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INTESTINAL OBSTRUCTION • Is a reduction to the normal passage of intestinal contents Classification: 1. Paralytic (Adynamic) 2. Mechanical 1/20/2022 Intestinal Obstruction 3

Classification of intestinal obstruction 1. Speed of onset Acute Chronic Acute on top of chronic 2. Site High Low 3. Nature Simple Strangulated 4. Aetiology 1/20/2022 Intestinal Obstruction 4

Classification of intestinal obstruction • 1. According to speed of onset 1. Acute--------- rapid-severe symptoms 2. Chronic ---------- insidious-slowly progressive 3. Acute on top of chronic • 2. According to site High ----------small bowel Low-----------large bowel • 3. According to Nature Simple ---------- obstruction-damage of blood supply Strangulated --------- obstruction+damage of blood supply. (strangulated hernia. volvulus) 1/20/2022 Intestinal Obstruction 5

Classification of intestinal obstruction • 4. According to Aetiology Whenever one considers obstruction of a tube anywhere in the body 1. In the lumen 2. In the wall 3. Outside the wall • Lumen (FI -Gallstone - Food bolus - Peduculated tumor) • WALL (Cong. atresia- Crohn’s- Diverticulitis – Tumors) • OUTSIDE Strangulated hernia 1/20/2022 Volvulous Intestinal Obstruction Band of adhesions 6

PATHOLOGY SIMPLE • intestine distal to obst. -------- Empty collapsed • intestine proximal to obst ------ dilated with gas and fluid • Increase peristalsis------ colics • Bowel distend ----- decrease blood supply------- mucosal ulceration -------perforation Strangulated ISCHEMIA→LOSS OF MUCOSAL BARRIER INTEGRITY→TRANSUDATION OF BACTERIA&TOXINS→TO PERITONEAL CAVITY→ 2 ry PERITONITIS→GANGRENE OF SMALL INTESTINE. COMPLICATION: 1. FLUID&ELECTROLYTE IMBALANCE. 2. PERITONITIS(either by intact ischemic gut OR perforation) 1/20/2022 Intestinal Obstruction 7

INTESTINAL OBSTRUCTION ACCORDING TO AGE 1. NEONATAL: 1. INTESTINAL ATRESIAS 2. VOLVULOUS NEONATORUM 3. MECONIUM ILEUS 4. NECROTIZING ENTEROCOLITIS 5. HIRSCHSPRUNG’DISEASE 6. ANORECTAL ATRESIAS 2. INFANTS: 1. INTUSSUSCEPTION 2. HIRSCHSPRUNG’DISEASE 3. STRANGULATED HERNIA 4. MECKEL’S DIVERTICULUM 1/20/2022 Intestinal Obstruction 8

INTESTINAL OBSTRUCTION ACCORDING TO AGE 3. YOUNG ADULTS&MIDDLE AGE 1. STRANGULATED HERNIA 2. ADHESIONS&BANDS 3. CROHN’S DISEASE 4. OLD AGE 1. STRANGULATED HERNIA 2. CARCINOMA 3. COLONIC DIVERTICULITIS 4. IMPACTED FAECES 1/20/2022 Intestinal Obstruction 9

Clinical features 4 Cardinal symptoms 1. Colicky abdominal pain 2. Distension 3. Absolute constipation 4. Vomiting NB : Not all 4 need to be present The sequence→ help diagnosis 1/20/2022 Intestinal Obstruction 10

Clinical features 1. Pain 1 st symptom Colicky SI → periumblical LI → Suprapubic 2. Distension Marked in ----- ( ch. Large bowel – volvulus ) Less marked in------- ( High SI ) 1/20/2022 Intestinal Obstruction 11

Clinical features 3. Absolute constipation Failure to pass either flatus or faces Early in LI Late in SI If partial or chronic → passage of small amount of flatus 4. Vomiting Early in ………………. . small intestine Late or even absent in ………………large intestine First → food → bile stained → faeculent ( not faecal ) NB: Faeculent – faecal vomiting ↓ only in gastrocolic fistula 1/20/2022 Intestinal Obstruction 12

