INTESTINAL OBSTRUCTION Mudasir Bashir DIVISION OF SURGERY AND RADIOLOGY-IVRI
<ul><li>Blockage of aborad flow of intestinal contents (chyle). </li></ul><ul><li>Classification (etiological) </li></ul>I...
Clinical Signs <ul><li>Depend upon :- </li></ul><ul><li>Location   </li></ul><ul><ul><li>More orad –more acute signs (secr...
<ul><li>Obstruction in duodenum and proximal jejeunum-   </li></ul><ul><li>* Acute vomition especially post-prandial. </li...
<ul><li>Severity   </li></ul><ul><ul><li>Complete – significant and early signs </li></ul></ul><ul><ul><li>Partial – few o...
General signs <ul><li>Depression </li></ul><ul><li>Lack of responsiveness </li></ul><ul><li>Halitosis </li></ul><ul><li>De...
Pathogenesis   Obstruction Bowel distention (increased secretion reduced absorption, hypomotility) Gas production, lack of...
Sepsis and septic shock <ul><li>sepsis with septic shock occurs as a result of host response to bacterial signal molecules...
<ul><li>Extensive microvascular thrombosis disseminated intravascular coagulation. </li></ul><ul><li>Vasodilatation. </li>...
<ul><li>Lung -increased alveolar permeability---increased pulmonary fluid----decreased oxygen exchange. </li></ul><ul><li>...
<ul><li>Systolic and diastolic ventricular volume with a decreased ejection fraction . </li></ul><ul><li>strangulation obs...
Diagnosis <ul><li>History </li></ul><ul><li>Clinical findings </li></ul><ul><li>Physical examination – abdominal palpation...
<ul><li>Radiography  </li></ul><ul><li>Plain  </li></ul><ul><li>Dilated and gas filled loops of bowel </li></ul><ul><li>Id...
<ul><li>Contrast radiography   </li></ul><ul><li>May take 6-24 hrs </li></ul><ul><li>Barium  (insoluble contrast agent) </...
 
 
Linear foreign body
<ul><li>Ultrasonography </li></ul><ul><li>More rapid method </li></ul><ul><li>More chances of false -ve and false +ve </li...
Intussusception-Radiographic trident appearance   Transverse   Longitudinal
Laparoscopy (Intestinal polyps)
Foreign bodies <ul><li>Most common cause of intestinal obstruction in animals. </li></ul><ul><li>Space occupying   </li></...
<ul><li>Linear foreign body </li></ul><ul><li>Thread, nylon stockings, rope, string, carpet etc. </li></ul><ul><li>Most fr...
Tumors  <ul><li>Mostly malignant (thoracic radiography and hepatic ultrasonography). </li></ul><ul><li>Adenocarcinoma  </l...
<ul><li>Lymphosarcoma </li></ul><ul><li>Protein losing enteropathy – most common </li></ul><ul><li>Chemotherapy is treatme...
Polyps
Intestinal tumors
Intussusception  <ul><li>Invagination or telescopy of intestines </li></ul><ul><li>Intussusceptum – intussuscipiens </li><...
 
Intussusception ant ileo-caeco-colic junction
Volvulus  <ul><li>Twisting of intestine on its mesenteric axis </li></ul><ul><li>Susceptibility –  </li></ul><ul><li>GSD –...
Intestinal volvulus
Intestinal volvulus
Congenital defects <ul><li>Atresia of intestinal segments </li></ul><ul><li>Signs visible in neonatal life </li></ul><ul><...
 
Ileus / Pseudo- obstruction <ul><li>Def.  – ineffective aborad intestinal propulsion </li></ul><ul><li>Occurs  – (a) after...
Strangulation / Incarceration <ul><li>Entrapment of intestines in traumatic wall hernia, omental tears, congenital hernia,...
Causes of strangulation
Appearance of strangulated intestines in a horse suffering from colic
Intestinal Surgery <ul><li>GENERAL PRINCIPLES </li></ul><ul><li>Maintenance of fluid and electrolyte imbalance (hypokalemi...
<ul><li>Choice of suture pattern </li></ul><ul><li>Submucosa (incorporation) </li></ul><ul><li>* Single layer – preferred ...
<ul><li>* Apposition – preferred method </li></ul><ul><li>* Eversion  - adhesions </li></ul><ul><li>* Inversion – reduced ...
 
