INTESTINAL OBSTRUCTION

Prepared by:
Ahmad Iqbal Syafiq
Zuhratun Nazihah

Supervisor : Dr. Hilda

Outlines

DEFINITION
CLASSIFICATION
CAUSES
HISTORY
EXAMINATION
INVESTIGATION
PSEUDO-OBSTRUCTION
MANAGEMENT
SURGERY : INDICATIONs
TAKE HOME MESSAGES

Definition
Intestinal obstruction is
blockage of bowel that
prevents the contents of
the intestine
frompassing through.

Classification
Mechani
cal
Functional
Extramural
Intramural
Intraluminal

Paralytic ileus
Postoperative
Inflammatory
Metabolic
neurogenic

Mechanical

Extramural

Intramural

Intraluminal

Adhesions
Hernia
Volvulus
Neoplasms

Neoplasms
Stricture
Intussucepti
on

Gallstones
Fecal
impaction
Bezoar
Foreign
body
Intramural
haematoma

 ELDERLY carcinoma, diverticulitis,

sigmoid volvulus
ADULT hernia, adhesion, carcinoma
PAEDIATRICS intussusception,
congenital hypertrophic pyloric
stenosis, atresia (duodenum, ileum),
meconium obstruction, volvulus
neonatorum

Pathophysiology

Pathophysiology
Bowel distal to obstruction collapse
Bowel proximal to obstruction distends and becomes
hyperactive (distension due to intestinal secretions and
swallowed air)
Bowel wall becomes edematous. Fluid electrolytes
accumulate in the wall and lumen (third space loss)
Bacteria proliferate in the obstructed bowel
As the bowel distends, intramural vessels become
stretched/compromised
Ischemia and necrosis

History
4

Cardinal Signs :
Abdominal pain
Nausea & vomiting
Abdominal distension
Absolute constipation

Others :
Dehydration, hypotension, tachycardia,
pyrexia, abdominal tenderness, empty
rectum on DRE, high pitched bowel sound.

 Pain
Small bowel :
- periumbilical and colicky
- comes in spasm
- builds up in crescendo
- then tappers off
- regular pain at intervals of 2-3 minutes
Large bowel : below the umbilicus & comes
at intervals of 6-10 minutes.
Severe & continuous pain suggest
strangulation obstruction.

 Vomiting
The higher the obstruction, the vomiting is
more severe
In large bowel obstruction vomiting comes
later and sometimes patient may not vomit
at all.
As obstruction progresses the character of
the vomitus alters (digested food
feculent material; as a result of the
presence of enteric bacterial overgrowth)

 Abdominal distention
The more distal the obstruction, the more
distention of abdomen.
Visible peristalsis may be present.
Constipation
May pass feces or flatus if early onset
Occurs early in lower large bowel
obstruction
Occurs late in high small bowel obstruction
Absolute constipation is a feature of
complete intestinal obstruction.

 In high small bowel obstruction,

vomiting occurs early and is profuse with
rapid dehydration. Distension is minimal
In low small bowel obstruction,
Vomiting is delayed. pain is predominant with
central distension.
In large bowel obstruction,
distension is early and pronounced. Pain is
mild and vomiting and dehydration are late.

Examination
Inspection
Visible scar
Palpation
hernial orifices

-band
-adhesion
-incarcerated
-strangulated hernia
+torsion
+intussusception
-mass of Ascaris worms

large, slightly tender,

mobile
mass changes its
position with colicky
+intraperitoneal abscess
pain
tender indurated mass -fecaloma
hard impacted masses

Percussion

- tympanic sound

Auscultation

-runs of borborygmi
-tinkling high pitched musical
sounds

Rectal examination
fresh blood and mucus
hard mass of faeces
hard mass in the
rectovesical pouch

-strangulating lesion
-carcinoma of large gut
-intussusception
+constipation
-extraintestinal tumour

Investigation
Blood
FBC:
Hb anaemic
PCV elevated due to dehydration
TWBC normal or elevated (strangulation,
ischemia, perforation)
RP:
dehydration
electrolyte imbalance (hypokalemia,
hyponatremia)
ABG:
alkalosis proximal obstruction (severe
vomiting)
acidosis strangulation

 Radiological
AXR
Gas pattern
Fluid level
Masses shadow
Fecal pattern
Chest X-Ray
Elevated diaphragm
Air under diaphragm
Aspiration

USG:
to differentiate mechanical obstruction & paralytic ileus,
poor visualization of gas filled structure,
only useful in selected patient ie pregnant, when CT is
contraindicated, in critically ill patients

Free fluid
Masses
Mucosal folds
Pattern of peristalsis

CT scan:
level of obstruction (transition point)
Causes (hernias, inflammatory changes, masses)
sign of strangulation, ischemia, perforation

Large Bowel:

Small Bowel:

Peripheral
Presence of haustration,
diameter >8 cm
distended caecum a
rounded gas shadow in the
right iliac fossa. >10cm
diameter.

Central
jejunum valvulae
conniventes
Ileum featureless
Diameter >5 cm
No gas is seen in the colon

Pseudo-obstruction
DEFINITION
Describes an obstruction that occurs in the
absence of mechanical cause or acute intra
abdominal disease
Diagnosis of exclusion in the absence of
mechanical cause
CAUSES
Idiopathic
Metabolic
Severe trauma
Shock
Septicaemic
Retroperitoneal irritation

Ogilvies Syndrome
Acute large bowel obstruction
Absence of mechanical cause
AXR evidence of colonic obstruction, usually marked
cecal distension
Single contrast water soluble barium enema, CT scan
and colonoscopy can be done
Once diagnosis confirmed, treat with colonoscopic
decompression
Recurrence occurs in 25%
Complication cecal perforation
Repeat colonoscopy with simultaneous placement of
flatus tube may be required
Surgical intervention subtotal colectomy and
ileorectal anastomosis

Principles of Treatment

Gastrointestinal drainage
Fluid and electrolytes replacement
Relief of obstruction
Surgical intervention
necessary for most cases
Need to be delayed until resuscitation is complete

Early Management
ABC
Resuscitation
Oxygen supply
fluid replacement with hartman or normal saline

Nasogastric decompression
KNBM
NG tube with free flow or 4hly aspirate

Close monitoring
BP, PR, Temp, Input/output, CVP

Antibiotic s cover
Analgesia

Indication For Surgery

Immediate intervention
Evidence of strangulation
Signs of peritonitis resulting from perforation or
ischemia

In the next 24-48H

Clear indication of no resolution of obstruction
(clinical or radiological)
Diagnosis is unclear in virgin abdomen

Take Home Message

4 cardinal signs of intestinal obstruction are
abdominal pain, abdominal distension, vomiting
and constipation
Pseudo-obstruction is the diagnosis of exclusion in
the absence of mechanical obstruction
Decompress the obstructed gut (NGT!!)

 Replace fluid and electrolytes loses

Strict IO (CBD is least, CVP - especially in elderly,
immuno compromised patient)
CT if only patient is stable and cause of
obstruction is unclear
Surgical intervention promptly if signs of
peritonitis or strangulation, underlying cause
needs surgical treatment ie colonic carcinoma or
hernias or patient does not improve with
conservative treatment

References
http://www.primary-surgery.org/ps/vol1/ch-10.pdf
Bailey & Loves Short Practice Of Surgery 25th
edition