Property of Prof Dr. Ismail Tantawy, Department of General Surgery, Faculty of Medicine. University of Zagazig

1. By
Prof. Dr.Prof. Dr. ISMAIL TANTAWYISMAIL TANTAWY

2. Learning objectives to understand
The pathophysiology ofThe pathophysiology of
dynamic and adynamicdynamic and adynamic
intestinal obstructionintestinal obstruction
The causes, clinicalThe causes, clinical
Pictures and complicationsPictures and complications
of intestinal obstructionof intestinal obstruction..
The indications and contraindications of either surgical orThe indications and contraindications of either surgical or
conservative treatment of intestinal obstruction.conservative treatment of intestinal obstruction.

3. Definition:Definition:
Failure of propulsion of intestinal contents.Failure of propulsion of intestinal contents.
Due to either mechanical occlusion of the lumenDue to either mechanical occlusion of the lumen
((dynamic obstructiondynamic obstruction) or failure of the propulsive) or failure of the propulsive
movement (movement (adynamic obstructionadynamic obstruction).).
AetiologyAetiology
Mechanical (Mechanical (DynamicDynamic))
ObstructionObstruction
Functional (Functional (adynamicadynamic))
Due to occluded lumen
Patent lumen

4. Mechanical (Dynamic) ObstructionMechanical (Dynamic) Obstruction
In the lumenIn the lumen In the wallIn the wall Outside the wallOutside the wall
 Meconium ileusMeconium ileus
 Gall stone ileus andGall stone ileus and
bolus obstructionbolus obstruction
 Ascaris massAscaris mass
 Faecal impaction, F.B.,Faecal impaction, F.B.,
or enterolithor enterolith
Congenital atresia.Congenital atresia.
Inflammatory stricture. e.g.Inflammatory stricture. e.g.
T.B. Crohn’s, ulcerativeT.B. Crohn’s, ulcerative
colitis, diverticulitis.colitis, diverticulitis.
Malignancy: cancer colon,Malignancy: cancer colon,
and rectum.and rectum.
Bands and adhesions (theBands and adhesions (the
commonest cause).commonest cause).
Tight rings of hernia sacTight rings of hernia sac
Tumours and enlarged LNs.Tumours and enlarged LNs.
Functional (adynamic)Functional (adynamic)
Paralytic ileusParalytic ileus Spastic ileusSpastic ileus: Hirschsprung's: Hirschsprung's
disease is a good exampledisease is a good example
Mesentric vascularMesentric vascular
occlusion (occlusion (MVOMVO))

5. PathologyPathology
Types of intestinal obstructionTypes of intestinal obstruction
SimpleSimple
obstructionobstruction
StrangulatedStrangulated
obstructionobstruction
Occluded lumen withoutOccluded lumen without
interference with blood supplyinterference with blood supply
Obstruction with interference with blood supply of theObstruction with interference with blood supply of the
affected loop:affected loop:
Strangulated herniaStrangulated hernia VolvolusVolvolus IntussusceptionIntussusception
Adhesive obstruction (someAdhesive obstruction (some
cases e.g. internal herniation)cases e.g. internal herniation)
Mesentric vascularMesentric vascular
occlusion.occlusion.

6. Patho-pathologyPatho-pathology
Local effectsLocal effects
Proximal to the site of obstructionProximal to the site of obstruction At the site of obstructionAt the site of obstructionDistal to obstructionDistal to obstruction
Proximal to the site of obstruction:Proximal to the site of obstruction:
The proximal loop passes through the following phases:The proximal loop passes through the following phases:
(A) Proximal to the site of obstruction:(A) Proximal to the site of obstruction:
The proximal loop passes through the following phases:The proximal loop passes through the following phases:
Hyperperistaltic with antiperistaltic waves: occurs early inHyperperistaltic with antiperistaltic waves: occurs early in
trial to overcome the obstruction .trial to overcome the obstruction .
Stage of dilatation (due to exhaustion and paralysis) & TheStage of dilatation (due to exhaustion and paralysis) & The
loop becomes distended with:loop becomes distended with:

