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Discuss intestinal obstruction
 

Discuss intestinal obstruction

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    Discuss intestinal obstruction Discuss intestinal obstruction Presentation Transcript

    • DISCUSS INTESTINAL OBSTRUCTION PRESENTER : DR AROJU S.A MODERATOR : DR P ABUR DEPARTMENT OF SURGERY ABUTH, SHIKA – ZARIA5/19/2012
    • OUTLINE • INTRODUCTION • CLASSIFICATION • AETIOLOGY • PATHOPHYSIOLOGY • CLINICAL PRESENTATION • MANAGEMENT • COMPLICATIONS • PROGNOSIS • CONCLUSION5/19/2012
    • Introduction Definition• Stoppage of the cranio-caudal movement of bowel contents due to narrowing or complete blockage of the bowel lumen.• It is one of the commonest surgical emergencies worldwide.5/19/2012
    • Introduction• It is commoner in the small bowel than the large bowel.• It is important to make early and correct diagnosis.• Treatment must be prompt & appropriate5/19/2012
    • Classification • Dynamic / Adynamic • Acute / Chronic / Acute on chronic • High / Low • Simple / Strangulated / Close loop • Complete / Partial5/19/2012
    • Adynamic Ileus• Paralytic ileus• It is due to paralysis of intestinal musculature• Characterized by absence of peristalsis & pain5/19/2012
    • Dynamic Ileus• Peristalsis is working against a mechanical obstruction.• It may be acute or chronic.• Associated with abdominal pain5/19/2012
    • Aetiology5/19/2012
    • Aetiology 1. Extramural i. Strangulated Hernia ii. Adhesions & Bands iii. Volvolus5/19/2012
    • Strangulated External Hernia5/19/2012
    • Adhesions & Bands5/19/2012
    • Volvolus5/19/2012
    • Annular pancreas5/19/2012
    • Aetiology 2. Intraluminal i. Ascariasis ii. Gallstone iii. Faecal impaction iv. Foreign bodies5/19/2012
    • Gallstone ileus5/19/2012
    • Ascariasis5/19/2012
    • F.B in GIT5/19/2012
    • Aetiology 3. Intramural i. Atresia ii. Anorectal anomalies iii. Intussusception iv. Aganglionic megacolon v. Tumours vi. Inflammatory lesions5/19/2012
    • Intussusception5/19/2012
    • Small & Large bowel tumors5/19/2012
    • Multiple atresia5/19/2012
    • Duodenal web5/19/2012
    • Crohn’s dx & Diverticulitis5/19/2012
    • COMMON CAUSES OF INTESTINAL OBSTRUCTION ACCORDING TO AGE5/19/2012
    • Causes of Adynamic Ileus Metabolic Medications Post. Operative ileus cases Response to localized Neuropathic Inflammatory disorders process Diffuse Retroperitoneal peritonitis process5/19/2012
    • Metabolic Causes1.Hypokalemia.2.Hypomagnesemia.3.Hyponatremia.4.Ketoacidosis.5.Uremia.6.Porphyria.7.Heavy metal poisoning.5/19/2012
    • Medications1.Narcotics.2.Antipsychotics.3.Anticholinergics.4.Ganglionic blockers.5.Agents used to treat Parkinson’s disease.5/19/2012
    • Retroperitoneal process1.Retroperitoneal hematoma.2.Pancreatitis.3.Spinal or pelvic fracture.5/19/2012
    • Neuropathic disorders1.Diabetes.2.Multiple sclerosis.3.Scleroderma.4.Lupus erythromatosis.5.Hirshsprungs disease.5/19/2012
    • Intra-abdominal surgery Motility usually returns for the:• small bowel within 24 – 48 hrs.• gastric within 48 hrs.• colonic within 3-5 days.5/19/2012
    • Pathophysiology5/19/2012
