Small and Large bowel

Obstruction

GAYM G.
Small Bowel
Obstruction(SBO)
Classified
 Mechanical obstruction =luminal contents cannot pass
through the gut tube because the lumen is physically
blocked or obstructed

 functional obstruction = luminal contents fail to pass

because of disturbances in gut motility that prevent
coordinated transit from one region of the gut to the next

 simple/strangulation

 Proximal /Intermediate/Distal

 open-loop /closed-loop
Etiology of Mechanical Small Bowel
Obstruction
Extrinsic Intrinsic
 *Adhesions (usu postop)  Inflammatory
 Hernia -Crohn's disease
 *Neoplastic -Infections
-Carcinomatosis Tuberculosis
-Extraintestinal neoplasms Actinomycosis
 Intra-abdominal abscess Diverticulitis
 *Volvulus  Neoplastic
Primary
Metastatic
 Intussusception
Etiology cont…

Intraluminal
• Gallstone ileus
• Enterolith
• Bezoar
• Swallowed foreign body
• Parasites-tapeworm and
Ascaris species
Pathophysiology

 With onset of obstruction, gas and fluid accumulate within the

intestinal lumen proximal to the site of obstruction

 intestinal activity increases in an effort to overcome the

obstruction »»» colicky pain and diarrhea

 gas-most swallowed air +some is produced within the intestine

 fluid consists of swallowed liquids and GI secretions

 With ongoing gas and fluid accumulation, the bowel distends

and intraluminal and intramural pressures rise

 intestine becomes fatigued and dilates, with contractions

becoming less frequent and less intense
Pathophysiology …

 With obstruction the flora of the small intestine

changes dramatically, in both the type of organism
and the quantity

 If the intramural pressure becomes high enough,

intestinal microvascular perfusion is
impaired»»intestinal ischemia »»necrosis

 With partial SBO, only a portion of the intestinal

lumen is occluded, allowing passage of some gas and
fluid

 pathophysiologic events occur more slowly & development of

strangulation is less likely
Clinical Presentation
 sxs:colicky abdominal pain, nausea, vomiting, and
obstipation

 Vomiting is a more prominent symptom with proximal

obstructions than distal

 with bacterial overgrowth, the vomitus is more

feculent » a more established obstruction

 Continued passage of flatus and/or stool beyond 6 to

12 hours after onset of sxs is xtic of partial
obstruction
C/P…

Sns
• abdominal distention- most pronounced if site of
obstruction is in the distal ileum

- may be absent if site of obstruction is in the proximal

small intestine

• Bowel sounds - hyperactive initially/minimal or absent

in late stages

• Lab findings - hemoconcentration and electrolyte

abnormalities. Mild leukocytosis is common
C/P…
Features of strangulated obstruction

 abdominal pain often disproportionate to the degree

of abdominal findings

 tachycardia, localized abdominal tenderness, fever,

marked leukocytosis, and acidosis
Diagnosis

Goals
(a) distinguish mechanical obstruction from ileus
(b) determine the etiology of the obstruction
(c) discriminate partial from complete obstruction, and
(d) discriminate simple from strangulating obstruction
Dx...
Hx-prior abdominal operations, presence of abdominal
disorders (e.g., intra-abdominal cancer )

P/E-search for hernias

- Previous surgical scars

-PR:to assess for intraluminal masses and to examine

the stool for occult blood
Dx...
 dx confirmed with radiographic examination

 The finding most specific for SBO is the triad of :

 dilated small bowel loops (>3 cm in diameter),

air-fluid levels seen on upright films, and
 a paucity of air in the colon
Figure -  SBO. Supine radiograph showing very distended small
bowel identified by its central position, multiple loops and valvulae
conniventes.
Figure -  SBO: strangulated right inguinal hernia, supine position.
Small-bowel dilatation with a grossly dilated loop passing down into
the right inguinal region. 80-year-old woman with abdominal pain
and vomiting for 5d.
Figure -  Gallstone ileus. Supine radiograph showing evidence of
small-bowel obstruction. In addition gas can be identified within
the right and left hepatic ducts and the common bile duct. The 79-
year-old woman presented with a 5-day history of abdominal pain
 Dx...
o sensitivity of abdominal radiographs - 70 to 80%

 Specificity is low because ileus and colonic obstruction

can be asst’ed with findings that mimic those observed
with SBO

 False-negative occurs when :

 obstruction site is proximal

 bowel lumen is filled with fluid but no gas(closed loop) , preventing

visualization of air – fluid levels or bowel distension .
 Dilatation of the bowel occurs in
mechanical intestinal obstruction,
paralytic ileus and air swallowing.
The radiological differentiation of
these different causes depends
mainly on the size and distribution of
the loops of the bowel.

