Intestinal Obstruction

Intestinal ObstructionByMohamed MouradAssistant Lecturer of General Surgery

DefinitionAny condition interferes with normal propulsion and passage of intestinal contents.

Classification

Mechanical obstruction

Mechanical obstructionThis mechanical obstruction can be partial ( lumen narrowed but allow transit some content) or complete ( lumen totally obstruction) this classify to:Simple obstruction (no vascular impairment)Closed loop ( both ends are obstructed e.g volvulus)Strangulation obstruction

Functional obstructionEither paralysis or dysmotility of intestinal peristalsis.Postoperative ileus is the most common form of functional bowel obstruction.

Epidemiology1% of all hospitalization3% of emergency surgical admissionsAdhesion is the most common cause of intestinal obstructionMortality rate range between 3% for simple bowel obstruction to 30% when there is strangulation or perforation

80% with gangrenous bowel segments

70 % of the patients were below the age of 15 years Intestinal obstructionPattern in Africa

EtiologyMechanical bowel obstructionSmall bowel obstruction:Adhesion 60%Hernia 20%Neoplasm 5%Volvulus 5%.Others: IBD - gall stone - foreign body - intussusception.Large bowel obstruction :Cancer 60%.Diverticular disease 15%.Volvulus 15%.Others: hernia fecal impaction - IBD.

EtiologyFunctional bowel obstructionVascular occlusion ileus.Adynamic or inhibition ileus :Post operative.Metabolic causes: DKA- hyponateremia-hypokalemia hypomagnesaemia.Drugs: morphine TCA-antacid-anticonvulsant.Intra-abdominal inflammationsepsisoccult wound infection.Pneumoniarenal stoneretroperitoneal hematomafracture spine and ribs.Spastic ileus. ( intestine remain contracted and no propulsive) causes are:Uremia.Porphyria.Heavy metal poison.

Pathophysiology

Pathophysiology

Pathophysiology (cont.)

Pathophysiology

Proximal bowel dilates & develops an altered motility. Below the obs, the bowel exhibits normal peristalsis & absorption until it becomes empty it contracts & become immobileInitially, proximal peristalsis is increased to overcome the obs. If the obs is not relieved, the bowel begins to dilate reduction in peristaltic strength flaccidity & paralysis This is a protective phenomenon to prevent vascular damage 2 to increased intraluminal pressure

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NOTEAccording to LAPLACEs law: maximum pressure is at the maximum diameter AREA Caecum is at the greatest risk of perforation

PathophysiologyDehydration results from:Reduced oral intake, Defective intestinal absorption, Loses from vomiting & sequestration in bowel of lumen.

DiagnosisHistory and physical examination Four cardinal symptoms PainVomitingDistensionobstipation).Location and characteristic of pain?? Examination :Vital signs.( PR-Temp-BP)Hydration status.Abdominal and rectal examinations

Location and characteristic of pain differentiate between mechanical obstruction and ileus which sever cramp and localized in mid of abdomen in mechanical while diffuse and mild in ileus.

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Physical ExaminationINSPECTIONAbdominal distention, scars, visible peristalsis.PALPATIONMass, tenderness, guardingExamination of hernial orificesPERCUSSIONTympanic, dullnessAUSCULTATIONBowel sound are high pitch and increase in frequencyOr silent.

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Difference between High & Low intestinal obstructionHIGHLOWBEGINNINGAcuteSlow, insidiousGENERAL CONDITIONEarly compromissionpreservedPAINCrampy pain in paroxismLess intensityVOMITINGEarly, profuse, biliaryLate, feculent may be absentABDOMINAL DISTENTIONModerate, upper quadrantEarly, intenseCONSTIPATION++++ELECTOLYTESCl, K, Na rapid lossLate hydro electrolytic imbalance

DiagnosisLaboratoryCBC: Increase PCV (dehydration ) and increase in WBC.KFT: Increase in BUN and creatinine .Lactate concentration-amylase-lactic dehydrogenase useful but not sensitive To rule out necrosisABG: metabolic alkalosis and respiratory acidosis.

Thehematocrit(HtorHCT, British English spellinghaematocrit), also known aspacked cell volume(PCV) orerythrocyte volume fraction(EVF), is thevolume percentage(%) ofred blood cellsinblood.20

DiagnosisRadiologyCXR :Detect extra-abdominal condition present with bowel obstruction e.g. pneumonia.Presence of pneumoperitoneum indicates perforated viscus.

DiagnosisRadiologyAbdominal X-RAYSmall bowel considered dilated when diameter more than 3 cm while proximal colon 9 cm and the sigmoid 5 cm.The cause of bowel obstruction can often determined Presence of pneumobilia suggest G.S ileus.Sigmoid and cecal volvulus produce pathognomnic images

Radiology

Fluid levels with gas above; stepladder pattern. Ileal obstruction by adhesions; patient erect.Prone radiograph from a patient with complete large bowel obstruction shows distended lagre bowel in the periphery of abdomen with haustration.