Clinical Examination General Dehydrated Rolling about with colic Pulse ↑ ( very rapid = strang. ) Tº Normal ( ↑ = strang. ) Local a. Inspection Look for - Strangulated external hernia ( take care → femoral ) - presence of an abdominal scar + Distension + Visible peristalsis b. Palpation - Generalized tenderness - Masses ( carcinoma - intussusception ) c. Auscultation accentuated and tinkling d. PR → Mass , apex of an intussusception , fecal impaction 1/20/2022 Intestinal Obstruction 13

Simple obstruction vs strangulation obstruction - Toxic appearance - ↑ pulse , Tº - Colicky pain becoming contineous - Tenderness , rigidity ( more marked ) - Bowel sounds ( reduced or absent ) - ↑ WBC = infracted bowel 1/20/2022 Intestinal Obstruction 14

Investigations 1. Abdominal X-ray ( erect and supine ) 2. Barium follow through 3. Water-soluble contrast enema 4. CT 5. Serum electrolytes 1/20/2022 Intestinal Obstruction 15

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Treatment Role Chronic large bowel obstruction ( slowly progressive & incomplete ) → can be investigated at ease & treated electively While Acute obstruction ( with ! risk of strangulation ) → require emergency intervention Preoperative preparation in acute obstruction 1. Gastric Aspiration 2. IV fluid replacement 3. Antibiotics 1/20/2022 Intestinal Obstruction 25

Operative Treatment * Determine bowel viability | ( Peristalsis - Lustur – Colour – Pulsation ) ↓¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯↓ Viable Unviable | ↓¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯¯↓ SI LI | | Resection &anastmosis ↓¯¯¯¯¯¯¯¯↓ Proximal to splenic flexure Distal to it As SI │ ↓¯¯¯¯¯¯¯¯¯↓ Exteriorization Hartman’s Of both ends 1/20/2022 Intestinal Obstruction 26

Conservative Treatment BY (DRIP&SUCK)=IV FLUIDS&ANTIBIOTICS • Is indicated: 1. Postoperative paralytic ileus. 2. Reapted episodes of adhesive I. O. 3. Chronic obstruction for good preparation. 1/20/2022 Intestinal Obstruction 27

CLOSED LOOP OBSTRUCTION Increase distension of loop of bowel due to ……. . DISTAL COMPLETE OBSTRUCTION +COMPETENT VALVE-LIKE MECHANISM PROXIMALLY EXAMPLES: 1. Left-sided colonic obstruction+competent ileocaecal valve→CAECUM is most distensible →perforation. 2. VOLVULOUS. 3. AFFERENT LOOP OBSTRUCTION 1/20/2022 Intestinal Obstruction 28

ADHESIVE INTESTINAL OBSTRUCTION After surgery or inflammation TIMING: FROM IMMEDIATE POSTOPERATIVE PERIOD TO MANY YEARS LATER TREATMENT: mainly conservative unless Strangulation Peritonitis Failure of conservative treatment 1/20/2022 Intestinal Obstruction 29

VOLVULOUS DEFINITION • A TWISTING OF A LOOP OF BOWEL ARROUND ITS MESENTRIC AXIS LEAD TO OBSTRUCTION&OCCLUSION OF BLOOD SUPPLY. SITES: 1. SIGMOID(MAINLY) 2. CAECUM. 3. SMALL INTESTINE. 4. STOMACH 5. GALLBLADDER. AETIOLOGY: 1. ABNORMAL MOBILITY. 2. . ABNORMAL DISTENSIBILITY. 3. A FIXED LOOP AT ITS APEX. 4. A LOOP WITH NARROW MESENTRIC ATTACHMENT. 1/20/2022 Intestinal Obstruction 30