Most of the gas within the bowel has been swallowed; it

normally reaches the colon within 30 min.
Dx...
 CT- 80 to 90% sensitive and 70 to 90% specific
 findings of SBO include :
 a discrete transition zone with dilation of bowel
proximally ,decompression of bowel distally
 intraluminal contrast that does not pass beyond the
transition zone, and
 a colon containing little gas or fluid
Dx...
 CT also provide evidence for the presence of closed-loop
obstruction and strangulation :

 Closed-loop obstruction suggested by –

 a U-shaped or C-shaped dilated bowel loop associated with a
radial distribution of mesenteric vessels converging toward a
torsion point

 Strangulation suggested by –
 thickening of the bowel wall,
 pneumatosis intestinalis,
 portal venous gas,
 mesenteric haziness, and
 poor uptake of IV contrast into the wall of the affected bowel

 CT also offers a global evaluation of the abdomen(reveal etiology)

CLOSED-LOOP INTESTINAL STRANGULATING
OBSTRUCTION: CT SIGNS OBSTRUCTION: CT SIGNS
Dilated fluid-filled Wall thickening of
loop affected loop
U-shape configuration High attenuation in
Thickening of bowel wall
mesenteric vessels (haemorrhage)
Radial distribution of Gas in bowel wall
mesenteric vessels Gas in mesenteric
Tapering of the loop veins
(beak sign) Mesenteric congestion
Triangular loop
Mesenteric
Twisted mesentery haemorrhage
(whirl sign)
Dx...
 A limitation of CT -low sensitivity (<50%) in the
detection of low-grade or partial SBO

 either small bowel series (small bowel follow-through)

or enteroclysis, can be helpful

-may offer greater sensitivity in the detection of

luminal and mural etiologies of obstruction
Treatment
 fluid resuscitation with an isotonic saline solution

 indwelling bladder catheter placed to monitor urine

output

 Serial electrolyte measurements, Hct and WBC count-

to assess the adequacy of fluid repletion

 Broad-spectrum antibiotics ???

 NG tube
Treatment...
 for complete SBO-surgery

 Patients with a partial intestinal obstruction may be

treated conservatively with resuscitation and tube
decompression alone.

 Resolution of symptoms and discharge without the

need for surgery -in 60% to 85% of pts , of these only
5-15% reported to have sxs that were not
substantially improved with in 48hrs after initiation of
therapy .

 If symptoms do not improve within 48 hours after

initiation of nonoperative therapy -surgery
Treatment...
 Conservative therapy in the form NGT decompression
& fluid resuscitation is the initial recommendation for:
1. Partial SBO

2. Obstruction occurring in the early postoperative

period

3. Intestinal obstruction due to Crohn's disease

4. Carcinomatosis
Operative Management

 varies according to the etiology of the obstruction

 adhesions are lysed, tumors are resected, and hernias

are reduced and repaired

 Regardless of the etiology, the affected intestine

should be examined, and nonviable bowel resected

 Criteria suggesting viability - normal color, peristalsis,

and marginal arterial pulsations
Treatment...
 In general, if the patient is hemodynamically stable,
short lengths of bowel of questionable viability should
be resected and primary anastomosis of the
remaining intestine performed.

 However, if the viability of a large proportion of the

intestine is in question, a concerted effort to preserve
intestinal tissue should be made.

 the bowel of uncertain viability should be left intact

and the pt re-explored in 24 to 48 hours in a
"second-look" operation
SPECIFIC TYPES OF BOWEL
OBSTRUCTION
Small intestinal Volvulus (SIV)
• A torsion of all or part of a segment small intestine on ist
mesenteric axis

• The most common cause of SBO in Southern Ethiopia and

North west Ethiopia(Gondar)

• 1°-when the cause for twisting not known(Majority)

• 2°-when cause is due to peritoneal bands,

adhesion ,diverticulum or tumor
SIV...

