Dr.
Pankaj Kumar
Assistant Professor
Surgical Gastroenterology
One of the common cause of acute
abdomen
May lead to high morbidity and mortality
if not treated correctly
It can be classified into two types:
Dynamic (mechanical)
Adynamic
Dynamic: where peristalsis is working
against a mechanical obstruction.
Adynamic: mechanical element is
absent
- Peristalsis my be absent(paralytic ileus)
-May be present in non propulsive form.
(mesenteric vascular occlusion or
pseudo-obstruction)
DYNAMIC
1.Intraluminal: impacted faeces, foreign
bodies, gallstones, Bezoars.
2.Intramural: tumors, inflammatory
strictures,
3.Extramural: adhesion, hernias,
volvulus, intussusception, tumors
also can be divided into:
1. Small bowel obstruction (SBO)
-high ->early perfuse vomiting
rapid dehydration
-low->predominant pain, and central
distention
Vomiting delayed
multiple central air-fluid levels seen on AXR
2. Large bowel obstruction (LBO)
early pronounced distension, mild pain
vomiting, dehydration late
e.g. -carcinoma
-diverticulitis or volvulus
Acute obstruction:- usually in small bowel
-obstruction with severe colicky central
abdominal pain, distension, early vomitting
and constipation.
Chronic obstruction: -usually in large bowel
- lower abdominal colic & obstipation
followed by distension.
Acute on chronic: short history of
distension & vomiting against background
of pain & constipation.
Subacute obstruction : incomplete
obstruction.
Simple: blockage without interfering with
vascular supply
Strangulation: significant impairment of blood
supply most commonly associated with
hernia, volvulus, intussusception, mesentric
infarction, adhesions/Bands
-surgical emergency
Closed loop obstruction: bowel is obstructed
at both the proximal and distal end.
Adhesions- 40%
Tumors -15%
Inflamatory- 15%
Obstructed hernia-12%
Intraluminal-10%
Miscellaneous -8%
Irrespective of etiology or acuteness of onset:
Proximal to obstruction
Increased fluid secretion abdominal distention
Accumulation of gas abdominal distention
Increased intraluminal pressure
Vomiting
Dehydration
Dilatation of bowel
Reflex contraction of smooth muscle colicky pain
Increased peristalsis to overcome obstruction increased
bowel sounds
If obstruction not overcome bowel atony
Decreased reabsorption with time and flaccidity to prevent
vascular damage from high pressure
Distal to obstruction: nothing is passed & bowel collapse
constipation
The four cardinal features of intestinal
obstruction:
-abdominal pain
-vomiting
-distension
-constipation
Vary according to:location of obstruction
Duration of obstruction
underlying pathology
intestinal ischemia
Abdominal pain
- colicky in nature, around the umbilicus in
SBO while in the lower abdomen in LBO
- if it becomes continuous, think about
perforation or strangulation.
- does not usually occurs in paralytic ileus.
Vomiting
-starts early in SBO and late in LBO
-As obstruction progresses vomitus alters
from digested food to faeculent due to enteric
bacterial overgrowth
Distension
-more with lower obstruction
Constipation
-more with lower or complete obstruction
- constipation is either absolute (no feces or
flatus)
cardinal feature of complete Int.Obst.
or relative (flatus passed).
it does not apply in
-Richters Hernia
-Gallstone obturation.
-mesentric vascular occlusion.
- obstruction associated with pelvic abscess.
-diarrhea may be present with partial
obstruction
Dehydration
More common in small bowel
obstruction.due to repeated vomiting .
Secondary polycythemia due to raised
B.urea & hematocrit.
Pyrexia
Onset of ischemia.
Intestinal perforation.
Inflamation associated with int. obst.
In strangulation:
severe constant abdominal pain
fever
tachycardia
tenderness with rigidity/rebound
tenderness.
shock
General examinationVital signs
Signs of dehydration tachycardia, hypotension
dry mucus membrane, decreased skin turgor, decreased
urine output
Inspection
distension, scars, peristalsis, masses, hernial orifices
Palpation
tenderness, masses, rigidity
Percussion
tympanitic abdomen
Auscultation
high pitched bowel sound or silent abdomen
*Examine rectum for mass, blood, feces or it may be empty
in case of complete obstruction
Hemogram - WBC (neutrophiliastrangulation)
Hyper kalemia, hyperamylasemia &
raised LDH may be associated with
stangulation.
Plain AXR
Sigmoidoscopy (carcinoma, volvulus)
Contrast x-ray
CT abdomen.
When distended by gas:
Jejunum is characterized by valvulae
conniventes(completely pass across the width &
regularly placed)
Ileum is featureless.
Caecum is shown by rounded gas shadow in RIF.
Colon shows haustral folds.
Fluid level appears later than gas shadow
Two fluid level in small bowel considered
normal.
No. of fluid level is proportional to degree of
obstruction and distal site in small bowel.
Colonic obstruction does not commonly
give rise to small bowel fluid level unless
advanced.
Associated with large ammount of gas in
caecum.
Ba-follow through is contraindicated in
acute intestinal obstruction.
Three main measures- GI drainage
Fluid &Electrolyte replacement
- Relief of obstruction, usually surgical
Treatment
Conservative:
-Nasogastric
aspiration by Ryles tube
-IV fluids- volume varies depending on
dehydration
-NPO
-urinary catheter
-check temp. and pulse 2 hourly
-abdominal examination 8 hourly
-Broad spectrum antibiotics initiated earlyreduce bacterial overgrowth.
Some cases will settle by using this conservative
regimen, other need surgical intervention.
Surgery should be delayed till resuscitation is
complete unless signs of strangulation and
evidence of closed-loop obstruction.
