Ім'я файлу: Intestinal_Obstruction.ppt Розширення: ppt Розмір: 2490кб. Дата: 07.02.2022 скачати Пов'язані файли: Макієнко М.К.Білет №5.docx autoref-protsessy-polucheniya-aerogelei-s-vnedrennymi-uglerodnym Ціноутворення-в-будівництві_-Конспект-лекцій.pdf СУЧАСНІ ЗАСОБИ ПІДГОТОВКИ РУК ХІРУРГА.pptx VR1406(1).docx 5 Ст Брусова Анна.docx МЕТОДИЧНІ ВКАЗІВКИ 2018 брошюра.pdf Пінькас задача нефрологія + ЗАК.doc 1 урок.docx Intestinal ObstructionDr Bina Ravi Associate Professor and Consultant Department of Surgery Abdomen- Bowel soundPresent- Mechanical obstruction Not present-
Perforation (gas under diaphragm) ObjectivesPathophysiology – dynamic, adynamic Cardinal features – history, examination Causes – small, large gut obstruction Indications – contraindications for conservative Mx ObstructionDynamic – peristalsis, mechanical obstruction Adynamic- paralytic ileus, non propulsive Mesenteric vascular obstruction or, pseudo obstruction Dynamic ObstructionPain, distention, vomiting, absolute constipation Two- small gut – high , low Large gut Acute , chronic, acute on chronic or, sub-acute Simple – intact vascularity Strangulated – compromised vascularity Intestinal obstruction: CausesCauses –Dynamic obstructionIntra-luminal –impaction, FB, Bezoars, gallstones Intramural- strictures, malignancy Extra-luminal- bands/adhesions, hernia, volvulus, intussusception Adynamic obstruction-causesParalytic ileus Mesenteric vascular occlusion Pseudo obstruction PathophysiologyProximal gut dilates- altered motility Below the obstruction – normal motility, immobile Proximal – increased peristalsis, dilates, reduced peristalsis, flaccid Gas- bacteria. Aerobic/anaerobic, 90% N2 Fluid- dig. Juices, PathophysiologyDehydration and electrolyte imbalance Reduced intake Defective absorption Vomiting Sequestration in gut StrangulationBlood supply compromised Venous return first affected, arterial Hemorrhagic infarction Translocation and systemic exposure to microbes/ toxins Morbidity/ mortality- age, extent, Peripheral vascular failure Closed loop obstructionStrangulation Distention Necrosis perforation Acute Intestinal Obstruction-CPLocation, age of obstruction, pathology, ischemia Pain Vomiting Distension Constipation Dehydration, Hypokalemia, fever, abdomen tenderness Pain – severe, colicky, umbilical, lower abdomen Increases with peristalsis, later reduces Severe pain - strangulation VomitingHigh obstruction- violent Low obstruction- slow onset nausea/vomit Gradually digestive food changes to feculent material DistensionGreater if distal obstruction Visible peristalsis Peristalsis delayed in colonic obstruction Absent in Mesenteric vascular obstruction ConstipationAbsolute Relative Absent in – Richter’s hernia, gallstone, MVO, Pelvic abscess, partial obstruction DehydrationVomiting, fluid sequestration Dry skin, poor venous filling, sunken eyes, oliguria Raised blood urea, Hb, - secondary polycythemia HypokalemiaK, amylase, LDH – strangulation, raised TLC or, leucopenia Fever – indicates – ischemia, perforation, inflammation Hypothermia – septic shock Abdomen tendernessLocalized – ischemia Peritonitis – infarction or, perforation StrangulationDiagnosis is clinical Features of obstruction Persistent pain, Shock, local tenderness Non-responsive to conservative Mx Hernia strangulation – tender, irreducible, absent cough impulse, recent increase in size RadiologySupine/ erect plain abdomen films Small gut- central, transverse, no gas-colon Jejunum- valvulae connivantes Ileum- featureless Cecum- round gas in RIF Large gut- haustral folds SupineSigmoid volvulusDilated, no haustral pattern Small gut- air and fluid levels More the fluid levels, more distal the lesion Inv:Plain x ray- impacted foreign body Fluid levels – non obstructing conditions – inflammatory bowel disease, acute pancreatitis, abdominal sepsis Treatment3 measures Intestinal drainage Fluid and electrolyte replacement Relief of obstruction Surgical MxMx of segment at the site of obstruction The distended proximal bowel Underlying cause of obstruction SupportiveNG tube drainage Na , water replacement Antibiotics Large gutCa or diverticular disease Contrast study – pseudo-obstruction Caecal perforation- caecostomy, ileostomy Adhesions/bandsCommonest Fibrin – adhesions-fibrinous, fibrous Appendectomy , gynaecological op. Bands- congenital, bacterial peritonitis, greater omentum causing band Mx- conservative – 72 hrs –lap adhesiolysis Special obstructionsInt. hernia – foramen of Winslow, hole in the mesentery, hole in transverse colon, defects in broad ligament, cong diaphragmatic hernia, paraduodenal fossae, intraperitoneal fossae Mx- release the ring, reduction of hernia Enteric stricturesTB, Crohn’s, Ca, lymphomas, stricturoplasty Bolus obstruction – food, gall stone, trichobezoars, phytobezoars, stercoliths, worms Ac IntussusceptionProximal gut enters distal gut Adults – lead point, polyp, submucosal lipoma, tumor, Colo-colic – adults Pathology- inner tube, outer tube, returning of middle tube Strangulating obstruction- ileoileal, ileocaecal, ileocolic Clinical pictureSevere attacks of pain – lasts few minutes Later - red currant jelly stool Exam –between episodes-50-60% sausage shaped lump – empty RIF –Sign de Dance P/R – blood stained finger Later vomit, distension RadiologyPlain film – absent caecal gas Ba enema- claw sign CT scan Mx- Hydrostatic reduction with enema Operative reduction Recurrent – 5%- anchorage of ileum to ascending colon Differential diagnosisAcute enterocolitis Henoch Schoenlein perpura Rectal prolapse VolvulusAxial rotation of bowel at its mesentery Congenital or secondary Small intestine, caecum, sigmoid-common Small gut- spontaneous, vegetable consumption – untwist Caecal – clockwise- females- lap . Untwist, resection if gangrene SigmoidAnticlockwise Bands, overloaded colon, large mesocolon, narrow pelvic mesocolic attachment TreatmentFlexible sigmoidoscopy/ rigid Laparotomy- untwisting Viable – fixing to retroperitoneum Resection – Paul Mickulikz- gangrene Sigmoid colectomy/ Hartmann’s procedure later re-anastomosis Compound volvulusRare, ile-osigmoid knotting Gangrene Laparotomy - Decompression, resection and anastomosis Thanks |