 Young adult (age-16-65)(mean age 34)

 Peak age-b/n 20 and 40 yrs(63%)

 Males(M:F=8.8:1)

 Farmers

 Mainly occurs in rainy season when there is heavy work in

farming(June-Nov)
Contributing factors

 Hypermobility

 Hyper motility

 Rapid sudden filling of an empty intestine with

voluminous diet-initiate rotation of intestine
SIV...
 Pesence of a short mesenteric root with elongated
intestine and mesentery would allow abnormal
mobilty(hypermobility)-might favor rotation

 Low grade enteritis(bacterial and parasitic)

 Ingestion of a bulky meal after a long interval of

fasting might increase peristaltic wave(Hypermobility)
thereby initiating rotation of small intestine
SIV...
 SXS & Sn-similar to other causes of SBO

o Rx

 Simple derotation & decompression-for viable bowel

 Resection and anastomosis-for gangrenous bowel

Adhesions
 account for 40 to 64% of all episodes of SBO

 5% of pts undergoing laparotomy develop abdominal

adhesions

 more common precursor operations --

appendectomy,hysterectomy, APR , and small bowel
resection

» bowel is more mobile in the pelvis and more tethered

in the upper abdomen.

• 80% episodes of SBO due to adhesions may resolve non-

operatively
Adhesions...
 Intraperitoneal injury » peritoneal inflammation

 Ischemia from ligatures, devascularized fat, or other

traumatized tissues and
 foreign body reaction(usually to talc, starch, lint,
intestinal content, or suture) plays an important role
in the formation of adhesions
prevention of postoperative adhesions

 use of nonreactive monofilament sutures for fascial closure

 avoidance of closure of the peritoneum as a separate layer

 meticulous attention to hemostasis

 gentle surgical technique ( minimizing serosal or

peritoneal injury)

 removal of foreign material (excessive suture material,

gauze and cotton lint from shredded or cut drapes) from
the peritoneal cavity

 laparoscopic approach
Early Postoperative Adhesions

 Early postoperative adhesive SBO is observed in

about 1% of pts

 Early postoperative adhesions account for about 90%

of SBO during the 4 weeks after laparotomy

 Hernias,Intussusception,abscess, or technical errors -

responsible for the remainder
Adhesions...
 A common scenario is

 a pt will undergo colectomy uneventfully, pass flatus,

and have bowel sounds by postoperative day 3

 On 4th postop day the pt suddenly becomes distended

and uncomfortable, and stops passing flatus and
stool.

• Pts with acutely evolving sxs & sns represent

complete obstruction
Adhesions...
 vast majority of such cases may be treated as partial
intestinal obstruction(NG tube &iv fluid will resolve
sxs)

 When the clinical course does not demand earlier

intervention , a non operative approach may be tried
for 10 to 14 days

»»»resolve obstruction in over 75% of cases

Ileus

Etilogies
Clinical Presentation

 resembles that of a mechanical SBO

 Abdominal distention, usu without the colicky

abdominal pain, is the typical and most notable
finding

 Inability to tolerate liquids and solids by mouth

 ±Nausea & vomiting

 lack of flatus or bowel movements

 Bowel sounds – diminished/absent

Diagnosis

 Routine postoperative ileus should be expected and

requires no diagnostic evaluation

 If ileus persists beyond 3 to 5 days postop or occurs

in the absence of abdominal surgery, dxic evaluation
is warranted

 Patient medication lists

 Measurement of serum electrolytes

 Abdominal radiographs
 CT scan-test of choice
 it can demonstrate the presence of an intra-
abdominal abscess

 can exclude the presence of complete mechanical

obstruction

 CT with oral contrast has a sensitivity and specificity

of 90% to 100% in distinguishing ileus from a
complete postoperative SBO
Therapy

 entirely supportive

 limiting oral intake

 nasogastric decompression and IV fluids

 The most effective treatment- to correct the

underlying condition
Measures to Reduce Postoperative Ileus

Minimize handling of the bowel

Laparoscopic approach, if possible

limiting intra and postoperative fluid admin

early postoperative feeding

admin of NSAIDs such as ketorolac and concomitant

reductions in opioid

Epidural anesthesia

Correct electrolyte abnormalities

LARGE BOWEL OBSTRUCTION (LBO)
Etiologies

1. Intraluminal 3. Extraluminal
 fecal impaction  *Volvulus
 inspissated barium  hernias
 foreign bodies
 tumors in adjacent
2. Intramural organs
 *carcinoma  abscesses &
 inflammation
 adhesions
(diverticulitis, Crohn's
disease, tuberculosis, and
schistosomiasis)
 ischemia
 radiation
 intussusception, and
 anastomotic stricture
Pathophysiology

