
dehydration)

Creatinine level: Creatinine level elevations


may indicate dehydration
Lab Study
Small bowel
CBC:
WBC count may be elevated in simple or
strangulated obstructions

Increased hematocrit is an indicator of  volume


state (i.e.: dehydration)

Type and crossmatch: The patient may


require surgical intervention
Urinalysis
Small bowel
Imaging Studies
1) Plain radiography
Obtain plain radiographs first for patients in
whom SBO is suspected

At least 2 views are required:


supine or flat
and upright
Small bowel
Imaging Studies
1) Plain radiography
Plain radiographs are diagnostically more
accurate in cases of simple obstruction

►Remember
The diagnostic failure rates of as much as
30% have been reported
Small bowel
Imaging Studies
1) Plain radiography
Dilated small-bowel loops with air fluid
levels indicate SBO
Small bowel
Imaging Studies
2) Enteroclysis ( bowel enema)
*Enteroclysis is valuable in detecting the presence of
obstruction and
* in differentiating partial from complete blockages

This study is useful when plain radiographic findings


are:
* normal in the presence of clinical signs of SBO
or
* if plain radiographic findings are nonspecific
Small bowel
Imaging Studies
3) CT scanning
CT scanning is useful in making an early
diagnosis of strangulated obstruction

Sensitivity: 90% in detecting SBO


Small bowel
Imaging Studies

4) Ultrasonography
Ultrasonography is less costly and less invasive
than CT scanning

Specificity is reportedly 100%


Treatment
Emergency Department Care
Initial ED treatment consists:
► aggressive fluid resuscitation
► bowel decompression
► administration of analgesia and antiemetic
as indicated clinically
► antibiotics (to cover against gram-negative
and gram-positive) and
► early surgical consultation

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