NOTEAccording to LAPLACEs law: maximum pressure is at the maximum diameter AREA Caecum is at the greatest risk of perforation

DiagnosisRadiologyContrast studies:Indications are controversial.Identify site and often the cause of obstruction.Differentiate between colonic and distal small bowel obstructionDifferentiate between ileus-partial and complete obstruction.Computed tomography:Recently become valuable in B.O especially when plain films failed in diagnosis or suspect strangulation.Sensitivity 93% and specificity 100%Accuracy 94% in diagnosis of BO

Barium should not be used in a patient with peritonitis

TreatmentFor optimal treatment to be instituted, five questions must be answered:Is the diagnosis intestinal obstruction?. Is the obstruction is mechanical? .What is the level of obstruction?.Is there evidence of bowel wall ischemia or perforation?.How sever is the associated systemic disorders?.

TreatmentResuscitation.Conservative treatment Previous surgery.Incomplete obstruction.Advanced malignancy.Indications for surgery Generalized or localized peritonitis.Perforation.Strangulated hernia.Closed loopFailure to improve on conservative treatment.

Obstruction by Adhesions Peritoneal irritation local fibrin production adhesionsAs early as 4 weeks post laparotomy. The majority of patients present between 1-5 yearsColorectal Surgery 25%Gynaecological 20%Appendectomy 14%Prevention: good surgical technique, washing of the peritoneal cavity with saline to remove clots, etc, minimizing contact w/ gauze, covering anastomosis & raw peritoneal surfaces

Radiation enteritisis a bowel pathology resulting from toxic effects of radiotherapy on the bowel wall and vasculatureIn the acute phase, radiation affects bowel mucosa causing cell death with ulceration. It also causes inflammation with mucosal and submucosal oedema. In the subacute and chronic phases healing and fibrosis occurs. Additionallyradiation induces endarteritis obliterans, which results in a state of chronic mesenteric ischaemia leading to bowel strictures.The clinical presentation is nonspecific with abdominal pain, vomiting, bloody diarrhoea and steatorrhoea. Patients with chronic radiation enteritis may develop deficiencies of calcium, iron and vitamin B12 deficiency.28

Treatment of adhesive obstructionConservatively provided there is no signs of strangulation; should rarely continue conservative treatment for longer than 72 hoursAt operation, divide only the causative adhesion and limit dissection.

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Treatment of adhesive obstruction

Obstructed HerniaCommonest Femoral herniaID inguinalUmbilicalOthers: incisional Ischaemia occurs initially by venous occlusion, followed by oedema and arterial compromise.Strangulation is noted by: Persistent painDiscolourationTendernessConstitutional symptomsLoss of impulse with cough

-volvulus: Intestinal volvulus is defined as a complete twisting of a loop of intestine around its mesenteric attachment site.-incarceration: passage of a loop of intestine through a small orifice, e.g. inguinal canal, with resulting swelling, obstruction and occlusion of blood supply-Obstruction:partial or complete blockage of the bowel that prevents the contents of the intestine from passing through-intussusception: process in which there is telescoping of a proximal segment of intestine invaginates into the (distal) adjoining intestinal lumen

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Management For Large Bowel ObstructionAppropriate operations include:Right sided lesions right hemicolectomyTransverse colonic lesion extended right hemicolectomyLeft sided lesions various options

Management of Left Colonic ObstructionThree-staged procedureDefunctioning colostomyResection and anastomosisClosure of colostomy

Two-staged procedureHartmanns procedureClosure of colostomy

One-stage procedureResection, on-table lavage and primary anastomosisTotal colectomy with ileorectal anastomosis

VolvulusA twisting or axial rotation of a portion of bowel about its mesentery. When complete it forms a closed loop obstructionRelieved by decompression per anum.Surgery is required to prevent or relieve ischaemiaFeatures: palpable tympanic lump (sausage shape) in the midline or left side of abdomen. Constipation, abdominal distension (early & progressive)

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Volvulus

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Acute intussusceptionOccurs when one portion of the gut becomes invaginated within an immediately adjacent segment.Common in 1st year of lifeCommon after viral illness enlargement of Peyers patchesIleocolic is the commonest variety in child. Colocolic intussusception commonest in adult

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Classically, a previously healthy infant presents with colicky pain and vomiting (milk then bile). Between episodes the child initially appears well. Later, they may pass a red currant jelly stool.

Red currant jelly stoolsAcute intussusception

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Intussusception

Barium reduction of intussusceptionHead of intussusception is at hepatic flexure Free flow of contrast into distal small bowel indicates complete reduction Partial reduction

Post Operative IleusPrevention Use of nasogastric suction and Restriction of oral intake until bowel sound and passage of flatus returnMaintain electrolyte balanceSpecific treatment:Removed primary causeDecompressed GI distensionIf prolong paralytic ileus , consider laparotomy exclude hidden cause and facilitate bowel decompression

THANKSGOOD LUCKANY QUESTION??

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