Enterotomy and Anastomosis
 
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Intestinal Obstruction, MUDASIR BASHIR

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FROM Dr.MUDASIR BASHIR
M.V.Sc. SCHOLAR
VETERINARY SUGERY AND RADIOLOGY
I.V.R.I

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Intestinal Obstruction, MUDASIR BASHIR

  1. 1. INTESTINAL OBSTRUCTION Mudasir Bashir DIVISION OF SURGERY AND RADIOLOGY-IVRI
  2. 2. <ul><li>Blockage of aborad flow of intestinal contents (chyle). </li></ul><ul><li>Classification (etiological) </li></ul>Intestinal Obstruction Mechanical Functional Intraluminal (foreign bodies) Intramural (tumors and polyps) Intussusception Volvulus Hypodynamic state (ileus) Strangulation/ incarceration Congenital
  3. 3. Clinical Signs <ul><li>Depend upon :- </li></ul><ul><li>Location </li></ul><ul><ul><li>More orad –more acute signs (secretion- absorption) </li></ul></ul><ul><ul><li>More aborad – mild, non specific and chronic signs </li></ul></ul><ul><li>Animals with more orad obstruction respond better to fluid and electrolyte therapy. </li></ul>
  4. 4. <ul><li>Obstruction in duodenum and proximal jejeunum- </li></ul><ul><li>* Acute vomition especially post-prandial. </li></ul><ul><li>* Praying posture </li></ul><ul><li>Obstruction in mid and caudal jejeunum – </li></ul><ul><li>*mild, non specific and chronic signs. </li></ul><ul><li>*Letharginess, anorexia, oligodipsia and </li></ul><ul><li>scanty stool </li></ul><ul><li>Intussusception – Bloody, fetid smelling feces </li></ul>
  5. 5. <ul><li>Severity </li></ul><ul><ul><li>Complete – significant and early signs </li></ul></ul><ul><ul><li>Partial – few or no signs (in later stages) </li></ul></ul><ul><li>Duration </li></ul><ul><ul><li>Long standing obstruction – severe signs </li></ul></ul><ul><ul><li>Early obstruction – few non specific signs. </li></ul></ul>
  6. 6. General signs <ul><li>Depression </li></ul><ul><li>Lack of responsiveness </li></ul><ul><li>Halitosis </li></ul><ul><li>Dehydration with dry mucosa </li></ul><ul><li>Moaning </li></ul><ul><li>Painful abdomen (treading and stretching out, kicking at belly, lying on ground) </li></ul><ul><li>Retching </li></ul><ul><li>Bilateral lower abdominal distention at later stages </li></ul>
  7. 7. Pathogenesis Obstruction Bowel distention (increased secretion reduced absorption, hypomotility) Gas production, lack of absorption Progressive distention, fluid accumulation, emesis Systemic dehydration Reduced venous return Poor tissue perfusion Obstruction of venules and lymphatics in bowel wall Edema of bowel wall Ischaemia of bowel wall Necrosis of bowel wall Enterotoxemia Death Rupture of bowel wall Peritonitis
  8. 8. Sepsis and septic shock <ul><li>sepsis with septic shock occurs as a result of host response to bacterial signal molecules-endotoxin of gram negative,exotoxins of peptidoglycan,lipotechoic acid,etc. </li></ul><ul><li>Toll-like receptors –essential in innate recognition of microbial signal molecules in triggering acquired immunity. </li></ul><ul><li>Ten types of TLRs have been found.TLR-4 is essential for lps signelling. </li></ul><ul><li>Biological effects of LPS-induced host immunolgical responses are- </li></ul><ul><li>Increased vascular permeability </li></ul>
  9. 9. <ul><li>Extensive microvascular thrombosis disseminated intravascular coagulation. </li></ul><ul><li>Vasodilatation. </li></ul><ul><li>Decreased myocardial contractility. </li></ul><ul><li>Fever. </li></ul><ul><ul><ul><ul><li>No organ is left by sepsis-multiple organ dysfunction syndrome. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Following are the effects of sepsis and septic shock on different organs:- </li></ul></ul></ul></ul>
  10. 10. <ul><li>Lung -increased alveolar permeability---increased pulmonary fluid----decreased oxygen exchange. </li></ul><ul><li>GIT -haemorrhagic necrosis of mucosa due to ischaemia. </li></ul><ul><li>Kidney -acute tubular necrosis---acute renal failure. </li></ul><ul><li>Liver -stasis of bile,focal necrosis and jaundice. </li></ul><ul><li>Endocrine and metabolic effects- increased levels of cortisol,catecholamines and glucagon—increased proteolysis,lipolysis and gluconeogenesis. </li></ul><ul><li>Heart -decreased myocardial function--increased </li></ul>
