Adhesions and bands

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Adhesions and bands

  1. 1. <ul><li>INTESTINAL </li></ul><ul><li>OBSTRUCTION </li></ul>
  2. 2. <ul><li>ADHESIONS </li></ul>
  3. 3. <ul><li> Aetiology </li></ul><ul><li>Iatrogenic (Post operative) : </li></ul><ul><li>Individual susceptibility </li></ul><ul><li>May be induced by talc (powder from </li></ul><ul><li>gloves), cotton or linen (surgical </li></ul><ul><li>mops, suture material) </li></ul><ul><li>Inflammatory / Infections : </li></ul><ul><li>Following appendicitis and PID </li></ul><ul><li>Following peritonitis (specially biliary) </li></ul><ul><li>Plastic type of peritoneal tuberculosis </li></ul>
  4. 4. <ul><li> </li></ul><ul><li>Ischaemia : </li></ul><ul><li>Arterial or venous occlussion </li></ul><ul><li>Occurs at sites of anastomoses </li></ul><ul><li>Ischaemia due to mobilisation of peritoneum </li></ul><ul><li>Irradiation : </li></ul><ul><li>Radiation enteritis </li></ul><ul><li>Drugs : </li></ul><ul><li>Practolol </li></ul>
  5. 5. <ul><li> Types </li></ul><ul><li>Fibrinous : </li></ul><ul><ul><li>Early </li></ul></ul><ul><li>Easy to do adhesiolysis / flimsy </li></ul><ul><li>May reduce over time </li></ul><ul><li>Fibrous : </li></ul><ul><ul><li>Occurs later </li></ul></ul><ul><li>Difficult to do adhesiolysis / dense </li></ul><ul><li>No tendency to improve over time </li></ul><ul><li>Occurs due to associated ischaemia and </li></ul><ul><li>vascular ingrowth and replacement </li></ul><ul><li>with mature fibrous tissue </li></ul>
  6. 6. <ul><li> Treatment - Medical </li></ul><ul><ul><li>Monitor the vital signs : </li></ul></ul><ul><ul><li>TPR / BP / IO / Abdominal girth chart </li></ul></ul><ul><ul><li>Nil Per Oral </li></ul></ul><ul><ul><li>Nasogastric tube (Ryle’s tube) insertion and </li></ul></ul><ul><ul><li>dependent drainage. Intermittent (fourth </li></ul></ul><ul><ul><li>hourly) aspiration </li></ul></ul><ul><ul><li>IV fluid supplement : Ringer’s lactate or </li></ul></ul><ul><ul><li>Normal saline </li></ul></ul><ul><ul><li>Antibiotics if strangulation suspected </li></ul></ul><ul><ul><li>Reassess periodically </li></ul></ul>
  7. 7. <ul><li> Treatment – Surgical </li></ul><ul><ul><li>Indications : </li></ul></ul><ul><li>When conservative treatment for 3 to 5 </li></ul><ul><li>days does not result in resolution </li></ul><ul><li>When strangulation is suspected / cannot </li></ul><ul><li>be ruled out </li></ul>
  8. 8. <ul><li> Treatment – Surgical </li></ul><ul><ul><ul><li>Emergency exploratory laparotomy </li></ul></ul></ul><ul><ul><li>Adhesiolysis / Enterolysis </li></ul></ul><ul><ul><li>Resect the strangulated bowel and do </li></ul></ul><ul><ul><li>end to end anastomosis </li></ul></ul><ul><ul><ul><li>Handle the bowel carefully (less abrasion) </li></ul></ul></ul><ul><ul><ul><li>Do not produce ischaemia of peritoneum </li></ul></ul></ul><ul><ul><ul><li>Do not mobilize and suture peritoneum </li></ul></ul></ul><ul><ul><ul><li>Do thorough peritoneal lavage with saline </li></ul></ul></ul><ul><ul><ul><li>Instillation of inhibitors - controversial </li></ul></ul></ul>
  9. 9. <ul><li>Treatment for recurrent intestinal obstruction due to adhesions </li></ul><ul><ul><li>Repeat Adhesiolysis / Enterolysis </li></ul></ul><ul><ul><li>Noble’s plication </li></ul></ul><ul><ul><li>Charles – Phillips transmesentric plication </li></ul></ul><ul><ul><li>Intestinal intubation </li></ul></ul>
