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Intestinal obstruction

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  • Intramural: within the walls of a cavity or hollow organ Extramural: Occurring or situated outside of the walls or boundaries - Bezoars  are retained concretions of undigested vegetable material, hair, fruit or other ingested materials that forms in the gastrointestinal tract
  • Proximal bowel dilates & develops an altered motility. Below the obs, the bowel exhibits normal peristalsis & absorption until it becomes empty  it contracts & become immobile Initially, proximal peristalsis is increased to overcome the obs. If the obs is not relieved, the bowel begins to dilate  reduction in peristaltic strength  flaccidity & paralysis This is a protective phenomenon to prevent vascular damage 2° to increased intraluminal pressure
  • Radiation enteritis  is a bowel pathology resulting from toxic effects of radiotherapy on the bowel wall and vasculature In the acute phase, radiation affects bowel mucosa causing cell death with ulceration. It also causes inflammation with mucosal and submucosal oedema. In the subacute and chronic phases healing and fibrosis occurs. Additionally  radiation induces endarteritis obliterans, which results in a state of chronic mesenteric ischaemia leading to bowel strictures. The clinical presentation is nonspecific with abdominal pain, vomiting, bloody diarrhoea and steatorrhoea. Patients with chronic radiation enteritis may develop deficiencies of calcium, iron and vitamin B12 deficiency.
  • -volvulus: Intestinal volvulus is defined as a complete twisting of a loop of intestine around its mesenteric attachment site. -incarceration: passage of a loop of intestine through a small orifice, e.g. inguinal canal, with resulting swelling, obstruction and occlusion of blood supply -Obstruction: partial or complete blockage of the bowel that prevents the contents of the intestine from passing through -intussusception: process in which there is telescoping of a proximal segment of intestine invaginates into the (distal) adjoining intestinal lumen
  •   indicate whether it is a high or low small bowel obstruction by the presence of jejunal loops (distinguished by prominent plicae semicircularis) only, or both jejunum and smooth-walled ileum. Caecal tumours present with small bowel obstruction Colicky central abdominal pain Early vomiting Late absolute constipation Variable extent of distension Left sided tumours present with large bowel obstruction Change in bowel habit Absolute constipation Abdominal distension Late vomiting
  • Small bowel: approximately 2.5–3 cm in diameter. Large bowel: app 6.3cm
  • The upper limit of normal diameter of the bowel is generally accepted as 3cm for the small bowel, 6cm for the colon and 9cm for the caecum (3/6/9 rule).
  • Immediate intervention: Evidence of strangulation (hernia….etc) Signs of peritonitis resulting from perforation or ischemia In the next 24-48 hours Clear indication of no resolution of obstruction ( Clinical, radiological). Diagnosis is unclear in a virgin abdomen Viable: -dark color comes lighter, peristalsis, shiny peritoneum, maesentery bleeds if pricked, firm intestinal musculature, pressure ring may or may not disappear Non viable: -dark color remains, no peristalsis, dull and lusterless peritoneum, no bleeding if mesentery is pricked, flabby, thin, and friable intestinal musculature, pressure ring persist. Resuscitation then opened abdomen through midline incision Assess caecum : distension means large bowel involvement Removable lesion found in caecum, ascending colon, or proximal transverse colon  right hemicolectomy should be performed Lesions is irremovable, a proximal stoma or ileo transverse bypass should be considered