7. FluidsFluids LateLateGasesGases
1000-1500 ml saliva
1500 - 2500 ml gastric juice
1000 ml bile
1500 ml pancreatic secretion.
3000 ml intestinal secretion
Swallowed, secretedSwallowed, secreted
& diffused from& diffused from
bloodblood ((The secretedThe secreted
part alone is morepart alone is more
than 8 liters per daythan 8 liters per day).).
Either swallowedEither swallowed
((70%70%), diffused), diffused
from blood (from blood (20%20%))
or produced fromor produced from
putrefaction ofputrefaction of
food (food (10%10%).).
Bacterial proliferation withBacterial proliferation with
breakdown of retainedbreakdown of retained
intestinal contentsintestinal contents
produces toxins thatproduces toxins that
accumulate in the stagnantaccumulate in the stagnant
fluid and do not pass to thefluid and do not pass to the
circulation except aftercirculation except after
release of obstruction,release of obstruction,
which may lead towhich may lead to
toxaemia which may betoxaemia which may be
fatal.fatal.

8. Distal to obstructionDistal to obstruction
Normal peristalsis to evacuateNormal peristalsis to evacuate
the residual content.the residual content.
The distal segment is empty, collapsed,The distal segment is empty, collapsed,
contracted and immobile.contracted and immobile.
EarlyEarly LateLate
At the site of obstructionAt the site of obstruction
SimpleSimple
obstructionobstruction
StrangulatedStrangulated obstructionobstruction
The strangulated loopThe strangulated loop
becomes distendedbecomes distended
with gas & fluidwith gas & fluid
At first, the venous flow is occluded (being of low pressure) leadingAt first, the venous flow is occluded (being of low pressure) leading
to oedema and congestion.to oedema and congestion.
Arterial flow is then occluded leading to ischaemia and gangrene.Arterial flow is then occluded leading to ischaemia and gangrene.
The devitalized wall of the intestine permits passage of toxins &The devitalized wall of the intestine permits passage of toxins &
bacteria to the peritoneal cavity & circulation causing toxaemia.bacteria to the peritoneal cavity & circulation causing toxaemia.
Lastly, perforation leads to peritonitis.Lastly, perforation leads to peritonitis.

9. Complications (Complications (general effectsgeneral effects))
 Hypovolaemic shock:Hypovolaemic shock: due to fluid loss by vomiting,due to fluid loss by vomiting,
sequestration of fluids in the third space (dilatedsequestration of fluids in the third space (dilated
loops).loops).
 In strangulated obstruction:In strangulated obstruction: shock is more markedshock is more marked
due to additional blood loss into the strangulateddue to additional blood loss into the strangulated
loop.loop.
 Dehydration & electrolytes imbalance:Dehydration & electrolytes imbalance:
hyponatraemia & hypokalaemia.hyponatraemia & hypokalaemia.
 Toxaemia:Toxaemia: in strangulated obstruction.in strangulated obstruction.
 Perforation & peritonitis.Perforation & peritonitis.

10. Clinical pictureClinical picture
SymptomsSymptoms
PainPain VomitingVomiting ConstipationConstipation DistensionDistension
 Simple obstSimple obstruction:ruction:
colicky pain in attackscolicky pain in attacks
with long free intervals.with long free intervals.
 Strangulated obstructionStrangulated obstruction::
colicky pain with shortcolicky pain with short
intervals with constantintervals with constant
dull aching pain betweendull aching pain between
the attacks of colics.the attacks of colics.
 Paralytic ileus:Paralytic ileus: No colic.No colic.
The higher theThe higher the
obstruction,obstruction,
the earlier thethe earlier the
vomiting.vomiting.
 Absolute constipation toAbsolute constipation to
both faeces and flatus.both faeces and flatus.
 The lower theThe lower the
obstruction, the earlierobstruction, the earlier
the constipation.the constipation.
The lower theThe lower the
obstructionobstruction
the more isthe more is
distension.distension.