Cases that show reasons for delay should be
monitored continuously for 72 hours in hope of
spontaneous resolution e.g. adhesions with
radiological findings but no pain or tenderness
The sun should not both rise and set in cases
of unrelieved obstruction.
Indication for surgery:
- failure of conservative management
- tender, irreducible hernia
- strangulation
If the site of obstruction is unknown; laparotomy
assessment is directed to-The site of obstruction.
-The nature of obstruction.
-The viability of gut.
The site of obstruction can be determined by
caecum
Surgical treatment
Operative decompression required-if
dilatation of bowel loops prevent
exposure,
bowel wall viability is compromised,
or if subsequent closure will be
compromised.
Savages decompressor used within
seromuscular purse-string suture.
Or large-bore NG tube maybe used for
milking intestinal contents into stomach.
The type of surgical procedure depend upon the
cause of obstruction viz division of
bands,adhesiolysis, excision ,or bypass
*Once obstruction relieved, the bowel is inspected
for viability, and if non-viable, resection is
required.
Indication of non-viability
1.absent peristalsis
2.loss of normal shine
3.loss of pulsation in mesentry
4.green or black color of bowel
If in doubt of viability, bowel is wrapped
in hot packs for 10 minutes with
increased oxygen and reassessed for
viability.
Resection of non viable gut should be
done followed by stoma.
Sometimes a second look laprotomy is
required in 24-48 hours e.g. multiple
ischemic areas.
Most common cause of intestinal
obstruction.
Peritoneal irritation results in local fibrin
production, which produce adhesions.
BANDS
Congenital : obliterated vitellointestinal duct.
A string band following previous bacterial
peritonitis.
A portion of greater omentum adherent to
parietes.
Causes of adhesions :
Abdominal operation : anastomosis, raw
peritoneal surfaces
Foreign material: talc, starch, gauze, silk
Infection: peritonitis, T.B.
Inflammatory conditions: crohns disease.
Radiation entritis.
Prevention
Good surgical technique.
Washing the peritoneal cavity with saline to
remove the clots.
Minimizing contact with gauze.
Covering the anastomosis & raw peritoneal
surfaces.
Usually conservative treatment is
curative.
(i.v. rehydration & nasogastric
decompression)
It should not be prolonged beyond 72
hrs.
Surgery
Division of band.
Minimal adhisiolysis.
Repeat adhesiolysis alone.
Nobles plication : adjacent intestinal
coils (15-20 cms) are sutured with serosal
sutures.
Charles-Phillips trans-mesenetric
plication.
Intestinal intubation : initraluminal tube
insertion via a WITZEL jejunostomy or
gastrostomy.
When a portion of small intestine is
entrapped in one of retropritoneal fossae
or in a congenital mesentric defect.
Sites of internal herniation:
Foramen of winslow.
A hole in mesentry / transverse mesocolon.
Defects in broad ligaments.
Congenital/ acquired diaphragmatic
hernia.
Duodenal retroperitoneal fossae- Lt.
paraduodenal & rt. Duodenoojejunal.
intersigmoid fossae.
It is uncommon in the absence of
adhesions.
Treatment : to release the constricting
agent by division.
It tends to occur in elderly.
Erosion of large gallstone into duodenum.
Present with recurrent obstruction.
X-ray: small bowel obstruction with air in
billiary tree.
-may show a radio opaque gall stone.
Treatment : laparotomy & removal
/crushing of stone.
After partial /total gastrectomy.
Unchewed food can cause obstruction.
Treatment similar to gall stone.
BEZOARS
Trichobezoars
Phytobezoars
WORMS
Ascaris lumbricoides
Frequently follows initiation of antihelminthic
therapy.
Eosinophilia/worm with in gas filled bowel
loops.
Laparotomy.
One portion of gut becomes invaginated
with in adjacent segment.
Most common in children(3-9 months.)
Ideopathic-70%
Associated gastroenteritis/UTI- 30%
Hyperlpasia of Peyers patches in
terminal ileum can be initiating factor.
In older children intussusception is usually
associated with a lead point meckels
diverticulum, polyp, & appendix.
Adults: always with a lead point.- polyp,
submucosal lipoma/ tumor.
It is composed of three parts:
-Entering/ inner tube(Intussusceptum)
- Returning/ middle tube
-Sheath/ outer tube(intussuscipiens)
It is an example of strangulating
obstruction with impaired blood supply of
inner layer.
It may be ileoileal(5%); ileocolic(77%); ileoileo-colic(12%); colocolic (2%) & multiple.
Severe colic pain.
vomitting as time progress
blood & mucus (the redcurrent jelly
stool).
Abdominal lump(sausage shaped)
Emptiness in RIF(the sign of Dance).
Death may occur from bowel obstruction
or peritonitis secondary to gangrene.
Plain X-ray Abd.: Bowel obstruction with absent
caecal shadow gas in ileo-ileal & ileo-colic cases.
Ba-enema: the claw sign in ileocolic & colocolic
cases.
CT scan in equivocal cases of ileo-ileal
intussusception. (small bowel mass may be
revealed)
Differential Diagnosis
Acute enterocolitis: faecal matter/ bile is always
present.
Henoch-schoenlein purpura.
Rectal prolapse: projecting mucosa can be felt in
continuity with perianal skin
Theraputic Ba-enema : -in infants.
- unlikely to succeed in lead points.
- contrindications: peritonism, prolonged
history (> 48 hrs.).
Operative
After resuscitation ;Laparotmy with reduction.
Copes method.
Irreducible/ gangrenous intussusception:
excision of mass & anastomosis.
to be cont
