1.CONSERVATIVE MANAGEMENT OF ADHESIVE INTESTINAL OBSTRUCTION 2.pptx

Conservative management
of intestinal obstruction
Dr Shitu Hauwa
RESIDENT GENERAL SURGERY

Definition
Bowel obstruction occurs when the normal propulsion and
passage of intestinal contents does not occur
Image-KIU-TH

Embryology and development
Small intestine develops from midgut.
• This midgut loop has cranial and caudal limbs. As elongation starts from 5th
week of foetal life, cranial limb develops into distal duodenum,jejunum and
proximal ileum.
Distal ileum and proximal two-third of transverse colon are developed from
caudal limb.
Midgut also rotates 270°. Thus, proximal jejunum will go to left side and ileum
will go to right side

Blood Supply
• Superior mesenteric artery is the artery
of the midgut which supplies the entire
midgut (entire small intestines).
• venous drainage is through superior
mesenteric

Lymphatics
• From mucosa, lymphatics pass
through the wall of the bowel to
regional lymph nodes, then into
superior mesenteric nodes
Then it flows into cisterna chyli and into
thoracic duct to empty into venous
system.

Innervation
• Parasympathetic: These are derived
from vagus. It 1S secretomotor
• Sympathetic: These fibres arise from
three sets of splanchnic nerves.pain is
mediated through sympathetic system.

Intestinal Obstruction
• This Obstruction Can Involve Only the Small bowel, Large bowel or via systemic
alterations, involving both the small and large intestine (generalized ileus).
Obstruction Can involve mechanical obstruction or,in contrast,maybe related to
ineffective motility without any physical obstruction,called functional
obstruction, "pseudo-obstruction,"or paralytic ileus

CLASSIFICATION
● Dynamic/Adynamic
● Small Bowel Obstruction[ high or low]
● Large Bowel Obstruction
● Acute
● Chronic
● Acute on chronic
● Subacute
● Simple
● Strangulated
● Closed Loop Obstruction

INTESTINAL OBSTRUCTION IS CLASSIFIED IN TWO TYPES
DYNAMIC:where peristalsis is working against a mechanical obstruction.
ADYNAMIC: It may occur in two forms
1. where peristalsis may be absent(paralytic ileus,)occurring secondarily to
neuromuscular failure in the mesentery.
2. where peristalsis maybe present in non-propulsive form.(pseudo-
obstruction)

Mechanical obstruction
• There is physical blockage of intestinal lumen which due to:
1.Intraluminal
2.Intramural
3.Extraluminal

• This mechanical obstruction can be partial or complete obstruction) this
classify to
A. simple obstruction (no vascular impairment)
B.closed loop ( both ends are obstructed e.g volvulus)
C. strangulation obstruction

ACUTE OBSTRUCTION
It usually occur in small bowel obstruction with sudden onset of severe colicky
central abdominal pain, distention, early vomiting and constipation
CHRONIC OBSTRUCTION :
Usually seen in large bowel obstruction with lower abdominal colic and absolute
constipation followed by distention.

ACUTE ON CHRONIC OBSTRUCTION:
It starts in large bowl but gradually involves small intestines
Early symptoms are pain and constipation but when small intestine is involved
it’s characterized by vomiting and generalized distension

Symptoms
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.
- Hyperactive, high-pitched peristalsis with rushes coinciding with cramps is typical.
- 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 feculent due to enteric
bacterial overgrowth

Distension
-more with lower or complete obstruction
- constipation is either absolute,complete or relative (flatus passed).
Dehydration
-More common in small bowel obstruction.due to repeated vomiting .
-Secondary polycythemia

Pyrexia
•Onset of ischemia.
•Intestinal perforation.
•Inflammation associated with intestinal obstruction

Laboratory studies
• Complete blood cell (CBC) count:
(WBC) count may be elevated with a left shift in simple or strangulated
obstructions; increased hematocrit
• Blood urea nitrogen (BUN)/creatinine levels:
increased due to a decreased volume state (eg, dehydration)
• Serum lactate levels: Increased levels are suggestive of dehydration or tissue
underperfusion
• Urinalysis
• Type and crossmatch.

1.Supine abdominal x-ray showing obstruction of the small bowel. Dilated loops of small bowel should be noted.
2.Upright abdominal x-ray showing obstruction of the small bowel. Multiple air-fluid levels should be noted.
Radiology

Cause Of Intestinal Obstruction
● Adhesions-40%
● Tumors-15%
● Inflammatory-15%
● Obstructed Hernia-12%
● Intraluminal-10%
● Miscellaneous-8%

ADHESIVE INTESTINAL OBSTRUCTION
Obstruction By Adhesions Bands
• Most Common Cause of small bowel obstruction but a very rare cause of
large bowel obstruction
• Peritoneal Irritation Results local fibrin production, which produce
adhesions.