  10. 11. <ul><li>BANDS </li></ul>
  11. 12. <ul><li> Aetiology </li></ul><ul><li>Congenital : </li></ul><ul><li>Ladds bands </li></ul><ul><li>Obliterated vitellointestinal duct </li></ul><ul><li>Mesodiverticular band </li></ul><ul><li>Inflammatory : </li></ul><ul><li>A string band following bacterial peritonitis </li></ul><ul><li>Greater omentum adherent to the parietes </li></ul>
  12. 13. Gall Stone ileus
  13. 14. Definition <ul><li>Gall stone obstructing the lumen of bowel, usually the small intestine </li></ul>
  14. 15. Pathogenesis <ul><li>Gall stone erodes the wall of the gall balder and enters the duodenum </li></ul><ul><li>Impaction 60 cm proximal to ileo-cecal junction </li></ul>
  15. 16. Clinical Features <ul><li>Elderly female </li></ul><ul><li>Severe colicky pain </li></ul><ul><li>Recurrent attacks –ball valve obstruction </li></ul><ul><li>Vomiting </li></ul><ul><li>Distension </li></ul><ul><li>Usually no constipation </li></ul>
  16. 17. Investigations <ul><li>Routine </li></ul><ul><li>Plain x-ray abdomen </li></ul><ul><ul><li>Air fluid level with Air in the biliary tree- pneumobilia (diagnostic) </li></ul></ul><ul><ul><li>Gall stone may or may not be seen </li></ul></ul>
  17. 20. <ul><li>CT scan </li></ul>
  18. 21. <ul><li>CT scan </li></ul>
  19. 22. Treatment <ul><li>General measures </li></ul><ul><li>Laparotomy </li></ul><ul><ul><li>Explore by palpating bowel </li></ul></ul><ul><ul><li>Crush the stone without opening bowel </li></ul></ul><ul><ul><li>Enterotomy and removal </li></ul></ul>Do not explore gall bladder
  20. 24. Intussusception <ul><li>Definition: </li></ul><ul><li>Invagination of one portion of the gut within the other and it is usually proximal into the distal bowel; </li></ul><ul><li>Rarely retrograde. </li></ul><ul><li>- Telescoping </li></ul>
  21. 27. Etiology: <ul><li>Primary - Idiopathic </li></ul><ul><li>Seen in children; no lead point </li></ul><ul><li>Peak incidence 3 - 9 months </li></ul><ul><li>Hyperplasia of Payer’s patches in the terminal ileum </li></ul><ul><li>- Secondary to weaning </li></ul><ul><li>- URTI due to adenovirus or rotavirus </li></ul><ul><li>Adults – Secondary </li></ul><ul><li>Meckel’s diverticulum, HS Purpura </li></ul><ul><li>Polyp (Peutz – Jegher syndrome) </li></ul><ul><li>Submucous lipoma , submucous haemorrhage </li></ul><ul><li>Malignancy of the colon </li></ul><ul><li>- Lead point always </li></ul>
  22. 28. Types: <ul><li>Simple - Ileocolic, ileoileal, colocolic </li></ul><ul><li>Retrograde - Jejunogastric </li></ul><ul><li>Compound - Ileoileocolic </li></ul><ul><li>Multiple </li></ul><ul><li>Chronic intussusception </li></ul><ul><li>Recurrent intussusception </li></ul>
  23. 29. Parts of the intussusception: <ul><li>Intussusceptum: Proximal bowel which enters inside – inner tube </li></ul><ul><li>Intussuscipiens : Distal bowel which receives the intestine – outer tube </li></ul><ul><li>Apex: Starting point or the part which advances </li></ul><ul><li>Neck : Narrowest portion </li></ul>
  24. 30. INTUSSUSCEPTUM INTUSSUSCIPIENS NECK APEX LEAD POINT
