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Intestinal Obstruction

Zeeshan Razzaq MRCS Ire, MRCS Ed, MRCS Eng


Colorectal Registrar
12-October-2015

M.C 80 yr Female

ED

1/7 History of:


Abdominal pain

Abdominal distension

Progressively worsening

Vomiting

Intermittent, Colicky, Periumbilical

Non-Projectile, 2-3 times / day

Constipation

Passing flatus

PAST HISTORY

MEDICAL:

Hypertension

SURGICAL:

Open Appendicectomy at age of 30


Years
Caesarean Sections x 2

On Examination

Vitals

Pulse:70/min, Regular
BP: 130/80
Temp: 36.5 C
RR: 15/min

Dehydrated
CNS: GCS 15/15
CVS: S1 + S2 + 0
Chest: Bilateral NVB

Abdominal Exam

Grid Iron + Pfennensteil incisions


Distended
No Guarding or Tenderness
Non Peritonitic
No Hernias
Bowel Sounds: Hyperdynamic
Per Rectum: Empty Rectum

Investigations

FBC:
Hb: 12 gm/dl
WCC: 9000
Platelets: 299,000
U&E

K: 4 meq/l

CRP: 17
Lactate: 1.3

Investigations

PFA

Investigations

CT Abdomen / Pelvis

Investigations

CT Abdomen / Pelvis (With Oral & IV


Contrast)

Dilated proximal small bowel loops with


collapsed distal small bowel
Transition point at Right Lower quadrant
at level of Mid to Terminal ileum
No features suggesting bowel
Perforation / Ischaemia

Management
Conservative

Drip & Suck


NG

Intake-Output Record

Wide Bore
Left on free drainage
IV Fluids
Foleys Catheter to aim Urine output > 1ml/kg/hour

Analgesia
Thrombo-Prophylaxis

TEDS
Tinzaparin

Management

Failed to respond to conservative


management
High NG tube outputs
Abdominal distension not settling
No flatus or Bowel movements

Management

Laparoscopy

Distended proximal small bowel loops


with collapsed distal loops
Dense adhesions at right lower quadrant
Free fluid
Proximal small bowel viability
Questionable

Management

Converted to Laparotomy

Band adhesion at terminal ileum: Divided


Adhesions at Right lower quadrant: Adhesiolysis
Hot packs for proximal segment of small bowel
Good peristalsis
Good Mesenteric blood flow
Colour changed to pink
Distended small bowel decompressed proximally
via NG

INTESTINAL OBSTRUCTION

Classification

Dynamic

Where peristalsis is working against a mechanical


obstruction
In Small Bowel

High

Low
Large Bowel
Intra Luminal
Intra Mural
Extra Mural

Adynamic

Dynamic Obstruction
Causes
Intraluminal

Impaction
Foreign bodies
Bezoars
Gall stones
Worms

Dynamic Obstruction

Intramural

Stricture
Malignancy

Dynamic Obstruction

Extramural

Bands
Adhesions
Hernia
Volvulus
Intussusception

Etiology

Adynamic Obstruction

Absent Peristalsis

Paralytic Ileus

Present but non-propulsive form

Mesenteric vascular Occlusion


Pseudo-obstruction

Classification of Intestinal
Obstruction

By Surgical Pathology

Simple

Where blood supply is intact

Strangulated

Where there is direct interference of the blood supply

By Nature of Presentation

Acute
Subacute
Chronic
Acute on Chronic

Pathophysiology

Simple occlusion

Peristalsis increases then


uncoordinated then absent
Increase secretion and
decreased absorption leads to
loss of fluids and electrolytes

Proximal distension is
because of:

Gas

Nitrogen 90 %
H2S

Fluid collection

Excessive fluid collection


Retarded absorption

Pathophysiology

Causes for dehydration and electrolyte


loss

Reduce oral intake


Defective intestinal absorption
Losses due to vomiting
Sequestration in bowel lumen

Pathophysiology

In closed Loop
Obstruction

Occlusion occurs at both


ends of loop

Classic cause: tumour of


Right Colon and
competent Ilocaecal
valve

Pathophysiology

In strangulation

End result of closed


loop obstruction
Results in gangrene

Clinical Features: Look for


following questions

Is it obstruction and if so at what


level?
Is strangulation present?
Is dehydration present?
What is the cause?
What is the treatment of individual
cause?