  11. 11. <ul><li>Systolic and diastolic ventricular volume with a decreased ejection fraction . </li></ul><ul><li>strangulation obstruction </li></ul><ul><li>Strangulation—intestinal wall integrity disturbance—ischaemia/haemorrhagic intestinal wall infarction—anoxia and necrosis of bowell wall—bacterial growth and multiplication{bacteroids,clostridium,coliforms}—penetration of bacterial products into peritonium—through portal lymphatic—blood stream—septic shock. </li></ul>
  12. 12. Diagnosis <ul><li>History </li></ul><ul><li>Clinical findings </li></ul><ul><li>Physical examination – abdominal palpation </li></ul><ul><li>Imaging </li></ul><ul><ul><li>Radiography </li></ul></ul><ul><ul><li>Ultrasonography </li></ul></ul><ul><ul><li>Laparoscopy </li></ul></ul><ul><li>Measurement of diameters </li></ul><ul><li>Laboratory examination </li></ul>
  13. 13. <ul><li>Radiography </li></ul><ul><li>Plain </li></ul><ul><li>Dilated and gas filled loops of bowel </li></ul><ul><li>Identifiable foreign body </li></ul><ul><li>Clumping of bowel + intestinal gas pattern resembling rows of tear drops shaped lucencies arranged in palisades = linear foreign body </li></ul>
  14. 14. <ul><li>Contrast radiography </li></ul><ul><li>May take 6-24 hrs </li></ul><ul><li>Barium (insoluble contrast agent) </li></ul><ul><li>Adv. - more details </li></ul><ul><li>- soothing effect on irritated bowel </li></ul><ul><li>Disadv. – very irritating to peritoneum if spilled out </li></ul><ul><li>Diatrizoate meglumine (soluble contrast agent) </li></ul><ul><li>Adv. – less likely to cause peritonitis </li></ul><ul><li>Disadv. – poorer details </li></ul><ul><li>- increases dehydration (hypertonic). </li></ul>
  15. 17. Linear foreign body
  16. 18. <ul><li>Ultrasonography </li></ul><ul><li>More rapid method </li></ul><ul><li>More chances of false -ve and false +ve </li></ul><ul><li>Technique of choice for intussusception </li></ul><ul><li>Laparoscopy </li></ul><ul><li>Measurement of diameters </li></ul><ul><li>Max. SI diameter:L5body ht. At narrowest point = 1.6 (normally) </li></ul><ul><li>>2 = obstruction </li></ul><ul><li>Laboratory findings (abdominal fluid) </li></ul><ul><li>Increased total protein (>2.5 g/dl) </li></ul><ul><li>Increased cell count (> 10000 cell/cmm.) </li></ul>
  17. 19. Intussusception-Radiographic trident appearance Transverse Longitudinal
  18. 20. Laparoscopy (Intestinal polyps)
  19. 21. Foreign bodies <ul><li>Most common cause of intestinal obstruction in animals. </li></ul><ul><li>Space occupying </li></ul><ul><li>Round smooth </li></ul><ul><li>Complete obstruction </li></ul><ul><li>Trail of distended bowel (aborad propulsion) </li></ul><ul><li>Pressure necrosis </li></ul><ul><li>Sharp edged </li></ul><ul><li>Partial obstruction </li></ul><ul><li>Perforates bowel wall </li></ul>
  20. 22. <ul><li>Linear foreign body </li></ul><ul><li>Thread, nylon stockings, rope, string, carpet etc. </li></ul><ul><li>Most frequent in cats </li></ul><ul><li>One end – tongue base, pharynx, pylorus </li></ul><ul><li>Other end – carried to intestine through peristalsis </li></ul><ul><li>Mesenteric side – perforations </li></ul><ul><li>Oral examination – most important </li></ul><ul><li>Abdominal examination – pain, pleating and clumping of intestine </li></ul><ul><li>Radiography </li></ul><ul><li>Rx - surgical emergency </li></ul><ul><li>- enterotomy (multiple or single) </li></ul>
  21. 23. Tumors <ul><li>Mostly malignant (thoracic radiography and hepatic ultrasonography). </li></ul><ul><li>Adenocarcinoma </li></ul><ul><li>bowel stricture </li></ul><ul><li>Most common – distal jejunum and ileum </li></ul><ul><li>Treatment unrewarding </li></ul><ul><li>Leiomyoma/ Leiomyosarcoma </li></ul><ul><li>Impinge on bowel lumen </li></ul><ul><li>Leiomyoma- good prognosis </li></ul><ul><li>Leiomyosarcoma- grave prognosis </li></ul>