    • Simple Obstruction• Below the obstruction, the bowel exhibits normal peristalsis and absorption until it becomes empty, when it contracts and becomes immobile.5/19/2012
    • Simple Obstruction• Above the obstruction, peristalsis is increased to overcome the obstruction, If the obstruction is not relieved the bowel begins to dilate resulting in flaccidity and paralysis.5/19/2012
    • Simple Obstruction• The gases are mostly from swallowed air and products of putrefaction & of intestinal contents by bacteria.• The fluids are mainly digestive juices5/19/2012
    • Simple Obstruction• The fluids accumulate due to loss of the absorbing surface of bowel & disordered fluid & electrolyte transport in the obstructed segment.5/19/2012
    • Simple Obstruction• When raised intraluminal pressure is more than venous pressure, there would be venous congestion, oedema of the wall, & mvt of fluid from the plasma into the gut lumen & peritoneal cavity.• Death from intestinal obstruction is due to loss of water & electrolytes5/19/2012
    • Simple Obstruction• The higher the level of obstruction, the earlier the onset of fluid & electrolytes imbalance.• In high obstruction, metabolic acidosis is common because the fluid loss is acid.• In low obstruction, metabolic acidosis is likely bcs the sequestered fluid alkaline.5/19/2012
    • Strangulation Obstruction• When the pressure of the occluding band exceeds the venous pressure• Venous engorgement of gut wall• Dilatation of intramural lymph channels that carry multiplying bacteria from mucosa surface into systemic circulation.5/19/2012
    • Strangulation obstruction• If the strangulated loop is long, release of the obstruction may cause severe endotoxic shock because of faster absorption of toxins & bacteria from the devitalized gut.• Increased venous pressure ► rupture of capillaries ► bleeding into the lumen, wall of the gut & peritoneal cavity.5/19/2012
    • Strangulation obstruction • Necrosis of tissues may be due to i. Tight occluding band obstruct arterial supply ii. Reflex arterial spasm to venous congestion iii. Thrombosis of intramural & mesenteric veins due to stasis of venous engorgement iv. Hypoxia enhances the growth of anaerobic bacteria5/19/2012
    • Closed Loop Obstruction • Afferent & efferent limbs of bowel are obstructed. • Typically seen in colonic obstruction with competent iliocaecal valve5/19/2012
    • Closed loop obstruction • The rich bacterial floral adds to the production of gases • Rapid distension ► ↑luminal pressure ► circulation impairment ► bowel necrosis & perforation ► fulminant peritonitis.5/19/2012
    • Clinical Presentation5/19/2012
    • Clinical presentation The cardinal features of obstruction are pain, vomiting, distension & constipation but clinical presentation varies according to: • Site of obstruction . • Age of Presentation. • Underlying pathology. • The presence or absence of ischemia.5/19/2012
    • Clinical presentation1. Abdominal pain 1st symptom, colicky, intermit tent , central in small bowel obstruction, waxes rapidly & wanes slowly, relief in between spasm but persistent pain between spasms of colicky5/19/2012 pains.
