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Obstruction
Definition
Inability of the intestinal contents to pass
distally in the lumen of intestine either
from a mechanical barrier or absence of
peristalsis without any mechanical barrier
is known as Intestinal obstruction.
Mortality and Morbidity depend upon the
early recognition and correct diagnoses of
obstruction.
If untreated death occur in 100% of patients
with strangulated obstruction.
Classification
Intestinal obstruction can be classified in many ways.
Intraluminal causes
Gall stones ileus
Food bolus obstruction
Roundworm mass
Foreign body
Classification
Depending upon Severity
Acute Obstruction
Chronic Obstruction
Acute on Chronic Obstruction
Pathophysiology
Irrespective of the etiology and acuteness of onset, in Dynamic
obstruction the proximal Bowel dilates and develops an Altered
motility.
Dilation Obstruction leads to proximal dilation due to accumulation
of intestinal secretions and swallowed air. this bowel dilation
stimulates cell secretory activity resulting in more fluid
accumulation and progressive dilatation.
Altered motility accumulation of secretion in the intestine lumen
stimulates increased peristalsis both above and below the
obstruction . below the obstruction increased peristalsis leads to
frequent loose stools and flatus early in the course of disease.
Above the obstruction increased peristalsis try to overcome the
obstruction,if the obstruction is not relieved the bowel begins to
dilate causing a reduction in the peristaltic strength ultimately
resulting in flaccidity and paralysis.
Pathophysiology
The distention Proximal to obstruction is caused by two factors
Pathophysiology
Interference with blood supply : as the tension within
the bowel loops become more and more , venous
congestion takes place resulting in edema of bowel wall. If
the obstruction is not relieved capillary rupture and
hemorrhage takes place. In case of volvulus and
intussusception arterial compromise takes place fast which
causes gangrene of bowel wall very early.
Transmigration of Organisms : both aerobic and
anaerobic organisms transmigrate through the gangrenous
bowel and results in peritonitis. The organism release
powerful endotoxins which are absorbed from peritonial
surface and cause gram negative shock or septic shock
which caries high mortality.
Clinical Features
There are Four Cardinal features of Dynamic Obstruction.
1. Colicky pain
2. Distention
3. Vomiting
4. Absolute constipation
The clinical features are also influenced by the site of
obstruction whether
small bowel
large bowel
and on the onset of obstruction whether
Acute or
Chronic or
Acute on Chronic
Clinical Features
In High Small Bowel Obstruction Vomiting occurs
early and is profuse with rapid dehydration.
Distention is minimal with little evidence of fluid
levels on abdominal radiograph.
In Low Small Bowel Obstruction Pain is
predominant with central Distention . Vomiting is
delayed. Multiple central fluid levels are seen in
abdominal radiograph.
In Large Bowel Obstruction Distention is early
and pronounced. Pain is mild and Vomiting and
Dehydration is late. The proximal colon and
caecum are distended on abdominal radiograph.
Other Features
Dehydration : Most common in small bowel obstruction because of
repeated vomiting and fluid sequestration. Signs of dehydration appears
early
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Feature of Strangulation
It is important to distinguish strangulating from nonstrangulating obstruction because the Former is a surgical
emergency. The diagnoses is entirely clinical. Features include
1. Constant Pain
2. Tenderness with Rigidity
3. Guarding and absent bowel sound
4. Features of Septic Shock
5. In case of External hernia the lump is tense, tender,
irreducible with no expansile cough impulse
Pain is never completely absent in strangulation.
Symptoms Usually commence suddenly and recur regularly.
Any tenderness present is of great significance and need
frequent reassessment.
Investigations
Complete Blood Picture : Low Hb% indicates underlying malignancy.
Increased total WBC count indicates infection or sepsis.
Air-fluid levels
Haustrations
Treatment of Acute IO
There are Three main measures used to treat acute IO.
1. Gastro-intestinal drainage
2. Fluid and electrolyte replacement
3. Relief of Obstruction
Surgical treatment is necessary for most cases of IO but
should be delayed until resuscitation is complete, provided
there is no signs of Strangulation or evidence of closedloop obstruction.