  22. 24. <ul><li>Lymphosarcoma </li></ul><ul><li>Protein losing enteropathy – most common </li></ul><ul><li>Chemotherapy is treatment of choice </li></ul><ul><li>Adenoma </li></ul><ul><li>Also known as polyps </li></ul><ul><li>Partial obstruction </li></ul><ul><li>Irritation - intussussception </li></ul>
  23. 25. Polyps
  24. 26. Intestinal tumors
  25. 27. Intussusception <ul><li>Invagination or telescopy of intestines </li></ul><ul><li>Intussusceptum – intussuscipiens </li></ul><ul><li>Hypermotility (irritataed bowel) </li></ul><ul><li>Partial obstruction – complete obstruction </li></ul><ul><li>Ileo-caeco-colic junction – most common site </li></ul><ul><li>Common in young pups </li></ul><ul><li>Rx </li></ul><ul><li>Laparotomy – release of invagination with or without intestinal resection and anastomosis. </li></ul>
  26. 29. Intussusception ant ileo-caeco-colic junction
  27. 30. Volvulus <ul><li>Twisting of intestine on its mesenteric axis </li></ul><ul><li>Susceptibility – </li></ul><ul><li>GSD – dogs with GSD blood – other breeds. </li></ul><ul><li>Radiograph – massive dilation of multiple loops of bowel in stellate pattern originating from a central focus. </li></ul><ul><li>Prognosis – very grave. </li></ul>
  28. 31. Intestinal volvulus
  29. 32. Intestinal volvulus
  30. 33. Congenital defects <ul><li>Atresia of intestinal segments </li></ul><ul><li>Signs visible in neonatal life </li></ul><ul><li>Intestinal resection and anastomosis - only cure. </li></ul>
  31. 35. Ileus / Pseudo- obstruction <ul><li>Def. – ineffective aborad intestinal propulsion </li></ul><ul><li>Occurs – (a) after surgery </li></ul><ul><li>(b) secondary to diseases (uremia, </li></ul><ul><li>peritonitis, pancreatitis) </li></ul><ul><li>Mainly due to electrolyte disturbances </li></ul><ul><li>Usually transient </li></ul><ul><li>Rx – (a) prokinetic drugs </li></ul><ul><li>(b) correction of electrolyte disturbance </li></ul><ul><li>(c) correction of underlying disease </li></ul>
  32. 36. Strangulation / Incarceration <ul><li>Entrapment of intestines in traumatic wall hernia, omental tears, congenital hernia, mesenteric rents, volvulus and intussusception. </li></ul><ul><li>Compression of intestinal veins – inhibition of arterial flow – mucosal degeneration – endotoxemic shock and peritonitis (perforation) </li></ul><ul><li>Stabilize the animal – enterotomy / anastomosis </li></ul><ul><li>Prognosis - grave </li></ul>
  33. 37. Causes of strangulation
  34. 38. Appearance of strangulated intestines in a horse suffering from colic
  35. 39. Intestinal Surgery <ul><li>GENERAL PRINCIPLES </li></ul><ul><li>Maintenance of fluid and electrolyte imbalance (hypokalemia, hypochloremia, hyponatremia and metabolic acidosis) </li></ul><ul><li>Antibiotic prophylaxis (contaminated or clean contaminated surgery) </li></ul><ul><li>Assessment of intestinal viability </li></ul><ul><li>Choice of suture material </li></ul><ul><li>Monofilament synthetic absorbable (polydioxanone, polyglyconate) </li></ul>
  36. 40. <ul><li>Choice of suture pattern </li></ul><ul><li>Submucosa (incorporation) </li></ul><ul><li>* Single layer – preferred </li></ul><ul><li>* Double layered – Avascular necrosis of inverted cuff of tissues - Narrowing of lumen. </li></ul><ul><li>inadequate submucosal apposition. </li></ul><ul><li>. </li></ul>
  37. 41. <ul><li>* Apposition – preferred method </li></ul><ul><li>* Eversion - adhesions </li></ul><ul><li>* Inversion – reduced intestinal lumen </li></ul><ul><li>Interrupted single layered serosubmucosal suture pattern – gold standard </li></ul><ul><li>Suture line enforcement </li></ul><ul><li>Prevention of leakage </li></ul><ul><li>Revascularization </li></ul><ul><li>Omental wrapping </li></ul><ul><li>Serosal patching (surgical parachute) </li></ul>
  38. 43. Enterotomy and Anastomosis
  39. 45. THANK YOU
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