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Intestinal Obstruction


Dr Bina Ravi
Associate Professor and Consultant
Department of Surgery

Abdomen- Bowel sound


Present- Mechanical obstruction
Not present-
    Adynamic obstruction
      (no gas under diaphragm)

      Perforation

      (gas under diaphragm)

Objectives


Pathophysiology – dynamic, adynamic
Cardinal features – history, examination
Causes – small, large gut obstruction
Indications – contraindications for conservative Mx

Obstruction


Dynamic – peristalsis, mechanical obstruction
Adynamic- paralytic ileus, non propulsive Mesenteric vascular obstruction or, pseudo obstruction

Dynamic Obstruction


Pain, 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: Causes

Causes –Dynamic obstruction


Intra-luminal –impaction, FB, Bezoars, gallstones
Intramural- strictures, malignancy
Extra-luminal- bands/adhesions, hernia, volvulus, intussusception

Adynamic obstruction-causes


Paralytic ileus
Mesenteric vascular occlusion
Pseudo obstruction

Pathophysiology


Proximal 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,

Pathophysiology


Dehydration and electrolyte imbalance
Reduced intake
Defective absorption
Vomiting
Sequestration in gut

Strangulation


Blood 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 obstruction


Strangulation
Distention
Necrosis
perforation

Acute Intestinal Obstruction-CP


Location, 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

Vomiting


High obstruction- violent
Low obstruction- slow onset nausea/vomit
Gradually digestive food changes to feculent material

Distension


Greater if distal obstruction
Visible peristalsis
Peristalsis delayed in colonic obstruction
Absent in Mesenteric vascular obstruction

Constipation


Absolute
Relative
Absent in – Richter’s hernia, gallstone, MVO, Pelvic abscess, partial obstruction

Dehydration


Vomiting, fluid sequestration
Dry skin, poor venous filling, sunken eyes, oliguria
Raised blood urea, Hb, - secondary polycythemia

Hypokalemia


K, amylase, LDH – strangulation, raised TLC or, leucopenia
Fever – indicates – ischemia, perforation, inflammation
Hypothermia – septic shock

Abdomen tenderness


Localized – ischemia
Peritonitis – infarction or, perforation

Strangulation


Diagnosis 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

Radiology


Supine/ 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

Supine

Sigmoid volvulus


Dilated, 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

Treatment


3 measures
Intestinal drainage
Fluid and electrolyte replacement
Relief of obstruction

Surgical Mx


Mx of segment at the site of obstruction
The distended proximal bowel
Underlying cause of obstruction

Supportive


NG tube drainage
Na , water replacement
Antibiotics

Large gut


Ca or diverticular disease
Contrast study – pseudo-obstruction
Caecal perforation- caecostomy, ileostomy

Adhesions/bands


Commonest
Fibrin – adhesions-fibrinous, fibrous
Appendectomy , gynaecological op.
Bands- congenital, bacterial peritonitis, greater omentum causing band
Mx- conservative – 72 hrs –lap adhesiolysis

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
Mx- release the ring, reduction of hernia

Enteric strictures


TB, Crohn’s, Ca, lymphomas, stricturoplasty
Bolus obstruction – food, gall stone, trichobezoars, phytobezoars, stercoliths, worms

Ac Intussusception


Proximal 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 picture


Severe 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

Radiology


Plain 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 diagnosis


Acute enterocolitis
Henoch Schoenlein perpura
Rectal prolapse

Volvulus


Axial 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

Sigmoid


Anticlockwise
Bands, overloaded colon, large mesocolon, narrow pelvic mesocolic attachment

Treatment


Flexible sigmoidoscopy/ rigid
Laparotomy- untwisting
Viable – fixing to retroperitoneum
Resection – Paul Mickulikz- gangrene
Sigmoid colectomy/ Hartmann’s procedure later re-anastomosis

Compound volvulus


Rare, ile-osigmoid knotting
Gangrene
Laparotomy - Decompression, resection and anastomosis

Thanks


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