  • Postoperative: only 24 to 72 hours. Prolonged in hypoproteinemia, and metabolic abnormality Infection: intraabdominal sepsis Metabolic: uremia and hypokalemia Reflex ileus: spine, rib, retroperitoneal hemorrhage and application of plaster jacket
  • Transcript

    • 1. INTESTINAL OBSTRUCTION R.NANDINII GROUP K1
    • 2. OVERVIEW: •CLASSIFICATION •COMMON CAUSES OF OBSTRUCTION •CLINICAL FEATURES •INVESTIGATION •TREATMENT
    • 3. Accounts for 5% of all acute surgical admissions Patients are often extremely ill requiring prompt assessment, resuscitation and intensive monitoring Obstruction A mechanical blockage arising from a structural abnormality that presents a physical barrier to the progression of gut contents. Ileus is a paralytic or functional variety of obstruction Obstruction is: -Partial or complete -Simple or strangulated INTRODUCTION
    • 4. CLASSIFICATION
    • 5. DYNAMIC OBSTRUCTIONDYNAMIC OBSTRUCTION (MECHANICAL)(MECHANICAL)
    • 6. CAUSES OF I.O (DYNAMIC)CAUSES OF I.O (DYNAMIC)
    • 7. PATHOPHYSIOLOGY:
    • 8. OBSTRUCTION BY ADHESIONS • Peritoneal irritation local fibrin production produces adhesions between apposed surfaces • As early as 4 weeks post laparotomy. The majority of patients present between 1-5 years Colorectal Surgery 25% Gynaecological 20% Appendectomy 14% • Prevention: good surgical technique, washing of the peritoneal cavity with saline to remove clots, etc, minimizing contact w/ gauze, covering anastomosis & raw peritoneal surfaces
    • 9. TREATMENT OF ADHESIVE OBSTRUCTION INITIALLY TREAT CONSERVATIVELY PROVIDED THERE IS NO SIGNS OF STRANGULATION; SHOULD RARELY CONTINUE CONSERVATIVE TREATMENT FOR LONGER THAN 72 HOURS AT OPERATION, DIVIDE ONLY THE CAUSATIVE ADHESION AND LIMIT DISSECTION LAPAROSCOPIC ADHESIOLYSIS IN CASES OF CHRONIC SUBACUTE OBSTRUCTION
    • 10. HERNIA • ACCOUNTS FOR 20% OF SBO • COMMONEST 1. FEMORAL HERNIA 2. ID INGUINAL 3. UMBILICAL 4. OTHERS: INCISIONAL • THE SITE OF OBSTRUCTION IS THE NECK OF HERNIA • THE COMPROMISED VISCUS IS WITH IN THE SAC. • ISCHAEMIA OCCURS INITIALLY BY VENOUS OCCLUSION, FOLLOWED BY OEDEMA AND ARTERIALC OMPROMISE. • ATTEMPT TO DISTINGUISH THE DIFFERENCE BETWEEN: • INCARCERATION • SLIDING • OBSTRUCTION • STRANGULATION IS NOTED BY: • PERSISTENT PAIN • DISCOLOURATION • TENDERNESS • CONSTITUTIONAL SYMPTOMS
    • 11. VOLVULUS A TWISTING OR AXIAL ROTATION OF A PORTION OF BOWEL ABOUT ITS MESENTERY. WHEN COMPLETE IT FORMS A CLOSED LOOP OBSTRUCTION ISCHEMIA CAN BE PRIMARY OR SECONDARY:  1°: CONGENITAL MALFORMATION OF THE GUT (E.G: VOLVULUS NEONATORUM, CECAL OR SIGMOID VOLVULUS)  2°: MORE COMMON, DUE TO ROTATION OF A PIECE OF BOWEL AROUND AN ACQUIRED ADHESION OR STOMA COMMONEST SPONTANEOUS TYPE IN ADULT IS SIGMOID, CAN BE RELIEVED BY DECOMPRESSION PER ANUM SURGERY IS REQUIRED TO PREVENT Features: palpable tympanic lump (sausage shape) in the midline orleft side of abdomen. Constipation, abdominal distension (early & progressive)
    • 12. ACUTE INTUSSUSCEPTIONACUTE INTUSSUSCEPTION OCCURS WHEN ONE PORTION OF THE GUT BECOMES INVAGINATED WITHIN AN IMMEDIATELY ADJACENT SEGMENT. COMMON IN 1ST YEAR OF LIFE COMMON AFTER VIRAL ILLNESS ENLARGEMENT OF PEYER’S PATCHES ILEOCOLIC IS THE COMMONEST VARIETY IN CHILD. COLOCOLIC INTUSSUSCEPTION COMMONEST IN ADULT An intussusception is composed of three parts : the entering or inner tube; the returning or middle tube; the sheath or outer tube (intussuscipiens).