11. SignsSigns
GeneralGeneral LocalLocal
 Signs of dehydration,Signs of dehydration,
shock or toxaemia.shock or toxaemia.
 General signs of theGeneral signs of the
cause e.g. distantcause e.g. distant
metastasis of GITmetastasis of GIT
cancer.cancer.
InspectionInspection PalpationPalpation PercussionPercussion
AuscultationAuscultation Per-rectal examinationPer-rectal examination
(PR exam.)(PR exam.)
AbdominalAbdominal
distention.distention.
VisibleVisible
peristalsis on theperistalsis on the
abdominal wall.abdominal wall.
Simple obstruction: mildSimple obstruction: mild
tenderness over the distendedtenderness over the distended
loops maximum over the site ofloops maximum over the site of
the obstruction.the obstruction.
Strangulated obstruction:Strangulated obstruction:
tenderness & rebound tendernesstenderness & rebound tenderness
over the strangulated loop.over the strangulated loop.
Hyper-resonanceHyper-resonance
over the distendedover the distended
loopsloops
Loud exaggerated intestinal sounds inLoud exaggerated intestinal sounds in
the hyperperistaltic stage (the hyperperistaltic stage (earlyearly).).
Dead silent abdomen in paralytic ileusDead silent abdomen in paralytic ileus
and during the stage of dilatation (and during the stage of dilatation (latelate).).
Empty rectum supports the diagnosis.Empty rectum supports the diagnosis.
It may reveal anorectal carcinoma orIt may reveal anorectal carcinoma or
red currant jelly stool in intussusception.red currant jelly stool in intussusception.

12. How to suspect the level of obstruction clinically?How to suspect the level of obstruction clinically?
ItemsItems High small bowelHigh small bowel Low small bowelLow small bowel Large bowelLarge bowel
1-Pain1-Pain above theabove the
umbilicusumbilicus
Around & belowAround & below
itit
LowerLower
abdominalabdominal
2-Vomiting2-Vomiting
-Very early (with-Very early (with
pain)pain)
-Copious-Copious
-1-2h after pain-1-2h after pain
-moderate-moderate
1-2 day after1-2 day after
painpain
mildmild
3-Constipation3-Constipation LateLate IntermediateIntermediate EarlyEarly
4-Abd. distension4-Abd. distension -Mild or absent-Mild or absent
-central-central
-Inter mediate-Inter mediate
-central-central
-Marked-Marked
-peripheral-peripheral
5-Dehydration5-Dehydration Marked earlyMarked early IntermediateIntermediate Mild & lateMild & late

13. Differences between Simple, strangulated and functional obstruction (P. ileus)Differences between Simple, strangulated and functional obstruction (P. ileus)
ItemItem Simple obst.Simple obst. Strangulated. Obst.Strangulated. Obst. Paralytic ileusParalytic ileus
1-Pain1-Pain
IntermittentIntermittent
colicky pain withcolicky pain with
long free intervals.long free intervals.
Attacks of colickyAttacks of colicky
pain with shortpain with short
intervals of constantintervals of constant
dull aching pain.dull aching pain.
Mild dull achingMild dull aching
pain of distension orpain of distension or
no painno pain
2-Shock2-Shock Mild.Mild. Severe.Severe. Moderate.Moderate.
3-Palpation3-Palpation
TendernessTenderness
especially over theespecially over the
site of obstruction.site of obstruction.
Tenderness andTenderness and
rebound tenderness.rebound tenderness.
Very mildVery mild
tenderness.tenderness.
4-Auscultation4-Auscultation
HyperperistalsisHyperperistalsis
then silentthen silent
abdomen.abdomen.
HyperperistalsisHyperperistalsis
then silent abdomen.then silent abdomen.
Dead silentDead silent
abdomen.abdomen.
5-N/G suction5-N/G suction
It relieves pain inIt relieves pain in
hours.hours.
It does not relieveIt does not relieve
pain.pain.
It relieves distention.It relieves distention.
6- Leucocytic count6- Leucocytic count
Not increasedNot increased IncreasedIncreased Not increased exceptNot increased except
in cases secondary toin cases secondary to
sepsissepsis

14. InvestigationsInvestigations
Double enema test:Double enema test:
 Two enemas are given one hour apart.Two enemas are given one hour apart.
 If the second enema comes withoutIf the second enema comes without 3F3F ((Faeces FlatusFaeces Flatus oror ForceForce),),
intestinal obstruction is proved.intestinal obstruction is proved.
Radiological investigations:Radiological investigations:
**Plain X. ray abdomen erect position:Plain X. ray abdomen erect position:
It reveals distended loops with multiple fluidIt reveals distended loops with multiple fluid
levels inlevels in stepladder patternstepladder pattern..
 JejunumJejunum:: shows circular folds calledshows circular folds called
""valvulaevalvulae conniventsconnivents" giving" giving concertinaconcertina
appearanceappearance
 IleumIleum:: shows shapeless characterless tubes.shows shapeless characterless tubes.
 Colon:Colon: typical haustrations of the colon.typical haustrations of the colon. Multiple fluid levelsMultiple fluid levels