    • Clinical presentation2. Abdominal distension • The lower the site of obstruction the more the distension. • It varies inversely as the vomiting.5/19/2012
    • Clinical presentation2. Abdominal distension • Central in small bowel obstruction. • More in the flanks in colonic obstruction5/19/2012
    • Clinical presentation3. Vomiting Frequency & nature of vomitus depends on the level of obstruction.5/19/2012
    • Clinical presentationPyloric ObstructionWatery and acidic vomitusHigh Small Bowel Obstruction Bile-Stained vomitusLower Small Bowel Obstruction Feculent VomitusLarge Bowel Obstruction Uncommon & late symptom.5/19/2012
    • Clinical presentation 4. Absolute constipation • Occurs Early in “lower” Large Bowel Obstruction. • Occurs Late in “High” Small Bowel Obstruction.5/19/2012
    • Examination findings5/19/2012
    • Examination Findings• Dehydration Common in small bowel obstruction Vomiting and fluid sequestration5/19/2012
    • Examination FindingsPyrexiamay indicate: • the onset of ischaemia; • intestinal perforation; • inflammation associated with the obstructing disease.Hypothermia indicates septicaemic shock.5/19/2012
    • Inspection i. Surgical Scars ii. Hernias iii. Distention iv. Visible Peristalsis5/19/2012
    • Palpation i. Masses ii. Hernias iii. Tenderness  Perform Rectal Exam.5/19/2012
    • Percussion• Percuss to hear any Dullness or Resonance related to site of obstruction.5/19/2012
    • Auscultation• Bowel Sounds are Initially Loud and frequent→ Then as bowel distends the sounds become more resonant and high pitched→ Eventually becoming Amphoric5/19/2012
    • Investigations5/19/2012
    • Plain Abdominal X-rays usually diagnostic of bowel obstruction in more than 60% of the cases, but further evaluation (possibly by CT or barium ) may be necessary in 20% to 30% of cases.5/19/2012
    • X-RAY5/19/2012
    • X-RAY  Small Bowel Obstruction with characteristic air- fluid levels. The air rises above the fluid and there is a flat surface at the air- fluid interface.5/19/2012
    • X-RAY• Distended Large bowel tends to lie peripherally and to show the hustrations of the Taenia Coli.5/19/2012
    • Barium Studies are recommended in patients with a history of recurring obstruction or low- grade mechanical obstruction to precisely define the obstructed segment and degree of obstruction.5/19/2012
    • Barium meal • Jejunojejunal Intussusception5/19/2012
    • CT Scan• CT examination is particularly useful in patients with a history of abdominal malignancy, in postsurgical patients, and in patients who have no history of abdominal surgery and present with symptoms of bowel obstruction.5/19/2012
    • CT Scan• Rt colonic tumour5/19/2012
    • Other Investigations CBC Group & Xmatch blood Urea and Electrolyte RBS.5/19/2012
    • Treatment5/19/2012
    • Aim of Rx Aim is to relieve obstruction as soon as possible before strangulation occurs or before systemic complications set in.5/19/2012
    • Supportive Treatment• Nil per os• Fluid and electrolyte• Nasogastric aspiration• Urethral catheterization• Antibiotics• Analgesics• Correct anaemia5/19/2012
    • Conservative treatment• Partial obstruction• Early post op obstruction• Obstruction secondary to Crohn’s disease• Recurrent obstruction Open surgery if no improvement after 24hrs5/19/2012
    • Operative Treatment• Procedure depends on cause of obstruction• Non-viable gut must be resected• Questionable gut should be checked for viability5/19/2012
    • Non-viable bowel I. Loss of peristalsis II. Loss of Sheen III. Greenish or Black (Not Purple) IV. Loss of Pulsation in supplying vessels5/19/2012
    • Specific Rx • Adhesion obstruction: non operative • Strangulated Int. / Ext. hernia: release of obstruction, resection of gangrenous bowel, repair of defect5/19/2012
    • Specific Rx• Intussusception: Hydrostatic / Pneumatic reduction under fluoroscopy.• Volvolus: (viable) enema saponis for detorsion (nonviable appropriate resection & anastomosis)5/19/2012
    • Specific Rx • Hirshsprungs- pull through • Intestinal atresia- resection + anastomosis • Duodenal atresia- duodenoduodenostomy • Meconium ileus - resection + anastomosis • Pyloric stenosis - pyloromyotomy5/19/2012
    • Complications• Fluid and dyselectrolytaemia• Hypovolemic / Endotoxic Shock• Peritonitis• Adhesion/ Garres’ obstruction• Acute Renal Failure• Multiple organ5/19/2012
    • Prognosis• Type of obstruction• Duration of obstruction• Cause of obstruction• Age of the patient• Length of gangrenous bowel5/19/2012
    • THANK YOU FOR YOUR AUDIENCE “Never let the sun rise or set on small- bowel obstruction”5/19/2012