    • 13. CLASSICALLY, A PREVIOUSLY HEALTHY INFANT PRESENTS WITH COLICKY PAIN ANDVOMITING (MILK THEN BILE). BETWEEN EPISODES THE CHILD INITIALLY APPEARS WELL. LATER, THEY MAY PASS A ‘REDCURRANT JELLY’ STOOL. Red currant jelly stools
    • 14. LARGE BOWEL OBSTRUCTION • DISTINGUISHING ILEUS FROMMECHANICAL OBSTRUCTION IS CHALLENGING • ACCORDING TOLAPLACE’S LAW: MAXIMUMPRESSURE IS AT THE MAXIMUMDIAMETERAREA CAECUMIS AT THE GREATEST RISKOF PERFORATION • PERFORATION RESULTS IN THE RELEASE OF FORMEDFEACES WITHHEAVY BACTERIAL CONTAMINATION AETIOLOGY: 1. CARCINOMA: THE COMMONEST CAUSE, 18% OF COLONIC CA. PRESENT WITHOBSTRUCTION 2. BENIGN STRICTURE: DUE TODIVERTICULARDISEASE, ISCHEMIA, INFLAMMATORY BOWEL DISEASE. 3. VOLVULUS: -SIGMOIDVOLVULUS/CAECAL VOLVULUS 4. HERNIA. 5. CONGENITAL : HIRSCHPRUNG, ANAL STENOSIS ANDAGENESIS
    • 15. HIGHSMALL BOWEL OBSTRUCTION VOMITING OCCURS EARLY ANDIS PROFUSE WITH RAPIDDEHYDRATION. DISTENSION IS MINIMAL WITHLITTLE EVIDENCE OF FLUIDLEVELS ON ABDOMINAL RADIOGRAPHY LOWSMALL BOWEL OBSTRUCTION PAIN IS PREDOMINANT WITHCENTRAL DISTENSION. VOMITING IS DELAYED. MULTIPLE CENTRAL FLUIDLEVELS ARE SEEN ON RADIOGRAPHY LARGE BOWEL OBSTRUCTION DISTENSION IS EARLY ANDPRONOUNCED. PAIN IS MILDANDVOMITING ANDDEHYDRATION ARE LATE. THE PROXIMAL COLON ANDCAECUMARE DISTENDED ON ABDOMINAL RADIOGRAPHY CLINICAL FEATURESCLINICAL FEATURES CARDINAL FEATURES: Colicky pain Vomiting Abd distention Constipation OTHER FEATURES: Dehydration Hypokalaemia Pyrexia Abd tenderness
    • 16. PHYSICAL EXAMINATIONPHYSICAL EXAMINATION INSPECTION ABDOMINAL DISTENTION, SCARS, VISIBLE PERISTALSIS. PALPATION MASS, TENDERNESS, GUARDING PERCUSSION TYMPHANIC, DULLNESS AUSCULTATION BOWEL SOUND ARE HIGH PITCH AND INCREASE IN
    • 17. INVESTIGATIONS: • LAB: • FBC (LEUKOCYTOSIS, ANAEMIA, HEMATOCRIT, PLATELETS) • CLOTTING PROFILE • ARTERIAL BLOOD GASSES • U& CRT, NA, K, AMYLASE, LFT AND GLUCOSE, LDH • GROUP AND SAVE (X-MATCH IF NEEDED) • OPTIONAL (ESR, CRP, HEPATITIS PROFILE) • RADIOLOGICAL: • PLAIN ABDOMINAL XRAYS • USS ( FREE FLUID, MASSES, MUCOSAL FOLDS, PATTERN OF PARISTALSIS, DOPPLER OF MESENTERIC VASULATURE, SOLID ORGANS) • OTHER ADVANCED STUDIES (CT, MRI, CONTRAST STUDIES)
    • 18. Fluid levels with gas above; ‘stepladder pattern’. Ileal obstruction by adhesions; patient erect.  Supine radiograph from a patient with complete small bowel obstruction shows distended small bowel loops in the central abdomen with prominent valvulae conniventes (small white arrow)  Figure 3. Lateral decubitus view of the abdomen, showing air-fluid levels consistent with intestinal obstruction (arro ws).