  25. 32. Pathology: <ul><li>As the intussusception progresses the mesentery is dragged through the neck </li></ul><ul><li>Mucosal ulcers and hemorrhages </li></ul><ul><li>Venous engorgement with oedema of the wall </li></ul><ul><li>Blood and mucous from the wall and will be discharged per rectally – red currant jelly </li></ul><ul><li>Arteries get occluded and gangrene sets in </li></ul><ul><li>Perforation and peritonitis </li></ul>
  26. 33. <ul><li>Strangulating obstruction (compound obstruction ) </li></ul><ul><li>Gangrene sets in at the neck </li></ul><ul><li>Inner layer blood supply get impaired </li></ul>
  27. 34. Clinical features <ul><li>Male child between 3 -9 months of age commonly affected </li></ul><ul><li>Colicky pain abdomen - onset is sudden and the child screams with drawing up of the legs </li></ul><ul><li>Attack lasts for few minutes, recur every 15 minutes and becomes progressively severe. </li></ul><ul><li>Vomiting may or may not be there </li></ul><ul><li>Facial pallor </li></ul><ul><li>Red current jelly stools </li></ul><ul><li>Dehydration, tachycardia </li></ul>
  28. 35. On examination <ul><li>Abdomen </li></ul><ul><li>Visible peristalsis </li></ul><ul><li>Lump may be felt under the right or left coastal margin </li></ul><ul><li>Sausage shaped lump with the concavity towards the umbilicus; mass may disappear </li></ul><ul><li>Sign - de – Dance , Right iliac fossa is empty </li></ul><ul><li>Per rectal </li></ul><ul><li>Blood stained mucous </li></ul><ul><li>Apex of the intussusception may be felt </li></ul><ul><li>Intussusception may protrude from the anus </li></ul>
  29. 37. Investigations <ul><li>Haemogram </li></ul><ul><li>Plain X ray abdomen </li></ul><ul><li>Barium enema - </li></ul><ul><li>Diagnostic and therapeutic </li></ul><ul><li>Pincer shaped filling defect </li></ul><ul><li>( Claw sign / meniscus sign / coiled </li></ul><ul><li>spring appearance) </li></ul>
  30. 43. CT SCAN –YIN YANG SIGN
  31. 44. <ul><li>Ultra sound </li></ul><ul><ul><li>Concentric rings of high and low echogenicity (Target Sign ) </li></ul></ul>
  32. 45. Treatment: <ul><li>Nil per orally </li></ul><ul><li>IV fluids </li></ul><ul><li>Ryle’s tube aspiration </li></ul><ul><li>Electrolytes, Antibiotics </li></ul><ul><li>Hydrostatic reduction </li></ul><ul><li>Contraindicated in </li></ul><ul><li>Presence of obstruction </li></ul><ul><li>Peritonitis </li></ul><ul><li>Gangrene </li></ul><ul><li>Symptoms more than 48 hrs </li></ul>
  33. 46. <ul><li>Hydrostatic reduction - </li></ul><ul><ul><li>Selected cases </li></ul></ul><ul><ul><li>Barium enema </li></ul></ul><ul><ul><li>Infants </li></ul></ul><ul><ul><li>50% success </li></ul></ul>
  34. 47. <ul><li>Hydrostatic reduction - </li></ul><ul><ul><li>Enema can at height </li></ul></ul><ul><ul><li>Push barium rapidly </li></ul></ul><ul><ul><li>Confirm with x-ray </li></ul></ul>
  35. 48. Surgical treatment <ul><li>Laparotomy and reduction of intussusception </li></ul><ul><li>Reduction is done by squeezing the distal part proximally ( Do not pull) </li></ul><ul><li>Last part of the intussusception is the most difficult part to reduce </li></ul><ul><li>Free the adhesions between neck & distal bowel </li></ul><ul><li>Appedicectomy is done </li></ul><ul><li>If the intestine is gangrenous then resection and end to end anastomosis is done </li></ul>
  36. 50. <ul><li>THANK YOU </li></ul>
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