Intestinal Obstruction Dr Bina Ravi Associate Professor and
Intestinal Obstruction Dr Bina Ravi Associate Professor and Consultant Department of Surgery 1
Abdomen- Bowel sound n Present- Mechanical obstruction n. Not n Adynamic obstruction n n present- (no gas under diaphragm) Perforation n (gas under diaphragm) 2
Objectives Pathophysiology – dynamic, adynamic n Cardinal features – history, examination n Causes – small, large gut obstruction n Indications – contraindications for conservative Mx n 3
Obstruction Dynamic – peristalsis, mechanical obstruction n Adynamic- paralytic ileus, non propulsive Mesenteric vascular obstruction or, pseudo obstruction n 4
Dynamic Obstruction Pain, distention, vomiting, absolute constipation n Two- small gut – high , low n Large gut n Acute , chronic, acute on chronic or, sub-acute n Simple – intact vascularity n Strangulated – compromised vascularity n 5
Intestinal obstruction: Causes 6
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Causes –Dynamic obstruction n Intra-luminal –impaction, FB, Bezoars, gallstones n Intramural- strictures, malignancy n Extra-luminal- bands/adhesions, hernia, volvulus, intussusception 8
Adynamic obstruction-causes n Paralytic ileus n Mesenteric vascular occlusion n Pseudo obstruction 9
Pathophysiology n Proximal gut dilates- altered motility Below the obstruction – normal motility, immobile Proximal – increased peristalsis, dilates, reduced peristalsis, flaccid Gas- bacteria. Aerobic/anaerobic, 90% N 2 n Fluid- dig. Juices, n n n 10
Pathophysiology Dehydration and electrolyte imbalance n Reduced intake n Defective absorption n Vomiting n Sequestration in gut n 11
Strangulation Blood supply compromised n Venous return first affected, arterial n Hemorrhagic infarction n Translocation and systemic exposure to microbes/ toxins n Morbidity/ mortality- age, extent, Peripheral vascular failure n 12
Closed loop obstruction Strangulation n Distention n Necrosis n perforation n 13
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Acute Intestinal Obstruction-CP Location, age of obstruction, pathology, ischemia n Pain n Vomiting n Distension n Constipation n Dehydration, Hypokalemia, fever, abdomen tenderness n 16
Pain – severe, colicky, umbilical, lower abdomen n Increases with peristalsis, later reduces n Severe pain - strangulation n 17
Vomiting n High obstruction- violent n Low obstruction- slow onset nausea/vomit n Gradually digestive food changes to feculent material 18
Distension n Greater if distal obstruction n Visible peristalsis n Peristalsis delayed in colonic obstruction n Absent in Mesenteric vascular obstruction 19
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Constipation n Absolute n Relative n Absent in – Richter’s hernia, gallstone, MVO, Pelvic abscess, partial obstruction 21
Dehydration n Vomiting, fluid sequestration n Dry skin, poor venous filling, sunken eyes, oliguria n Raised blood urea, Hb, - secondary polycythemia 22
Hypokalemia n K, amylase, LDH – strangulation, raised TLC or, leucopenia Fever – indicates – ischemia, perforation, inflammation n Hypothermia – septic shock n 23
Abdomen tenderness n Localized – ischemia n Peritonitis – infarction or, perforation 24
Strangulation Diagnosis is clinical n Features of obstruction n Persistent pain, Shock, local tenderness n Non-responsive to conservative Mx n Hernia strangulation – tender, irreducible, absent cough impulse, recent increase in size n 25
Radiology Supine/ erect plain abdomen films n Small gut- central, transverse, no gascolon n Jejunum- valvulae connivantes n Ileum- featureless n Cecum- round gas in RIF n Large gut- haustral folds n 26
Supine 27
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Sigmoid volvulus n Dilated, no haustral pattern n Small gut- air and fluid levels n More the fluid levels, more distal the lesion 29
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Inv: n Plain x ray- impacted foreign body n Fluid levels – non obstructing conditions – inflammatory bowel disease, acute pancreatitis, abdominal sepsis 31
Treatment n 3 measures n Intestinal drainage n Fluid and electrolyte replacement n Relief of obstruction 32
Surgical Mx n Mx of segment at the site of obstruction n The distended proximal bowel n Underlying cause of obstruction 33
Supportive n NG tube drainage n Na , water replacement n Antibiotics 34
Large gut Ca or diverticular disease n Contrast study – pseudo-obstruction n Caecal perforation- caecostomy, ileostomy n 35
Adhesions/bands Commonest n Fibrin – adhesions-fibrinous, fibrous n Appendectomy , gynaecological op. n Bands- congenital, bacterial peritonitis, greater omentum causing band n Mx- conservative – 72 hrs –lap adhesiolysis n 36
Special obstructions Int. hernia – foramen of Winslow, hole in the mesentery, hole in transverse colon, defects in broad ligament, cong diaphragmatic hernia, paraduodenal fossae, intraperitoneal fossae n Mx- release the ring, reduction of hernia n 37
Enteric strictures TB, Crohn’s, Ca, lymphomas, stricturoplasty n Bolus obstruction – food, gall stone, trichobezoars, phytobezoars, stercoliths, worms n 38
Ac Intussusception Proximal gut enters distal gut n Adults – lead point, polyp, submucosal lipoma, tumor, n Colo-colic – adults n Pathology- inner tube, outer tube, returning of middle tube n Strangulating obstruction- ileoileal, ileocaecal, ileocolic n 39
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Clinical picture Severe attacks of pain – lasts few minutes n Later - red currant jelly stool n Exam –between episodes-50 -60% sausage shaped lump – empty RIF – Sign de Dance n P/R – blood stained finger n Later vomit, distension n 41
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Radiology Plain film – absent caecal gas n Ba enema- claw sign n CT scan n Mx- Hydrostatic reduction with enema n Operative reduction n Recurrent – 5%- anchorage of ileum to ascending colon n 43
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Differential diagnosis n Acute enterocolitis n Henoch Schoenlein perpura n Rectal prolapse 46
Volvulus Axial rotation of bowel at its mesentery n Congenital or secondary n Small intestine, caecum, sigmoidcommon n Small gut- spontaneous, vegetable consumption – untwist n Caecal – clockwise- females- lap. Untwist, resection if gangrene n 47
Sigmoid n Anticlockwise n Bands, overloaded colon, large mesocolon, narrow pelvic mesocolic attachment 48
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Treatment Flexible sigmoidoscopy/ rigid n Laparotomy- untwisting n Viable – fixing to retroperitoneum n Resection – Paul Mickulikz- gangrene n Sigmoid colectomy/ Hartmann’s procedure later re-anastomosis n 52
Compound volvulus n Rare, ile-osigmoid knotting n Gangrene n Laparotomy - Decompression, resection and anastomosis 53
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Thanks 55
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