    • 19. THE DIFFERENCE BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION Large bowel Small Bowel •Peripheral ( diameter 6 cm max) •Presence of haustration •Central ( diameter 3 cm max) •Vulvulae coniventae •Ileum: may appear tubeless
    • 20. ROLE OF CT • USED WITH IV CONTRAST, ORAL AND RECTAL CONTRAST (TRIPLE CONTRAST). • ABLE TO DEMONSTRATE ABNORMALITY IN THE BOWEL WALL, MESENTERY, MESENTERIC VESSELS AND PERITONEUM. • IT CAN DEFINE: • THE LEVEL OF OBSTRUCTION • THE DEGREE OF OBSTRUCTION • THE CAUSE: VOLVULUS, HERNIA, LUMINAL AND MURAL CAUSES • THE DEGREE OF ISCHAEMIA • FREE FLUID AND GAS • ENSURE: PATIENT VITALLY STABLE WITH NO RENAL FAILURE AND NO PREVIOUS ALERGY TO IODINE • FIGURE: AXIAL COMPUTED TOMOGRAPHY SCAN SHOWING DILATED, CONTRAST-FILLED LOOPS OF BOWEL ON THE PATIENT’S LEFT (YELLO W ARRO WS), WITH DECOMPRESSED DISTAL SMALL BOWEL ON THE PATIENT’S RIGHT (RED ARROWS). THE CAUSE OF OBSTRUCTION, AN INCARCERATED UMBILICAL HERNIA, CAN ALSO BE SEEN (GREENARRO W), WITH PROXIMALLY DILATED BOWEL ENTERING THE HERNIA AND DECOMPRESSED BOWEL EXITING THE HERNIA.Source: Jackson, PG. & Raiji M., Evaluation and Management of Intestinal Obstruction, January 2011, American Academy of Family Physicians
    • 21. ROLE OF BARIUM GASTROGRAFIN STUDIES • AS: FOLLOW THROUGH, ENEMA • LIMITED USE IN THE ACUTE SETTING • GASTROGRAFIN IS USED IN ACUTE ABDOMEN BUT IS DILUTED • USEFUL IN RECURRENT AND CHRONIC OBSTRUCTION • MAY ABLE TO DEFINE THE LEVEL AND MURAL CAUSES. • CAN BE USED TO DISTINGUISH ADYNAMIC AND MECHANICAL OBSTRUCTION Barium should not be used in a patient with peritonitis
    • 22. Source: Jackson, PG. & Raiji M., Evaluation and Management of Intestinal Obstruction, January 2011, American Academy of Family Physicians
    • 23. Source: Jackson, PG. & Raiji M., Evaluation and Management of Intestinal Obstruction, January 2011, American Academy of Family Physicians
    • 24. • SUPPORTIVE 1. RESUSCITATION 2. RYLE TUBE FREE FLOW WITH 4 HOURLY ASPIRATION -DECOMPRESSION OF PROXIMAL TO THE OBSTRUCTION, REDUCE SUBSEQUENT ASPIRATION DURING INDUCTION OF ANESTHESIA AND POST EXTUBATION. 3. IV DRIP NORMAL SALINE / HARTMANN (SODIUM & WATER LOSS DURING IO) 4. BROAD SPECTRUM ANTIBIOTIC (NOT MANDATORY BUT NEED IN ALL PATIENT UNDERGOING SURGERY. TREATMENT OF INTESTINAL OBSTRUCTION
    • 25. • SURGICAL IND: OBSTRUCTED/STRANGULATEDEXTERNAL HERNIA, INTERNAL INTESTINAL STRANGULATION ANDACUTE OBSTRUCTION 1.MIDLINE INCISION USUALLY LOOK ON CAECUM 2.OPERATIVE DECOMPRESSION 3.LOOK AT VIABILITY OF INTESTINE 4.LARGE BOWEL OBSTRUCTION: COLOSTOMY
    • 26. INDICATIONS FOR SURGERY • ABSOLUTE • GENERALISED PERITONITIS • LOCALISED PERITONITIS • VISCERAL PERFORATION • IRREDUCIBLE HERNIA • RELATIVE • PALPABLE MASS LESION • 'VIRGIN' ABDOMEN • FAILURE TO IMPROVE • TRIAL OF CONSERVATISM • INCOMPLETE OBSTRUCTION • PREVIOUS SURGERY • ADVANCED MALIGNANCY • DIAGNOSTIC DOUBT - POSSIBLE ILEUS Source: http: Surgical Tutor.co.uk