15. **Barium enema:Barium enema:
When colonic obstruction is suspected.When colonic obstruction is suspected.
**Upper GIT series:Upper GIT series:
Barium or Gastrograffin meal with follow-through to detectBarium or Gastrograffin meal with follow-through to detect
upper small intestinal obstruction in neonates and infants.upper small intestinal obstruction in neonates and infants.
Laboratory investigations:Laboratory investigations:
Total leucocytic countTotal leucocytic count:: markedly rises in cases of strangulation.markedly rises in cases of strangulation.
Serum electrolytes:Serum electrolytes: decreased sodium and potassium levels.decreased sodium and potassium levels.
Differential Diagnosis:Differential Diagnosis:
From other causes of acute abdomen.From other causes of acute abdomen.

16. Treatment:Treatment:
Conservative treatment:Conservative treatment:
 Correction of fluid & electrolytes imbalance i.e.Correction of fluid & electrolytes imbalance i.e. I.V.I.V. fluidsfluids
according to the deficit.according to the deficit.
 Fluid chart is mandatory.Fluid chart is mandatory.
 Nasogastric suction through Ryle's tube for:Nasogastric suction through Ryle's tube for:
**Preoperative benefits:Preoperative benefits:
 It relieves distension, which may cause cardiac &It relieves distension, which may cause cardiac &
respiratory embarrassment.respiratory embarrassment.
 It relieves congestion & oedema of the intestines and helpsIt relieves congestion & oedema of the intestines and helps
return of tone & peristalsis.return of tone & peristalsis.
**Operative benefits:Operative benefits:
 For anaesthesiaFor anaesthesia:: it prevents vomiting & aspirationit prevents vomiting & aspiration
pneumonia.pneumonia.
 For surgeon:For surgeon: it deflates the intestine providing easyit deflates the intestine providing easy
manipulation & easy closure of the abdomen.manipulation & easy closure of the abdomen.

17. **Postoperative benefits:Postoperative benefits:
 It prevents massive toxic absorption after release of obstruction.It prevents massive toxic absorption after release of obstruction.
 It reduces the incidence of postoperative paralytic ileusIt reduces the incidence of postoperative paralytic ileus
(distention and vomiting).(distention and vomiting).
 Antibiotics:Antibiotics: to guard against respiratory infection, peritonitis &to guard against respiratory infection, peritonitis &
septicemia.septicemia.
 Repeated enemata are used to break faecal impaction and stimulateRepeated enemata are used to break faecal impaction and stimulate
colonic motility.colonic motility.
Surgical treatment:Surgical treatment:
A part from few cases, in which the previousA part from few cases, in which the previous
conservative measures may be curative, most cases needconservative measures may be curative, most cases need
emergency exploration.emergency exploration.

18. Exploration:Exploration:
In adults, midline incision is preferred.In adults, midline incision is preferred.
Deliver the caecumDeliver the caecum
and examineand examine
Decompress the bowels ifDecompress the bowels if
greatly distended bygreatly distended by
Deal withDeal with
the causethe cause
If collapsed, it isIf collapsed, it is
small intestinalsmall intestinal
obstructionobstruction →→ followfollow
the ileum to thethe ileum to the
distended loops.distended loops.
If distended, it isIf distended, it is
large intestinallarge intestinal
obstructionobstruction →→ followfollow
the colon to thethe colon to the
collapsed part.collapsed part.
By this way you canBy this way you can
reach the site of thereach the site of the
obstruction .obstruction .
 Threading a longThreading a long
nasogastric tube throughnasogastric tube through
the intestine down to thethe intestine down to the
site of obstruction.site of obstruction.
 Decompression throughDecompression through
a small stab in the bowela small stab in the bowel
and introduction of wideand introduction of wide
bore catheter connectedbore catheter connected
to a sucker then close theto a sucker then close the
stab with sutures.stab with sutures.
Simple obstruction:Simple obstruction:
Remove the cause ifRemove the cause if
possible or do bypass orpossible or do bypass or
colostomy.colostomy.
StrangulatedStrangulated
obstruction:obstruction: Remove theRemove the
cause of strangulationcause of strangulation
and examine theand examine the
viability of the loop.viability of the loop.

