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Intestinal

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.

Depending upon the nature of obstruction


Dynamic obstruction
Adynamic obstruction
.Dependind

upon the Cause of obstruction

Intraluminal causes
Gall stones ileus
Food bolus obstruction
Roundworm mass
Foreign body

In the wall of the Gut


Strictures
Crohns disease
Carcinomas
Adhesions

Outside the wall of the Gut


Volvulus
Intussusception
Obstructed Hernia
Congenital Bands

Classification
Depending upon Severity
Acute Obstruction
Chronic Obstruction
Acute on Chronic Obstruction

Depending upon Blood Supply


Simple Obstruction
Strangulated Obstruction

Depending upon the site


Small bowel obstruction
Large bowel 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

Gas : obstruction leads to significant proliferation of both aerobic and


anaerobic organisms resulting in considerable gas production , Nitrogen
being the predominant(90%) Gas along with Hydrogen Sulfide.

Fluid : Fluid is made up of various digestive juices e.g 1500ml of


saliva\d, 2L of gastric juice\d,3L of intestinal secretion\d,1L of
pancreatic juice and bile\d. Following obstruction fluids accumulates
in the bowel wall and any excess fluid is secreted in the lumen. Because
absorption is retarded ,dehydration and electrolytes disturbance is
inevitable. Causes include
Reduced oral intake
defective intestinal absorption
result of vomiting
sequestration in bowel lumen

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

(?)

Hypokalemia : not a common feature in simple mechanical obstruction.


An increase in serum potassium, amylase and LDH may be associated
with presence of Strangulation along with leucocytosis or leucopenia.

Pyrexia : In the presence of obstruction indicates


1. Onset of Ischemia
2. Intestinal perforation
3. Inflammation associated with obstructing disease.

Hypothermia : Indicates Septic shock.


Abdominal tenderness : localized tenderness indicates pending and
established ischemia.

Signs of peritonism : indicates overt infarction or perforation.

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.

Electrolytes : most of the electrolytes are low in cases of intestinal


obstruction.

Plain X-ray Abdomen

: in erect position is an important investigation


in cases of intestinal obstruction.
Multiple gas fluid levels are pathognomic of IO. Gas level appears earlier than
fluid levels.
Plain X-ray may demonstrate Gall stone ileus or foreign body.
Sigmoid volvulus appear as a large dilated loop.
Jejunum is characterized by Regularly placed mucosal folds called volvulae
conniventes placed opposite to each other. They are produced by valves of
kirkring.
Large bowel is characterized by Haustrations : Incomplete mucosal folds,
not placed opposite to each other. They are large. Caecum has no
haustrations. However it appears as a round gas shadow in RIF.

Multiple air-fluid levels

Air-fluid levels

Haustrations

Small bowel obstruction

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.

Indications of early surgical intervention


4. Obstructed or strangulated external hernia
5. Internal intestinal strangulation
6. Acute obstruction

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