Adhesions and bands

INTESTINAL
OBSTRUCTION

ADHESIONS

Aetiology
Iatrogenic (Post operative) :
Individual susceptibility
May be induced by talc (powder from
gloves), cotton or linen (surgical
mops, suture material)
Inflammatory / Infections :
Following appendicitis and PID
Following peritonitis (specially biliary)
Plastic type of peritoneal tuberculosis

Ischaemia :
Arterial or venous occlussion
Occurs at sites of anastomoses
Ischaemia due to mobilisation of peritoneum
Irradiation :
Radiation enteritis
Drugs :
Practolol

Types
Fibrinous :
Early
Easy to do adhesiolysis / flimsy
May reduce over time
Fibrous :
Occurs later
Difficult to do adhesiolysis / dense
No tendency to improve over time
Occurs due to associated ischaemia and
vascular ingrowth and replacement
with mature fibrous tissue

Treatment - Medical
Monitor the vital signs :
TPR / BP / IO / Abdominal girth chart
Nil Per Oral
Nasogastric tube (Ryle’s tube) insertion and
dependent drainage. Intermittent (fourth
hourly) aspiration
IV fluid supplement : Ringer’s lactate or
Normal saline
Antibiotics if strangulation suspected
Reassess periodically

Treatment – Surgical
Indications :
When conservative treatment for 3 to 5
days does not result in resolution
When strangulation is suspected / cannot
be ruled out

Treatment – Surgical
Emergency exploratory laparotomy
Adhesiolysis / Enterolysis
Resect the strangulated bowel and do
end to end anastomosis
Handle the bowel carefully (less abrasion)
Do not produce ischaemia of peritoneum
Do not mobilize and suture peritoneum
Do thorough peritoneal lavage with saline
Instillation of inhibitors - controversial

Treatment for recurrent intestinal obstruction due to adhesions
Repeat Adhesiolysis / Enterolysis
Noble’s plication
Charles – Phillips transmesentric plication
Intestinal intubation

Aetiology
Congenital :
Ladds bands
Obliterated vitellointestinal duct
Mesodiverticular band
Inflammatory :
A string band following bacterial peritonitis
Greater omentum adherent to the parietes

Gall Stone ileus

Definition
Gall stone obstructing the lumen of bowel, usually the small intestine

Pathogenesis
Gall stone erodes the wall of the gall balder and enters the duodenum
Impaction 60 cm proximal to ileo-cecal junction

Clinical Features
Elderly female
Severe colicky pain
Recurrent attacks –ball valve obstruction
Vomiting
Distension
Usually no constipation

Investigations
Routine
Plain x-ray abdomen
Air fluid level with Air in the biliary tree- pneumobilia (diagnostic)
Gall stone may or may not be seen

CT scan

Treatment
General measures
Laparotomy
Explore by palpating bowel
Crush the stone without opening bowel
Enterotomy and removal
Do not explore gall bladder

Intussusception
Definition:
Invagination of one portion of the gut within the other and it is usually proximal into the distal bowel;
Rarely retrograde.
- Telescoping

Etiology:
Primary - Idiopathic
Seen in children; no lead point
Peak incidence 3 - 9 months
Hyperplasia of Payer’s patches in the terminal ileum
- Secondary to weaning
- URTI due to adenovirus or rotavirus
Adults – Secondary
Meckel’s diverticulum, HS Purpura
Polyp (Peutz – Jegher syndrome)
Submucous lipoma , submucous haemorrhage
Malignancy of the colon
- Lead point always

Types:
Simple - Ileocolic, ileoileal, colocolic
Retrograde - Jejunogastric
Compound - Ileoileocolic
Multiple
Chronic intussusception
Recurrent intussusception

Parts of the intussusception:
Intussusceptum: Proximal bowel which enters inside – inner tube
Intussuscipiens : Distal bowel which receives the intestine – outer tube
Apex: Starting point or the part which advances
Neck : Narrowest portion

INTUSSUSCEPTUM INTUSSUSCIPIENS NECK APEX LEAD POINT

Pathology:
As the intussusception progresses the mesentery is dragged through the neck
Mucosal ulcers and hemorrhages
Venous engorgement with oedema of the wall
Blood and mucous from the wall and will be discharged per rectally – red currant jelly
Arteries get occluded and gangrene sets in
Perforation and peritonitis

Strangulating obstruction (compound obstruction )
Gangrene sets in at the neck
Inner layer blood supply get impaired

Clinical features
Male child between 3 -9 months of age commonly affected
Colicky pain abdomen - onset is sudden and the child screams with drawing up of the legs
Attack lasts for few minutes, recur every 15 minutes and becomes progressively severe.
Vomiting may or may not be there
Facial pallor
Red current jelly stools
Dehydration, tachycardia

On examination
Abdomen
Visible peristalsis
Lump may be felt under the right or left coastal margin
Sausage shaped lump with the concavity towards the umbilicus; mass may disappear
Sign - de – Dance , Right iliac fossa is empty
Per rectal
Blood stained mucous
Apex of the intussusception may be felt
Intussusception may protrude from the anus

Investigations
Haemogram
Plain X ray abdomen
Barium enema -
Diagnostic and therapeutic
Pincer shaped filling defect
( Claw sign / meniscus sign / coiled
spring appearance)

CT SCAN –YIN YANG SIGN

Ultra sound
Concentric rings of high and low echogenicity (Target Sign )

Treatment:
Nil per orally
IV fluids
Ryle’s tube aspiration
Electrolytes, Antibiotics
Hydrostatic reduction
Contraindicated in
Presence of obstruction
Peritonitis
Gangrene
Symptoms more than 48 hrs

Hydrostatic reduction -
Selected cases
Barium enema
Infants
50% success

Hydrostatic reduction -
Enema can at height
Push barium rapidly
Confirm with x-ray

Surgical treatment
Laparotomy and reduction of intussusception
Reduction is done by squeezing the distal part proximally ( Do not pull)
Last part of the intussusception is the most difficult part to reduce
Free the adhesions between neck & distal bowel
Appedicectomy is done
If the intestine is gangrenous then resection and end to end anastomosis is done

THANK YOU

Adhesions and bands

by kcmct20 on Jul 17, 2011

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Adhesions and bands Presentation Transcript