19. ItemItem Viable loopViable loop Gangrenous loopGangrenous loop
-Inspection-Inspection
-luster-luster
-colour-colour
-peristalsis-peristalsis
Present (shining)Present (shining)
Red (light)Red (light)
SeenSeen
Absent (dull)Absent (dull)
Dark or blackDark or black
AbsentAbsent
-Palpation-Palpation -tone-tone
-Pulsation-Pulsation
Present (firm)Present (firm)
Felt in the mesenteryFelt in the mesentery
Absent (flabby)Absent (flabby)
AbsentAbsent
-Operative Doppler U/S-Operative Doppler U/S + ve+ ve -ve-ve

20. If the viability of a loop is questionable,If the viability of a loop is questionable,
try to improve it bytry to improve it by
Wrapping the loops withWrapping the loops with
hot fomentations.hot fomentations.
Increase oxygenationIncrease oxygenation
forfor 1010 minutes.minutes.
If not improved or proved gangrenous,If not improved or proved gangrenous,
resection of gangrenous loop is indicated.resection of gangrenous loop is indicated.
If it isIf it is ::
Small intestine or rightSmall intestine or right
colon then do primarycolon then do primary
resection anastomosis.resection anastomosis.
Left colon then either resectionLeft colon then either resection
ended by colostomy or recentlyended by colostomy or recently
primary resection anastomosisprimary resection anastomosis
after on table colonic lavageafter on table colonic lavage
((Dudely lavageDudely lavage) is done.) is done.

21. Common causes of obstruction inCommon causes of obstruction in
different age groupsdifferent age groups
Newborn (first month): (Newborn (first month): (see the chapter of pediatric surgery )see the chapter of pediatric surgery )
Jejuno ileal atresia or stenosis (Jejuno ileal atresia or stenosis (the commonest causethe commonest cause).).
Malrotation or volvolus neonatorum.Malrotation or volvolus neonatorum.
Congenital duodenal obstruction (Congenital duodenal obstruction (atresiaatresia).).
Duplication of the intestineDuplication of the intestine
Hirchsprung's diseaseHirchsprung's disease
Imperforate anus.Imperforate anus.
Meconium ileusMeconium ileus
InfancyInfancy ((1 month – 2 years1 month – 2 years) &) & ChildhoodChildhood ((2y-12y2y-12y):):
IntussusceptionIntussusception ((the commonest cause in infantsthe commonest cause in infants).).
Strangulated external herniaStrangulated external hernia ((the commonest cause in childrenthe commonest cause in children) .) .
Ascaris mass obstruction.Ascaris mass obstruction.

22. Young adult and middle age:Young adult and middle age:
Adhesive intestinal obstruction (Adhesive intestinal obstruction (the commonest causethe commonest cause).).
Strangulated hernia. (Strangulated hernia. (see the chapter of herniassee the chapter of hernias))
Paralytic ileus.Paralytic ileus.
Stricture obstruction e.g.Stricture obstruction e.g. T.BT.B..
Gall stone obstruction.Gall stone obstruction.
Old age:Old age:
Malignant obstruction (Malignant obstruction (the commonestthe commonest).).
Volvolus sigmoid.Volvolus sigmoid.
Faecal impaction.Faecal impaction.

