Intestinal Obstruction
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Intestinal Obstruction

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Intestinal Obstruction Intestinal Obstruction Presentation Transcript

  • Intestinal obstruction
  • Intestinal obstruction Mechanical obstruction Paralytic Ileus
  • Paralytic Ileus
    • After abdominal surgery (laparotomy)
    • Electrolyte imbalances (hypokalemia)
    • Abdominal thrauma
    • Spine fracture
    • Retroperitoneal hemorrhage
    • Ureter distension – Acute pancreatitis
    • Ischemia of the intestine
    • Drugs (Narcotics, Psychotropics)
    • Peritonitis (ex. Gangrenous cholecystitis)
    • Diabetic coma
    • Extra abdominal infections (Lung) – Sepsis
    • IBD (ulcerative colitis)
  • Intestinal mechanical obstruction Pathogenesis
    • Stenosis
    • Obstruction
    • Compression
    • Invagination
    • Torsion
    • Angulation
    • Strangulation
  • Intestinal obstruction Pattern in Africa 70 % of the patients were below the age of 15 years 80% with gangrenous bowel segments
    • Large gallstones -- cholecystoenteric fistula – gallstone ileus
    • Bezoars (children, mentally retarded, toothless, after gastrectomy)
    • Congenital lesions (atresia, stenosis, duplication)
    • Neoplasms of small bowel – peritoneal carcinosis
    • Inflammation (Chron’s disease- diverticulitis- BK- endometriois)
    • Fecal impaction (bedridden old patient)
    • Meconium
    • Foreign bodies
    • Iatrogenic strictures (intest. Anastomosis o RT)
    Intestinal mechanical obstruction E tiology
  •  
  •  
    • Accumulation of fluids and gas proximal to the obstruction
    Simple mechanical obstruction PATHOGENESIS
    • Distention of the intestine (self perpetuating)
    • Increase intestinal secretion
    • Losses of water, Na, Cl, K, H
    • Dehydratation, ipokalemia, hypochloremia
    • Metabolic alkalosis
    • Circultory changes
    • Low central venous pressure
    • Reduced cardiac output
    • Hypotention
    • Hypovolemic shock
    • Rapid proliferation of intestinal bacteria
    • Toxiemia
    Simple mechanical obstruction PATHOGENESIS
  • Paralytic Ileus Mechanical obstruction
    • Ischemia of the bowel
    Strangulation obstruction PATHOGENESIS
    • Loss of blood and plasma into the strangulated segment
    • Gangrene
    • Perforation
    • Peritonitis
    • Sistemic absorption of toxic materia
  • Strangulation Obstruction Simple Mechanical obstruction Surgical timing
  • Intestinal obstruction Site Proximal s.b. obstruction
    • Greather vomitimg and less intestinal distention than distal obstruction
    Colon obstruction
    • Less fluid and electrolyte disturbance
    • Large distension and perforation risk
  • Intestinal obstruction Clinical aspects
    • Abdominal pain
    • Vomiting
    • Obstipation
    • Abdominal distention
    • Failure to pass flatus
    • Fever
    • Dehydratation
    • Hypotention – hypovolemic shock
  • Intestinal obstruction Pain
    • Typical crampy pain in paroxysm at 4 to 5 minute intervals in proximal obstruction
    • Less frequently in distal occlusion
    • After a long period of mechanical obstruction the crampy pain may subside
    • A strangulation should be suspected when continuus severe pain replace crampy pain
  • Intestinal obstruction Vomiting
    • Proximal obstruction produce profuse vomiting and little abdominal distension
    • Distal obstruction is less frequent but feculent
    • Initial phase byliary aspect
    • Late phase feculent
    BUT
  • Intestinal obstruction - Level HIGH LOW PAIN Crampy pain in paroxism Less intensity VOMITING Early, profuse, biliary Late, feculent may be absent METEORISM + +++ BEGINNING Acute Slow, insidious ABDOMINAL DISTENTION Moderate, upper quadrant Early, intense GENERAL CONDIT Early compromission preserved ELECTOLYTES Cl, K, Na rapid loss Late hydro electrolytic imbalance
  • Intestinal obstruction Clinical examination
    • Palpation abdominal masses can suggest neoplasms, intussusception, abscess
    • Incarcerated hernias may be obscure (obese)
    • Surgical scars can suggest adhesions
    • Abdominal auscultation period of increasing separated by periods of quite bowel sounds (high pitched, tinkling or musical) in mechanical obstruction
    • Rectal examination to seek luminal masses. Blood in the feces suggest mucosal lesion (cancer, intussusception, infarction)
    Key points
  • Intestinal obstruction Clinical examination
    • Young children and babies
    • Atresia
    • Volvolus
    • Anal imperforation
    • Meconial ileus
    • Intestinal Duplication
    • Malrotation
    • Intussusception
    • Ascaris infestation
    • Hernia
    Patient age and sex
    • Adults
    • Hernia
    • Adhesions
    • Neoplasm
    • Inflammation
    • RT
    • Endometriosis
    • Gynecological pathology
  • Intestinal obstruction
    • Abdominal direct X ray exhamination
    • Barium enema
    • CT
    • Endoscopy
    • Ecography (very difficult because of the massive presence of gas)
    Radiological examination
  • Intestinal obstruction
    • Gas abnormally large quantities of gas in the bowel
    • Multiple gas-fluid levels in the upright or lateral decubitus position
    Abdominal direct X ray exhamination
  • Intestinal obstruction
    • Multiple gas-fluid levels does not always mean intestinal obstruction
    • Abdominal pain and diarrhea can be found in gastroenteritis (cytomegalovirus infection as well as salmonellosis) expecially if profuse watery for 12 or more hours.
    Abdominal direct X ray exhamination Remember
  • Intestinal obstruction
    • Identify the distended tract
    • Small bowel
    • Colon
    • Both plus stomach
    Radiological examination What can we see
  • Intestinal obstruction Gas in the small bowel outlines the valvulae conniventes, which usually occupy the entire trasverse diameter of the bowel image Radiological examination Small bowel
  • Intestinal obstruction Colonic haustral marking occupy only a portion of the transverse diameter of the bowel Radiological examination large bowel
  • Intestinal obstruction Radiological examination Typical the small bowel pattern occupies the more central portion of the abdomen, the colon shadow is on the periphery of the abdominal film or in the pelvis
  • Intestinal obstruction Radiological examination During paralytic ileus gaseous distention occurs somewhat uniformly in the stomach, small intestine and colon
  • Intestinal obstruction
    • Helpful in distal occlusion may be operative in intussusception
    Barium Enema
  • Intestinal obstruction
    • Is sensitive for diagnosing complete obstruction of the small bowel and determining the localization and cause of obstruction
    CT scan
  • Proximal obstruction Distal obstruction
  • Intestinal obstruction
    • Hematocrit
    • WBC
    • Electrolytes
    • PCR (C reactive protein)
    • AST -ALT – GGT- LDH
    Laboratory test
  • Intestinal obstruction
    • Fluid and electrolytes therapy
    • Intestinal decompression (NG tube)
    • Diuresys monitoring
    • Correct surgical timing for relief of obstruction
    Treatment
  • Intestinal obstruction
    • Duration of obstruction
    • Severity of fluid, electrolyte and acid base abnormalities
    • Opportunity to improve vital organ function
    • Consideration of the risk of strangulation
    Timing of operation depends