• colon becomes distended as gas, stool, and liquid

accumulate proximal to the site of blockage

• If the obstruction is the result of a segment of colon

trapped by a hernia or by a volvulus, the blood supply
can become compromised, or strangulated;

• initially, the venous return is blocked, causing

localized swelling »» occlude the arterial supply with
resultant ischemia »»necrosis, or gangrene
Pathophysiology

• the colon proximal to the entrapped segment

becomes progressively dilated

• A closed-loop obstruction occurs when both the

proximal and distal parts of the bowel are occluded

• A strangulated hernia,volvulus or when a cancer

occludes the lumen of the colon in the presence of a
competent ileocecal valve
Clinical features: History

 The hallmark of LBO is the sequential occurrence of:

1. Colicky/Crampy abdominal pain
2. Constipation
3. Big abdominal distention
4. Vomiting
Clinical features: Physical exam

 Vital signs: Remain stable until late

 Signs of dehydration: Shows gangrenous intestines.

 Abdominal examination
 Distension
 Tenderness or guarding
 Mass may represent a palpable tumor
 Hyper-tympanitic abdomen
 Visible or palpable colonic loops
 Bowel sounds -Hypoactive below the obstruction and
hyper active above the obstruction

 Rectal examination
 Usually empty and ballooned
 Blood may suggest presence of a carcinoma
 A rectal cancer may be palpable
 A mass in the Pouch of Douglas may suggest
carcinomatosis peritonea
Investigations

 Hct
 Serum electrolytes
 Radiology:
1. Erect and supine abdominal x-ray
2. Plain chest x/ray
3. Barium enema
4. CT scan
5. Rigid sigmoidoscopy
6. Flexible Colonoscopy
Treatment

 depends on the cause of the obstruction

 Resuscitation
 Volume replacement: IV crystalloids,may require blood
transfusion

 Correction of electrolyte abnormalities:Esp Na+ and K+

 Catheterize patient to monitor urine output

 Central venous line: In the elderly and seriously sick

 Nasogastric suction

 Peri-operative antibiotics:
Operative Rx for rt colonic obstruction

 Usu Rxed with a right hemi-colectomy and a primary

anastomosis

 If the causative pathology is non-resectable, by-pass

anastomosis is a good procedure.

 If the patient is not a candidate for resection.

Ileostomy + Colonic mucus fistula
Operative Rx for Lt colonic obstruction

 Colostomy alone: Indicated for

- For non-resectable tumors
-For Seriously sick patients

 Primary tumor resection and:

-Hartman's colostomy
-Anastomosis and creation of a proximal transverse
colostomy or ileostomy
COLONIC VOLVULUS

 occurs when an air-filled segment of the colon twists

about its mesentery
 sigmoid colon - 80%
 Cecum-<20%
 transverse colon-extremely rare
 A volvulus may reduce spontaneously
 more commonly produces bowel obstruction, which
can progress to strangulation, gangrene, and
perforation
Sigmoid Volvulus

INCIDENCE AND EPIDEMIOLOGY

 56% of bowel obstruction in Gondar,95% of
LBO(Mohammed K,1998)
 more common in men(M:F=13.5:1,in Gondar)

 average age-60 to 65 years(US), although it tends to

occur 15 to 20 years earlier in other parts of the
world(55 +/- 13,in GUH)

 rural area
ETIOLOGY
 Long and floppy sigmoid colon
 a lengthy mesentery
 narrow mesenteric root