23. The commonest causes of intestinalThe commonest causes of intestinal
obstruction as a whole areobstruction as a whole are
Strangulated externalStrangulated external
herniahernia
Adhesive intestinalAdhesive intestinal
obstructionobstruction
Paralytic ileusParalytic ileusMalignant obstructionMalignant obstruction

25. AetiologyAetiology
Peritoneal irritation leading to fibrinous exudate thatPeritoneal irritation leading to fibrinous exudate that
causes fibrinous adhesions between adjacent intestinalcauses fibrinous adhesions between adjacent intestinal
loops.loops.
They may resolve or change into mature permanentThey may resolve or change into mature permanent
fibrous tissue causing fibrous adhesions.fibrous tissue causing fibrous adhesions.
The irritating causes may be (theories)The irritating causes may be (theories)
Mechanical orMechanical or
thermal e.g.thermal e.g.
diathermy or hotdiathermy or hot
fomentationsfomentations
InfectionInfection
ForeignForeign
bodiesbodies
TraumaTrauma VascularVascular
PeritonitisPeritonitis
& TB.& TB.
Talk powderTalk powder
(over surgical(over surgical
gloves) & silkgloves) & silk
suturessutures
Ischaemia orIschaemia or
congestion.congestion.

26. Pathology:Pathology:
Types:Types:
Occurs early, which is easilyOccurs early, which is easily
broken by blunt dissectionbroken by blunt dissection
FibrinousFibrinous
adhesionsadhesions
Which is firm and needs sharpWhich is firm and needs sharp
dissection (dissection (adhesolysisadhesolysis).).
FibrousFibrous
adhesionsadhesions
Clinical pictureClinical picture
There is a history of previous operationThere is a history of previous operation
e.g. appendicectomy or gynecologicale.g. appendicectomy or gynecological
operations or past history of peritonitisoperations or past history of peritonitis
FibrinousFibrinous
adhesionsadhesions
Picture of simple obstruction but the adhesionsPicture of simple obstruction but the adhesions
may compress the blood supply and causemay compress the blood supply and cause
strangulated intestinal obstructionstrangulated intestinal obstruction
FibrousFibrous
adhesionsadhesions

27. TreatmentTreatment
ConservativeConservative SurgicalSurgical
ConservativeConservative
 Should be tried first even for few days so long as there is noShould be tried first even for few days so long as there is no
Suspicion of strangulation.Suspicion of strangulation.
 I.V. fluidsI.V. fluids,, N/GN/G suction may be beneficial and the intestinalsuction may be beneficial and the intestinal
movement may break down fibrinous adhesions.movement may break down fibrinous adhesions.
SurgicalSurgical
Exploration and division ofExploration and division of
the offending adhesions.the offending adhesions.
Prevention of recurrencePrevention of recurrence

28. Exploration and division of the offending adhesions:Exploration and division of the offending adhesions:
If adhesions are extensiveIf adhesions are extensive →→ bypass by lateral anastomosis.bypass by lateral anastomosis.
Prevention of recurrence:Prevention of recurrence:
 Instillation of different substances:Instillation of different substances: to reduce the fibrous tissueto reduce the fibrous tissue
formation e.g. hyaluronidase, heparin, steroids, fibrinolysin,formation e.g. hyaluronidase, heparin, steroids, fibrinolysin,
dextran…etc. is usually useless.dextran…etc. is usually useless.
 Noble's plicationNoble's plication:: The adjacent loops are sutured along their anti-The adjacent loops are sutured along their anti-
mesenteric border in ordered fashion.mesenteric border in ordered fashion.
 Charle-Phillip's transmesenteric plicationCharle-Phillip's transmesenteric plication:: In which placation isIn which placation is
done in the mesentery few centimeters from the bowel that looksdone in the mesentery few centimeters from the bowel that looks
like a pouch of sausagelike a pouch of sausage
 Baker's tube:Baker's tube: intraluminal tube splinting the loops gentle curves.intraluminal tube splinting the loops gentle curves.
This tube is removed 12 days later.This tube is removed 12 days later.

30. Aetiology:Aetiology:
Obstruction of the terminal ileum by aggregation ofObstruction of the terminal ileum by aggregation of AscarisAscaris
lumbricoideslumbricoides worms forming a mass, usually followingworms forming a mass, usually following
antihelminthic treatment.antihelminthic treatment.
Incidence:Incidence:
Rarely seen nowadays.Rarely seen nowadays.
Common in children belowCommon in children below 10 years10 years in tropics.in tropics.
Clinical picture:Clinical picture:
History of Ascaris infestation or intake of antihelminthics mayHistory of Ascaris infestation or intake of antihelminthics may
be positive.be positive.
The vomitus may contain worms.The vomitus may contain worms.
Picture of simple intestinal obstruction.Picture of simple intestinal obstruction.