SIGMOID VOLVULOUS - IN ELDERLY&CONSTIPATED PATIENTS -ANTICLOCKWISE TWIST C∕p SUDDEN ONSET OF ………………. PLAIN X-RAY “BENT INNER-TUBE” SIGN TTT TRY TO UNTWIST BY LONG-SOFT RECTAL TUBE BY SIGMOIDSCOPE -IF SUCCESS--------ELECTIVE SURGERY. -IF FAIL----------- LAPAROTOMY (UNTWIST OR RESECTION IF GANGERNOUS. ) 1/20/2022 Intestinal Obstruction 31

CAECAL VOLVULOUS -ASSOCIATED WITH A CONGENITAL MALROTATION. -CAECUM ROTATES BEYOND R. I. F. &IT HAS A PERSISTANT MESENTRY. -ACUTE ONSET OF PAIN IN RIF -X-RAY →GROSSLY DILATED CAECUM. -TREATMENT____UNTWIST ………. . OR RIGHT HEMICOLECTOMY(TO AVOID RECURRANCE) 1/20/2022 Intestinal Obstruction 32

MESENTRIC VASCULAR OCCLUSION AETIOLOGY: 1. MESENTRIC EMBOLUS --------AF --------MI --------AORTA --------PARADOXICAL 2. MESENTRIC ARTERIAL THROMBOSIS 3. MESENTRIC VENOUS THROMBOSIS ----------PORTAL HYPERTENSION ----------POSTSPLENECTOMY -----------PRESSURE BY TUMOUR ON SMV’s 4. NON OCCLUSIVE INFARCTION -----↓CARDIAC OUTPUT (MI or HF) 1/20/2022 Intestinal Obstruction 33

MESENTRIC VASCULAR OCCLUSION PATHOLOGY : . MESENTRIC VASCULAR OCCLUSION→INFARCTION &GANGRENE→PERFORATION DECREASE BLOOD WITHOUT INFARCTION→INTESTINAL ANGINA. C∕p CLASSICAL TRIAD - ACUTE COLICKY ABDOMINAL PAIN. - RECTAL BLEEDING - SHOCK …………… IN ELDERLY PATIENT WITH A. F. TTT 1. RESUSITATION (BLOOD IS IMPORTANT) 2. RESECTION OF THE GANGRENOUS PART (USUALLY FATAL) +2 -nd LOOK LAPAROTOMY. 3. IF EXTENSIVE RESECTION ______ TBN 1/20/2022 Intestinal Obstruction 34

NEONATAL INTESTINAL OBSTRUCTION CLASSIFICATION: 1. INTESTINAL ATRESIAS 2. VOLVULOUS NEONATORUM 3. MECONIUM ILEUS 4. NECROTIZING ENTEROCOLITIS 5. HIRSCHSPRUNG’DISEASE 6. ANORECTAL ATRESIAS CRITERIA FOR DIAGNOSIS: • BILE VOMITING • +CONSTIPATION • +DISTENSION • +VISIABLE PERISTALSIS • +X-RAY ----DISTENDED LOOPS WITH FLUID LEVELS 1/20/2022 Intestinal Obstruction 35

1. INTESTINAL ATRESIAS -BY SEPTUM -------COMPLETE OR PARTIAL -COMPLETE GAP WITH MESENTRIC DEFECT -MAY BE MULTIPLE -TTT----RESECTION&ANASTMOSIS (HIGH MORTALITY) 1/20/2022 Intestinal Obstruction 36

2. VOLVULOUS NEONATORUM -CONGENITAL MALROTATION OF BOWEL -CAECUM IS HIGH -NARROW MIDGUT MESENTRY -DUODENUM IS OBSTRUCTED BY LADD’S BANDS TREATMENT -UNTWIST THE VOLVULOUS -WIDENING OF THE NARROW MESENTRIC ATTACHMENT. -CUT LADD’S BANDS. • SO, CAECUM &ASCENDING COLON ON THE LEFT+APPENDECTOMY (AS ITS DIAGNOSIS IS DIFFICULT) 1/20/2022 Intestinal Obstruction 37