 It becomes clear that in order to have a volvulus, the

bowel has to be distended with air to float

 Associated factors:
 chronic constipation

 neuropsychiatric conditions and Rx with psychotropic

drugs

 *diet high in fiber and vegetables

PATHOGENESIS

 twist may be in a clockwise or counterclockwise

direction
 usu counterclockwise around the axis of the
mesocolon with varying degrees of rotation
 For significant obstruction to occur the torsion must
be at least 1800
 Torsion less than this is generally asymptomatic
 a closed-loop type of mechanical obstruction-simple
or strangulated
CLINICAL PRESENTATION

acute fulminating type subacute progressive type

• pt is younger • more common
presentation
• onset of sxs is sudden
• patient is older

• the course is rapid

• onset more gradual

• little history of previous

• early course more benign
episodes

• hx of previous attacks
and chronic constipation
Acute fulminating… subacute progressive
 early vomiting, diffuse • Vomiting occurs late, pain
abdominal pain and is minimal, and signs of
tenderness, marked peritonitis are usually not
prostration, and early present
appearance of gangrene
• Abdominal distention is
 Distention may be minimal extreme

 no distinctive diagnostic • Radiographic findings are

signs except for the diagnostic
clinical picture of an acute
abdominal catastrophe
DIAGNOSIS

 acute fulminating type-acute peritonitis is evident

 subacute progressive type-hx & P/E

 dx is usu confirmed by X-ray examination

-plain x-rays of abdomen » bent inner tube or coffee

bean appearance

-Gastrografin enema » a pathognomonic bird's beak

-CT » ‘‘whirl sign’’

TREATMENT

• appropriate resuscitation

• Decompression by placement of a rectal tube through a

proctoscope / use of a colonoscope/rigid sigmoidoscope

• rectal tube should be left in place for 1 or 2 days to allow

continued decompression and to prevent immediate
recurrence
TREATMENT

 If detorsion of the volvulus failed, laparotomy with

resection of the sigmoid colon (Hartmann's operation)
is required

 Even if detorsion of the sigmoid is successful, elective

sigmoid resection is indicated because of the
extremely high recurrence rate (40-50%)

 For gangrenous bowel, sigmoid resection with a

colostomy and Hartmann’s procedure is the safest
ILEOSIGMOID KNOTTING

 a unique entity in which a loop of ileum and the

sigmoid colon wrap around each other

 rare in the Western world but is not uncommon in

Africa,Asia, and the Middle East
MECHANISM

 the knot is not initiated by the colon but by a

hyperactive ileum that winds itself around the pedicle
of a passive sigmoid loop

 Bulk may be an important factor in stimulating small

bowel activity

 With one large evening meal,several pounds of food

are washed down with large quantities of liquid

 The most common intestinal knotting occurs in the

early hours of the morning
CLINICAL FEATURES

Knotting Sigmoid volvulus

• Females(2x) • Males(5x)
• Younger(av.42) • Older(53 yrs)
• *previous attacks • hx of recurrent attacks
absent of volvulus(30%)
• Pain onset is acute and • 25% of pts arrive at the
occurs most commonly hospital in the first 24
in the early hours of the hours
morning,awakening the
patient from sleep
• 75% of pts arrive at the
hospital in the first 24
hours
CLINICAL FEATURES

Knotting Sigmoid volvulus

 Vomiting occurs at  vomiting is a late
onset of pain feature/absent
 *distention is not a  distention is obvious
common complaint by
the pt
 patient usually arrives
at the hospital in shock,
with pale, cold, clammy
skin
 In the majority of cases,
gangrene is present and
a generalized peritonitis
is found
Dx

 pre-operative in< 20% of cases.

 Clinical features of small bowel obstruction

 Radiologic features of large bowel obstruction

 Inability to insert a rectal tube or a sigmoidoscope

SURGICAL TREATMENT

 requires an emergency operation

 If the bowels are viable

-knot can be safely untied

-After the bowel is decompressed and both small

bowel and
the colon are resected ±anastomosis

-operating mortality is 28%

SURGICAL TREATMENT

 If the bowel is gangrenous

-untying should not be attempted & should be

removed en bloc with its mesentery

-small intestine anastomosed

-sigmoid colon fashioned as Hartman’s

-operative mortality is 40% to 50%

CECAL VOLVULUS

 a cecocolic volvulus and consists of an axial rotation of

the terminal ileum, cecum, and ascending colon with
concomitant twisting of the associated mesentery

 1% of all cases of intestinal obstruction

 more common in women

 Patients younger than those having sigmoid

volvulus(30 to 70 yrs)