BANDS
• Congenital: obliterated vitellointestinal duct, Ladds band.
• A stringband following previous bacterial peritonitis.

Types
Type I- Fibrinous adhesions occur during 5-10th post-surgical period
It usually gets resolved completely.
Type Il- fibrous adhesions. Due to lack/poor blood supply.

Causes of adhesion
• Abdominal Operation: anastomosis,
• Malignancy
• Foreign material: talc,starch,gauze,silk
• Infection:peritonitis,T.B.
• Inflammatory Conditions: crohn's disease.
• Radiationentritis.

Procedures associated with increase risk of
adhesions
Gynecological procedures
Colorectal pathologies,
Lower abdominal and pelvic surgeries lead to obstruction more often than upper
GI surgeries.

Although postoperative adhesion is found to be the leading cause of obstruction,
other etiologies must not be under emphasized.
In case of strangulation, timely emergency surgery is required in order to
minimize bowel gangrene and subsequent resection.

Many attempts tried to prevent formation of postoperative adhesions
Initial failed procedures such as intra-operative plication of small intestine
Chemical agents, such as “Dextran 70 ” installation intraperitoneally has shown
relatively better results.
Ico- dextrin 4% solution and Hyaluronic acid-carboxycellulose membrane are able
to reduce adhesions

• The bioresorbable membrane called seprafilm is currently the most
effective membrane barrier. It consists of hyaluronic acid and
carboxymethy - cellulose.

Prevention
•Good surgical technique.
•Washing The Peritoneal Cavity With saline to remove the clots.
•Minimizing Contact With Gauze.
•Covering the anastomosis raw peritoneal surfaces.
• Avoid spillage of contents- bile, faecal matter.
•Prefer a Pfannenstiel incision to midline incision.

Conservative Management
Usually conservative treatment is curative.
Fluid Resuscitation
Patients with intestinal obstruction are usually dehydrated and depleted of
Electrolytes, requiring aggressive intravenous (IV) replacement with an isotonic
saline solution.
Tube Decompression.
Nasogastric decompression in a patient with small bowel obstruction is still
considered standard of care.

Antibiotic.
Antiemetics
Analgesic
Urinary catheter; to monitor fluid output.
Check temperature and pulse 2 hourly
Abdominal examination 8 hourly

Contrast Challenge
The use of a water-soluble contrast challenge in lower-grade obstructions (not
resolved conservatively after 48 hours)
The challenge requires 100 mL of gastrografin through the NGT and follow-up
radiographs obtained after 8 and 24 hours. If contrast material still has not
passed into the colon after 24 hours, conservative management will probably
fail and surgical intervention is likely needed.

Gastrografin challenge has also been proven to relieve symptoms
Due to its capability for diagnosis as well therapeutic effect, The mechanism is
believed to be due to its hypertonic constitution.

When to revert to surgery
Nonoperative management can be prolonged for up to 72 hours in the
absence of signs of strangulation or peritonitis; surgery is recommended
after 72 hours of nonoperative management without resolution
patients must be operated without further delay.
Most valuable clinical signs of ischaemia/gangrene are; tachycardia and
tenderness.

However repeated laparotomy and adhesiolysis may worsen the
process of adhesion formation and their severity.

Safe conservative management needs the
prerequisite of having ruled out any possibility
if strangulation of the bowel as the first step of
management. This in turn must be followed by
frequent vigilant assessment for any
progressing symptoms.

Reference
● SABISTON TEXTBOOK of SURGERY The BIOLOGICAL BASIS of MODERN SURGICAL
PRACTICE 21st EDITION
● Manipal Manual of Surgery, fifth Edition.
● Bologna Guidelines for Diagnosis and Management of Adhesive Small Bowel
Obstruction (ASBO): 2010 Evidence-Based Guidelines of the World Society of
Emergency Surgery
● Willy Arung, Meurisse Michel, Detry Olivier. Pathophysiology and Prevention of
Postoperative Peritoneal Adhesions. World Journal of Gastroenterology.
2011;17(41):4545–53.

● Comparison of 2 Different Barrier Solutions (icodextrin 4% vs. dextran 70) used as
Adhesion-prevention Agents after Microsurgical Adnexal Operations, Christiane
Deus christiane.deus@med.ovgu.de, Siegfried Kropf, and Jürgen Kleinstein, Volume
6, Issue 3
● Chelsea N. Fortin, Ghassan M. Saed, Michael P. Diamond, Predisposing factors to
post-operative adhesion development, Human Reproduction Update, Volume 21,
Issue 4, July/August 2015, Pages 536–551,
https://doi.org/10.1093/humupd/dmv021.

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