3. MECONIUM ILEUS -ASSOCIATED WITH MUCOVISIDOSIS -MUCOUS BLOCK -----INTESTINE ------PANCREATIC DUCT ------BRONCHIAL TREE C∕P: INTESTINAL OBSTRUCTION IN THE FIRST DAYS OF LIFE +GROUND GLASS APPEARANCE IN X-RAY. TREATMENT: 1. TRIAL BY GASROGRAFFIN ENEMA 2. LAPAROTOMY------REMOVAL VIA ENTEROTOMY OR -----RESECTION&ANASTMOSIS 3. PANCREATIC ENZYME+TTT OF CHEST INFECTION 1/20/2022 Intestinal Obstruction 38

4. NECROTIZING ENTEROCOLITIS -PREMATURE INFANTS -BACTERIAL INVASION TO MUCOSA -AFFECT TERMINAL ILEUM, CAECUM &DISTAL COLON C∕P: GENERALIZED SEPSIS VOMITING DISTENDED, TENSE ABDOMEN BLOOD&MUCOUS ∕RECTUM ----------------------LATER ON, PERFORATION OR STRICTURE X-RAY: DISTENSION+GAS BUBBLES IN BOWEL WALL 1/20/2022 Intestinal Obstruction 39

4. NECROTIZING ENTEROCOLITIS TREATMENT: 1. INITIALLY MEDICAL----TPN&ANTIBIOTICS. 2. SURGERY IF------FAILURE OF CONSERVATIVE. ---------HAGE ---------PERFORATION ---------OBSTRUCTION MORTALITY) 1/20/2022 BY RESECTION&ANASTMOSIS(HIGH Intestinal Obstruction 40

5. HIRSCHSPRUNG’DISEASE CONGENITAL OR AGANGLIONIC MEGACOLON PATHOLOGY: -ABSENCE OF GANGLION CELLS IN THE SUBMUCOSA -AFFECT THE RECTUM MAINLY. -SOMETIMES THE LOWER COLON. -RARELY THE WHOLE COLON. -THE INVOLVED SEGMENT------SPASTIC(FUNCTIONAL OBSTRUCTION) -THE PROXIMAL SEGMENT-----DILATE C∕P: -FAILURE TO PASS MECONIUM -LESS FREQUENTLY----CONSTIPATION -PR--------------NAROW EMPTY RECTUM FOLLOWED BY GUSH OF FLATUS&FAECES. 1/20/2022 Intestinal Obstruction 41

5. HIRSCHSPRUNG’DISEASE CONGENITAL OR AGANGLIONIC MEGACOLON INV: -X-RAY-----DILATED BOWEL EXCEPT AT THE PELVIS -BA. ENEMA. -RECTAL BIOPSY. DD: -ACQUIRED MEGA-COLON TREATMENT: -IF OBSTRUCTED------COLOSTOMY. -DEFINITIVE TREATMENT AT 6 -9 MONTHS BY RESECTION OF THE AGANGLIONIC SEGMENT +PULL THROUGH ANASTMOSIS 1/20/2022 Intestinal Obstruction 42

6. ANORECTAL ATRESIAS • • • RANGE FROM IMPERFORATE ANUS-----TO ----COMPLETE ABSENCE OF ANUS&RECTUM. -IT IS DUE TO FAILUR OF BREAKDOWN OF SEPTUM BETWEEN HINDGUT&PROCTODAEUM. -ASSOCIATED WITH FISTULA-♀------VAGINA -♂----BLADDER- URETHERA C/P: -ABSENT ANUS. -OR REPRESENTED BY DIMPLE. INV: INVERTOGRAM. TREATMENT: - IF SEPTUM IS THIN ------DIVID - IF THERE IS A GAP OR FISTULA--------COLOSTOMY THEN DEFINITIVE PROCEDURE LATER ON. 1/20/2022 Intestinal Obstruction 43

PARALYTIC ILEUS = TO roll =COLIC =Obstruction • DEF: A state of atony of the intestine -ITS principal clinical features: 1. Abdominal distension. 2. Absolute constipation. 3. Vomiting. 4. Absence of intestinal movement= no colics 1/20/2022 Intestinal Obstruction 44