Symptomatology

Pain

First symptom
Colicky in nature
Centered around umbilicus --- Small bowel
Lower abdomen-----Large bowel
With increasing distension, colicky is
replaced by diffuse pain
Severe pain is indicative of strangulation
Does not occur in Paralytic ileus

Symptomatology

Vomiting

The more distal the obstruction, the


longer the interval between symptoms
and development of the nausea and
vomiting

With progression, the vomitus alters


from digested food to ---- Faeculent
material

Symptomatology

Distension

In small bowel dependent on the


Site of obstruction
Visible peristalsis may be present
Delayed in colonic obstruction
Absent in mesenteric vascular occlusions

Symptomatology

Constipation

Absolute: Neither faeces nor flatus is passed


Relative: Where flatus only is passed

Constipation is not present in

Richter's Hernia
Gallstone ileus
Mesenteric vascular occlusion
Obstruction associated with pelvic abscess
Partial obstruction (faecal impaction/colonic neoplasm)
where diarrhoea may often occur

Examination

General

Dehydration

Repeated vomiting
Fluid sequestration
Urea and haematocrit rise

Pyrexia

Onset of ischemia
Intestinal obstruction
Inflammation associated with obstructing
diseases
Hypothermia indicates septicemia

Examination

Abdomen

Inspection

Scars
Site of distention
Visible peristalsis
Irreducible swellings

Examination

Palpation

Abdominal mass
Tenderness

Indicates pending or established gangrene


Peritonism indicates overt infarction or
perforation

Rigidity
Hernial Orifices

Examination

Percussion

Auscultation

Resonance

Hyper-resonant
Silence

DRE

Impacted faeces
Rectal tumor
Blood on finger

Features of Strangulation

Presence of shock
Pain
Symptoms commence suddenly and recur
regularly
Localised tenderness
Rebound tenderness
Rigidity
Raised WCC & CRP
Metabolic acidosis: Rising Lactate & Base
deficit

Investigations

Supine Abdominal X-ray (PFA)

Jejunum: Valvulae Conniventes


Ileum: Feature less
Caecum: Round gas Shadow in RIF
Large bowel: Haustral Folds
F.B and Gall stones could be seen

PFA

PFA

CT Abdomen / Pelvis

Management

Principles

Gastrointestinal Drainage
Fluid & Electrolyte replacement
Relieve of Obstruction

Management

Initial management

Pass NG
I/V fluids: Saline or Hartmanns
Catheterise
Antibiotic are not necessary but many
clinicians give because of overgrowth of
the bacteria

Management

Monitor

Pulse
Temp
BP
Respiratory rate
Urine out put
Abdominal girth
Abdominal tenderness
WCC, CRP & Lactate

Conservative Management

Done in

In 2-10 days of previous Surgery


Multiple prior attacks of adhesive obstruction
Poor general condition
Patient unfit for Surgery

Look for signs to stop conservative


treatment

Surgical Management

The sun should not both rise and set


on a case of unrelieved intestinal
obstruction

Conservative management may be


continued for 72 hours

Surgical Management

Indication for early interventions

Obstructed or strangulated external


hernia
Internal intestinal strangulation
Acute obstruction

Surgical Management

Contra indications to Surgery

Paralytic ileus
Impacted faeces
Volvulus
No strangulation seen on previous
exploration

Surgical Management

Operative assessment is directed to

Site of obstruction
Nature of obstruction
Viability of the gut

Midline incision gives the best


exposure

Surgical Treatment

Principles of surgical intervention

Management of the segment at the site


of obstruction
The distended proximal loop
The viability of the gut

Differences between Viable and Nonviable


bowel
Bowel
Circulation

Viable

Nonviable

Dark color becomes lighter

Dark color remains

Mesentery bleeds if pricked

No bleeding if mesentery is
pricked

Peritoneum

Shiny

Dull and lustless

Bowel musculature

Firm

Flabby, thin and friable

Pressure ring may or may not


disappear

Pressure rings persist

Peristalsis may be observed

No peristalsis

Dilated Viable bowel

Nonviable Gangrenous bowel

Large Bowel Obstruction

Causes

Carcinoma
Diverticular disease
Volvulus
Pseudo-obstruction

Types

Acute
Chronic

Management of Large bowel


obstruction

Full resuscitation

Lesions on Right side

Emergency right hemicolectomy


If not Removable

Proximal stoma
Ilio-transverse internal bypass

Management of Large bowel


obstruction

For left side Lesions

Primary resection with one of following

Left hemicolectomy
Double barreled colostomy (Paul-Mikulicz)
Hartmanns procedure
On table lavage of colon with primary
anastomosis
Primary anastomosis with proximal covering
stoma

Rare Causes

Rare Causes

Rare Causes

Rare Causes

Rare Causes

Rare Causes

Thank You