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Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
Adhesions and bands
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Adhesions and bands

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  • 1. <ul><li>INTESTINAL </li></ul><ul><li>OBSTRUCTION </li></ul>
  • 2. <ul><li>ADHESIONS </li></ul>
  • 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. <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. <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. <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. <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. <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. <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>
  • 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>
  • 13. Gall Stone ileus
  • 14. Definition <ul><li>Gall stone obstructing the lumen of bowel, usually the small intestine </li></ul>
  • 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>
  • 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>
  • 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>
  • 18.  
  • 19.  
  • 20. <ul><li>CT scan </li></ul>
  • 21. <ul><li>CT scan </li></ul>
  • 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
  • 23.  
  • 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>
  • 25.  
  • 26.  
  • 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>
  • 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>
  • 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>
  • 30. INTUSSUSCEPTUM INTUSSUSCIPIENS NECK APEX LEAD POINT
  • 31.  
  • 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>
  • 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>
  • 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>
  • 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>
  • 36.  
  • 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>
  • 38.  
  • 39.  
  • 40.  
  • 41.  
  • 42.  
  • 43. CT SCAN –YIN YANG SIGN
  • 44. <ul><li>Ultra sound </li></ul><ul><ul><li>Concentric rings of high and low echogenicity (Target Sign ) </li></ul></ul>
  • 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>
  • 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>
  • 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>
  • 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>
  • 49.  
  • 50. <ul><li>THANK YOU </li></ul>

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