AETIOLOGY 1. REFLEX PARALYTIC ILEUS -Fracture spine or pelvis. -Retroperitoneal hage&surgery. -Intestinal ischaemia. -Ureteric colic. 2. PERITONITIS -Toxic paralysis -May be associated with mechanical obstruction-------by fibrinous adhesions 3. METABOLIC FACTORS -POTASSIUM DEPLETION -URAEMIA -DIABETIC COMA 1/20/2022 Intestinal Obstruction 45

AETIOLOGY 4. DRUGS -ANTI-CHOLINERGIC -ANTI-PARKINSONIAN DRUG 5. POSTOPERATIVE -SYMPATHETIC OVER-ACTION -MANIPULATION OF THE BOWEL -POTASSIUM DEPLETION - IRRITATION ( BLOOD &PERITONITIS) ATONY OF THE STOMACH&LARGE BOWEL (AFTER EVERY ABDOMENAL OPERATION FOR A PERIOD OF 24 -48 HOURS) 1/20/2022 Intestinal Obstruction 46

PATHOLOGY • THE SAME AS MECHANICAL OBSTRUCTION. • SEVERE LOSS OF FLUID, ELECTROLYTES &PROTEIN. • DISTENSION-------IMPAIRS THE BLOOD SUPPLY OF THE WALL-------ABSORPTION OF TOXINS 1/20/2022 Intestinal Obstruction 47

CLINICAL FEATURES SEEN IN THE POSTOPERATIVE STAGE -ABDOMINAL DISTENSION -ABSOLUTE CONSTIPATION -EFFORTLESS VOMITING -PAIN IS NOT PRESENT( OF THE WOUND-OF DISTENSION) O-E: PATIENT IS ANXIOUS-UNCOMFORTABLEDISTENDED, SILENT&TENSE ABDOMEN X-RAY: GAS IN BOTH SMALL &LARGE INTESTINE+FLUID LEVELS 1/20/2022 Intestinal Obstruction 48

CLINICAL FEATURES THE PARALYTIC ILEUS MAY MERGE INSIDIOUSLY INTO MECHANICAL OBSTRUCTION PRODUCED BY ADHESIONS& BANDS FOLLOWING ABDOMENAL SURGERY. &AN IMPORTANT, OFTEN EXTREMELY DIFFICULT, DIFFERENTIAL DIAGNOSIS BETWEEN BOTH AS PARALYTIC ILEUS IS TREATED CONSERVATIVELY WHILE. MECHANICAL OBSTRUCTION USUALLY NEEDS URGENT OPERATION. 1/20/2022 Intestinal Obstruction 49

DIFFERENTIAL DIAGNOSIS 1. DURATION: - IF MORE THAN 3 -4 DAYS=NEARLY MECHANICAL 2. BOWEL SOUNDS: -SILENT=PARALYTIC -NOISY= MECHANICAL 3. PAIN - PAINLESS=PARALYTIC -COLICKY=MECHANICAL 4. TIMING: - IF SYMTOMS OCCUR AFTER THE PATIENT HAS ALREADY PASSED FLATUS=1. MECHANICAL =2. LEAKAGE 5. X-RAY: -DIFFUSE APPEARANCE OF GAS THROUGHTOUT THE SMALL&LARGE BOWEL=PARALYTIC -LOCALIZED LOOP WITHOUT GAS IN COLON OR RECTUM=MECHANICAL 1/20/2022 Intestinal Obstruction 50

TREATMENT PROPHYLAXIS: 1. BOWEL IS HANDLED GENTLY AT OPERATION. 2. NGT. 3. CORRECTION OF POTASSIUM LEVEL. IN ESTABLISHED CASES: 1. NGT. 2. I. V. FLUID&ELECTROLYTE THERAPY. 3. MOTILITY STIMULANTS METOCLOPRAMIDE=DOPAMINE ANTAGONIST ERYTHROMYCIN =++ MOTILIN RECEPTORS 1/20/2022 Intestinal Obstruction 51

THANK YOU 1/20/2022 Intestinal Obstruction 52