Intestinal Obstruction

Assessment

Investigations

Treatment

History-Onset, acute/chronic, bleeding, constipation, weight loss, anorexia, changes in bowel habits, associated features, previous surgery, drug usage.

Physical examination- General physical, vital signs, abdominal distention/mass, tenderness/guarding, auscultation (Bowel sounds)-high pitched, tinkling sounds.

Complete blood count- A raised white cell count will indicate an infection. A raised hematocrit may indicate hemoconcentration while a decreased hematocrit will signify blood loss.

Serum Urea & electrolytes- Derangements may be seen with vomiting & diarrhea. Dehydration will be reflected in raised serum urea & creatinine.

Liver function test- Elevated serum bilirubin & alkaline phosphatase point towards an obstructed cause.

Serum amylase It is a non-specific test & may be raised in

cases of small intestinal obstruction.

Erect chest x-ray- Free air under the diaphragm, without recent abdominal surgery, shows perforated viscus.

Supine abdominal x-ray- It may show abnormal bowel pattern (dilation of bowel loops in case of obstruction or sentinel loop). It may also show masses.

Erect Film- It shows fluid levels in case of obstructed bowel.

Ultrasound- It is less useful but may indicate presence of intraparitoneal fluid or mass. It can also detect gallstones or other biliary diseases.

CT- It is performed with oral or Intravenous contrast. Lower abdomen CT is useful in detection of acute appendicitis, acute diverticulitis, intestinal obstruction, aortic aneurysm & mesentric ischaemia.

Supportive NPO Rehydration & urine output monitoring Cross-match blood & transfusion if required Pass NG tube( diagnostic/therapeutic purpose) I.V antibiotics if indicated

Symptomatic Analgesia after confirming diagnosis

Specific Therapy directed at underlying disease

Investigations- Plain X-ray Duodenal obstruction- stomach & proximal

duodenum are distended- “double bubble” Jejunal & ileal obstruction- air fluid levels

present

Treatment: Correct electrolyte & fluid deficits Duodenal atresia requires

duodenojejuostomy & spliting of the anastomosis with a feeding tube.

Atretic segments in the jejunum or ileum may produce dilated proximal loops that require tapering prior to anastomosis.

Investigation: Plain x-ray of the small bowel gas shows

malrotation & level of obstruction.

Treatment: The volvulus is reduced, the

transduodenal band(Ladd’s band) divided, the duodenum mobilised & the mesentry freed.

Appendicectomy is routinely performed to avoid diagnostic difficulty with appendicitis in the future.

Infarcted bowel necessitates resection.

Investigation Differential white cell count is raised A Merkel’s radioisotope scan will reveal acid

producing gastric mucosa.

Treatment: Excision of the inflammed diverticulum Presence of gastric mucosa requires the

resection of the ileal loop containing the diverticulum to ensure complete excision of all acid producing mucosa.

Plain x-ray Shows small dilated bowel loops Gastrograffin enema (in the absence of

acute obstruction) shows up the meconium & excludes Hirshsprung’s disease.

Treatment: Colonic washouts may restore patency Proximal ileum is anastomosed end to side

to the colon with a distal ileostomy to clear the obstruction.

Gastrograffin enema demonstrates unhindered flow of contrast upto the cecum & beyond

Relief of constipation requires bowel washouts or manual evacuation.

Counselling

Investigations: Double contrast Gastrograffin enema (‘claw

sign’ of ileocolic intussusception) In adults, a contrast CT scan of the

abdomen or barium enema is confirmatory.

Rx: The diagnostic enema may be used to

reduce the intussusception by hydrostatic pressure (in children)

Surgical reduction by taxis; bowel resection if there is gross edema preventing reduction or vascular compromise.

Investigations: Plain x-ray may be diagnostic -Large gas-filled, ‘kidney bean-shaped’

swelling in the right upper zone: Sigmoid volvulus

-Large gas-filled, ‘kidney bean-shaped’ swelling in the left lower zone: Caecal volvulus.

Rx: Sigmoid volvulus may be relieved at right

sigmoidoscopy. Emergency laprotomy & resection of the

volvulus for strangulated or recurrent cases. Gangrenous bowel is exteriorised &

resected, with the formation of a ‘double barrel’ colostomy (Paul-Mikulicz procedure).

Investigations: White cell count: >20×109 /L Serum amylase: slightly raised (>200IU)Mesentric angiography

Rx: Laparotomy: superior mesentric

embolectomy; Resection of areas of non-viable bowel.‘second look’ laprotomy at 24 hours for further

resection of non-viable bowel.

Treatment: Surgical bypass of occlusion.

Investigations:Plain x-ray abdomen: Characteristics of the

distended bowel from which the level of obstruction is identified

Contrast enhanced CT: Delineates the type & level of obstruction

Treatment: Nasogastric decompression of stomach &

bowel proximal to the obstruction. I/v Fluids & electrolyte therapy Analgesia Antibiotics( inflammatory or infectious

causes) Emergency surgery * Post operative adhesion obstruction usually

resolves on conservative measures.

Operative procedures vary according to cause of obstruction.

Resection- The diseased part of the small intestine (ileum) is removed. The two healthy ends are then sewn back together and the incision is closed.

Indications Gangrenous bowel

In cases of strangulated Inguinal/femoral hernias the standard groin incision is given & the weakness repaired using hernioplasty or herniorrhaphy, with bowel resection if required.

In adhesive obstructed cases, laproscopic adhesiolysis (adhesive band lysis) maybe performed in selected patients or using open procedure through an incision dictated by scar from previous surgery.

Bypass: Anastomosis of proximal small bowel or large intestine distal to the obstruction may be a good procedure in some cases of carcinoma or radiation injury.

Decompression-Done by use of gastrostomy or jejunostomy tube where adhesions can’t be freed & bypass can’t be done. Parentral nutrition is provided that

allows spontaneous resolution.

The tube can be passed orally orBy needle aspiration through the bowel wall.

Short Practice of surgery- Bailey & love’s Acute surgical management- Hwang Nian

Chi Current surgery Medlineplus