31. Investigations:Investigations:
Leucocytic count may show marked esinophilia.Leucocytic count may show marked esinophilia.
TreatmentTreatment
ConservativeConservative ExplorationExploration
(N/G suction +(N/G suction +
IV. Fluids) mayIV. Fluids) may
succeed.succeed.
 The mass is identified and trial is done to knead itThe mass is identified and trial is done to knead it
along the ileum to the colon without opening thealong the ileum to the colon without opening the
bowel.bowel.
 If kneading fails, remove the mass throughIf kneading fails, remove the mass through
transverse incision in the bowel.transverse incision in the bowel.
 The bowel incision should be sutured withThe bowel incision should be sutured with silk suturessilk sutures
because the worms tend to eat the catgut sutures andbecause the worms tend to eat the catgut sutures and
re-open the sutured wound of the intestine, throughre-open the sutured wound of the intestine, through
their way to the peritoneum.their way to the peritoneum.

33. Aetiology:Aetiology:
Incidence:Incidence:
Clinical picture:Clinical picture:
Obstruction of the distal colon and rectum by inspissated faecesObstruction of the distal colon and rectum by inspissated faeces
((forming a massforming a mass).).
It is common in elderly bed ridden patients with chronic constipation.It is common in elderly bed ridden patients with chronic constipation.
Clinical picture of simple distal intestinal obstruction.Clinical picture of simple distal intestinal obstruction.
Indentible mass may be felt in the Lt. iliac fossa and the faecal mass isIndentible mass may be felt in the Lt. iliac fossa and the faecal mass is
felt per-rectumfelt per-rectum
Treatment:Treatment:
 Conservative measures + repeated enemata may succeed to loosen theConservative measures + repeated enemata may succeed to loosen the
mass and relieve obstruction.mass and relieve obstruction.
 If failed, anal dilatation under anaesthesia and manual removal of theIf failed, anal dilatation under anaesthesia and manual removal of the
mass is done.mass is done.

35. Aetiology:Aetiology:
Incidence:Incidence:
Clinical picture:Clinical picture:
 Obstruction of the terminal ileum by large gall stone (Obstruction of the terminal ileum by large gall stone (2.5 cm or more2.5 cm or more
in diameterin diameter) which had ulcerated through the gall bladder wall into) which had ulcerated through the gall bladder wall into
the duodenum.the duodenum.
 It passes down to be impacted usuallyIt passes down to be impacted usually 2 feet2 feet from the ileocaecal valvefrom the ileocaecal valve
causing simple intestinal obstruction.causing simple intestinal obstruction.
It is a rare condition, common in old obese multiparous females withIt is a rare condition, common in old obese multiparous females with
long history of dyspepsia.long history of dyspepsia.
Clinical picture of simple intestinal obstruction:Clinical picture of simple intestinal obstruction:
 Usually there is a long history of chronic cholecystitis with recentUsually there is a long history of chronic cholecystitis with recent
exacerbation.exacerbation.
 The diagnosis is usually delayed because it's clinical picturesThe diagnosis is usually delayed because it's clinical pictures
resemble exacerbation attacks of gall bladder disease.resemble exacerbation attacks of gall bladder disease.

36. Investigations:Investigations:
Plain X ray of abdomen in erect position: It may show:Plain X ray of abdomen in erect position: It may show:
The classic multiple fluid level but the stone is rarely seen.The classic multiple fluid level but the stone is rarely seen.
Gas in the gall bladder or biliary tree (Gas in the gall bladder or biliary tree (pneumobiliapneumobilia) is diagnostic.) is diagnostic.
Treatment “Treatment “SurgicalSurgical”:”:
Exploration after good preoperative preparation:Exploration after good preoperative preparation:
 Try to crush the stone between fingers without opening theTry to crush the stone between fingers without opening the
bowel.bowel.
 If failed, open the ileum above the stone, and remove it thenIf failed, open the ileum above the stone, and remove it then
close the incision transverselyclose the incision transversely
 Avoid any manipulation in the region of the gall bladder, whichAvoid any manipulation in the region of the gall bladder, which
may break down the cholecyto-enteric fistula and results inmay break down the cholecyto-enteric fistula and results in
external duodenal or biliary fistula.external duodenal or biliary fistula.