 Most patients having recurrent or intermittent forms of

cecal volvulus are younger(92% less than age 36)
ETIOLOGY AND PATHOGENESIS

 Cecocolic volvulus is possible because of a lack of

fixation of the cecum to the retroperitoneum
 precipitating factors:
 congenital bands
 adhesions from previous surgery
 trauma and manipulation from a recent abdominal
operation
 pregnancy
 space-occupying pelvic lesions
 presence of distal colonic obstruction(1/3rd to 1/2)
ETIOLOGY AND PATHOGENESIS

 twist in a clockwise fashion

 closed loop and complete type
 A cecal bascule is an anterior and superior folding of
the mobile cecum over the fixed distal ascending
colon
CLINICAL PRESENTATION

 sudden onset of abdominal pain and distention

 In the early phases -the pain is mild or moderate in

intensity

 If the condition is not relieved and ischemia occurs,

the pain increases significantly

 P/E-reveal asymmetric distention of the abdomen,

with a tympanitic mass palpable in either the LUQ or
midabdomen
DIAGNOSIS

 suspected from hx and can be confirmed by X-ray

studies

 Abdominal plain films -presence of a large dilated

cecum displaced to the left side of the abdomen

 Distended loops of small bowel are usually present

 contrast studies - characteristic ‘‘ace of spades’’ or

‘‘bird’s beak’’ deformity

 CT - ‘‘whirl sign’’ in the rt abdomen with marked

distention of the colon
Figure -  Caecal volvulus. The dilated caecum lies with its pole
under the left hemidiaphragm. In spite of the dilatation the
haustra are preserved. There is no dilated large bowel elsewhere
in the abdomen. The small bowel is fluid filled in this case.
TREATMENT

 Always operative

 Viable colon

 Detorsion and cecopexy

(recurrence13% to 28%)

 Detorsion & cecostomy(1% recurrence)

 Rt hemicolectomy with primary anastomsis-procedure

of choice
TREATMENT

 If colon gangrenous

 Gangrene occurs in 20%–30%

 resection of the gangrenous bowel +primary

anastomosis

 resection of the gangrenous bowel with ileostomy

+the colon closed or brought out as mucous fistula is
a safer approach
Pseudo-obstruction (Ogilvie's syndrome)

 distention of the colon, with sns and sxs of colonic

obstruction, in the absence of an actual physical cause
of the obstruction

 exact pathogenesis –unknown

 10 - a motility disorder that is either a familial visceral

myopathy or a diffuse motility disorder involving the
autonomic innervation of the intestinal wall

• 20 - more common & associated with opiates, severe

metabolic illness, myxedema, diabetes mellitus,
uremia, hyperparathyroidism, and traumatic
retroperitoneal hematomas
 One mechanism -sympathetic overactivity overriding
the parasympathetic system

*success in treating the syndrome with neostigmine, a

parasympathomimetic agent

* immediate resolution of the syndrome after

administration of an epidural anesthetic that provides
sympathetic blockade
presentation

 acute or chronic forms

 acute variety most commonly affects patients with

chronic renal, respiratory, cerebral, or cardiovascular
disease

 usua involves only the colon

 chronic form affects other parts of the GIT, usu

presents as bouts of subacute and partial intestinal
obstruction, and tends to recur periodically
presentation

 Acute colonic pseudo-obstruction should be

suspected when a medically ill patient suddenly
develops abdominal distention

 abdomen is tympanitic, nontender, and bowel sounds

are usually present

 Plain x-ray reveal a distended colon(appearance of

LBO)
Ix

 water-soluble contrast enema-most useful

 Colonoscopy - alternative dxic /therapeutic adv

TREATMENT

 NG decompression
 Replacement of EC fluid deficits
 correction of electrolyte abnormalities
 All medications that inhibit bowel motility-should be
D/C
 Patient response is monitored by serial abdominal
examinations and radiographs
 failure to resolve with supportive measures:
 colonoscopic decompression

 *Neostigmine-enhances parasympathetic activity

 2.5 mg is given iv over 3 minutes

 resolution of condition is indicated within <10 mins

of admn of the by the passage of stool and flatus

 recurrence rates far lower & successful in 90% of pts

after single admn