intestinal obstruction neo
Post on 03-Jun-2015
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Level
• High small bowel
• Low small bowel
• Large bowel
1. Dynamic- mechanical
obstruction
2. Adynamic- – Peristalsis –absent – Peristalsis -non-
propulsive form
Dynamic
• Acute
• Chronic
• Acute on Chronic
• Subacute
Type of presentation
• Simple – Intact blood supply
• Strangulated – Compromised blood supply
Pathology
Proximal to obstruction :
Altered mobility
Distension
Distension
Gaseous :
Swallowed air Diffusion from blood Products of digestion and bacterial activity
O2 & CO2 reabsorbed
Nitrogen 90% and H2S
Strangulation
• External compression –
Hernia/Adhesions/Bands
• Interruption of mesenteric flow – Volvulus/
Intussuception
• Rising intraluminal pressure – Closed loop
obstruction
• Veins compressed first - Edema
and hemorrhages
• Arterial compression –
Haemorrhagic infarction
• Translocation of bacteria, toxins
and systemic absorption
Strangulation External Internal
• Smaller absorptive surface
• Short segment – Less blood and fluid loss
• Larger absorptive surface
• Large segment – More blood and fluid loss - shock
Closed loop obstruction
• Obstruction both at proximal and
distal point
– Strangulated loops
– Colonic obstruction with a
competent ileocecal valve
Clinical features
• Pain
• Vomiting
• Distension
• Constipation
Other features
• Dehydration
• Hypokalemia
• Pyrexia –
Ischemia/perforation/Inflammatory obs.
• Abdominal tenderness
Signs of strangulation
• Continous pain
• Localised tenderness, rigidity,
rebound tenderness
• Shock
• Does not respond to conservative
management
Radiology
• X – ray abdomen ErectAir fluid levels
• X – ray abdomen SupineDistended bowel
Small bowel
• Central and transverse lie
• Jejunum – Valvulae conniventes
(concertina / Stack of coins)
• Ileum – Characterless
• Colon – Haustral folds
• Sigmoid volvulus
• Impacted foreign bodies
• Gallstone ileus
Treatment
• Gastrointestinal drainage
• Fluid and electrolyte replacement
• Relief of obstruction
Timing of surgery• Emergent
Obstructed/strangulated Ext hernia
Internal intestinal strangulation
Acute obstruction
• Other cases
Atleast within 24 hrs
• Adhesions
upto 72hrs
Principles of Surgical intervention
• Mt. of the segment at the site of
obstruction
• The distended proximal bowel
• Underlying cause of obstruction
Approach
Caecum
Dilated Not dilated
Large bowel Small bowel
Trace distally Trace proximally
Surgical procedure
• Adhesiolysis
• Excision / Resection
• Bypass / Proximal decompression
Viability of bowelViable
Dark color – Light Dark persists
Mesentery bleeds on pricking
No bleeding
Peritoneum – Shiny Dull & Lustreless
Int Musc – Firm, Peristalsis seen
Flabby, thin, friable
Non viable
Mesenteric pulsation + Absent
Doubtful – Resected ends as stomas
No resection / Multiple ischaemic areas (Mesenteric Vasc Occlusion)
2nd look laparotomy after 24-48hrs
Operative decompression
• Compromise of Exposure / Viability / Closure
• Septic complications of spillage
• Savage’s decompressor / NG tube
• Replace fluid
Large bowel obstruction
Caecum to Prox trans colon
– Rt. Hemicolectomy, if resectable
– Ileotransverse bypass if not
resectable
Splenic flexure
– Extended Rt.Hemicolectomy
Left colon / Rectosigmoid
• Decompression proximal colostomy
• Resection with – Anastamosis with covering colostomy– Paul Mikulicz procedure– Hartmann’s procedure
Adhesions
• Most common cause
• Difficult to differentiate from paralytic ileus
Causes
• Ischaemic areas
• Foreign material
• Infection & Inflammatory conditions
• Radiation enteritis
• Drugs – Practolol
Peritoneal irritation
Local fibrin production
Adhesion between apposed surfaces
Early fibrinous adhesions Late fibrous adhesions
Prevention
• Good Surgical technique
• Peritoneal wash
• Minimizing contact with gauze
• Covering anastamosis & raw
peritoneal surfaces
Classification
• Early / Flimsy
• Late/ Dense
Bands
• Congenital
• Acquired
– Peritonitis
– Greater omentum adherent to
parietes
Treatment
• Conservative
– NPO
– RT aspiration
– IV fluids
– Vital signs & Abd. girth monitoring
– Signs of strangulation
– Maximum 72hrs
Surgery
• Adhesiolysis
– Only those causing obstruction
– Covering with omental grafts
– Constriction sites
Recurrent adhesive obstruction
• Repeat Adhesiolysis
• Noble’s plication procedure
• Charles phillip Transmesenteric plication
• Intestinal intubation
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