    • 27. MANAGEMENT FORLARGE BOWEL OBSTRUCTIONAll patients require •Adequate resuscitation •Prophylactic antibiotics •Consenting and marking for potential stoma formation •At operation •Full laparotomy should be performed •Liver should be palpated for metastases •Colon should be inspected for synchronous tumours •Appropriate operations include: •Right sided lesions – right hemicolectomy •Transverse colonic lesion – extended right hemicolectomy •Left sided lesions – various options Source: http: Surgical Tutor.co.uk
    • 28. Three-staged procedure •Defunctioning colostomy •Resection and anastomosis •Closure of colostomy Two-staged procedure •Hartmann’s procedure •Closure of colostomy One-stage procedure •Resection, on-table lavage and primary anastomosis •Three stage procedure will involve 3 operations! •Associated with prolonged total hospital stay •Transverse loop colostomy can be difficult to manage •With two-staged procedure only 60% of stomas are ever reversed •With one-stage procedure stoma is avoided •Anastomotic leak rate of less than 4% have been reported •Irrespective of option total perioperative mortality is about 10% Source: http: Surgical Tutor.co.uk
    • 29. COMPLICATIONS ASSOCIATEDWITH INTESTINAL OBSTRUCTION REPAIR • INCLUDE EXCESSIVE BLEEDING • INFECTION • FORMATION OF ABSCESSES (POCKETS OF PUS) • LEAKAGE OF STOOL FROM AN ANASTOMOSIS • ADHESION FORMATION • PARALYTIC ILEUS (TEMPORARY PARALYSIS OF THE INTESTINES) • REOCCURRENCE OF THE OBSTRUCTION. Source: http://www.surgeryencyclopedia.com/Fi-La/Intestinal-Obstruction-Repair.html
    • 30. PARALYTIC ILEUS A STATE IN WHICH THERE IS A FAILURE OF TRANSMISSION OF PERISTALTIC WAVES 2° TONEUROMUSCULARFAILURE ( IN AUERBACH’S AND MEISSNER’S PLEXUSES) STASIS  LEADS TO ACCUMULATION OF FLUID AND GAS WITHIN BOWEL A/W DISTENSION, VOMITING, ABSENCE OF BOWEL SOUND AND ABSOLUTE CONSTIPATION VARIETIES FACTORS: POSTOPERATIVE, INFECTION, REFLEX ILEUS AND METABOLIC RADIOLOGICAL: GAS FILLED LOOPS OF INTESTINES WITH MULTIPLE FLUID LEVELS
    • 31. MANAGEMENT: ESSENCE OF TREATMENT PREVENTION WITH USE OF NASOGASTRIC SUCTION AND RESTRICTION OF ORAL INTAKE UNTIL BOWEL SOUND AND PASSAGE OF FLATUS RETURN MAINTAIN ELECTROLYTE BALANCE SPECIFIC TREATMENT: • REMOVED PRIMARY CAUSE • DECOMPRESSED GI DISTENSION • IF PROLONG PARALYTIC ILEUS , CONSIDER LAPAROTOMY EXCLUDE HIDDEN CAUSE AND FACILITATE BOWEL DECOMPRESSION
    • 32. PSEUDO-OBSTRUCTION OBSTRUCTION USUALLY COLON- OCCUR IN THE ABSENCE OF MECHANICAL CAUSE OR ACUTE INTRA-ABDOMINAL DISEASE. ASSOCIATED WITH A VARIETY OF SYNDROMES IN WHICH THERE IS UNDERLYING NEUROPATHY AND/OR A RANGE OF OTHER FACTORS IDIOPATHIC SEPTICAEMIA Metabolic Retroperitoneal irritation Severe trauma at lumbar area Drugs Shock Secondary GI involvement
    • 33. Small intestinal pseudo-obstruction Colonic pseudo-obstruction (Ogilvie’s syndrome, ) This condition may be primary (i.e. idiopathic or associated with familial visceral myopathy) or secondary. The clinical picture consists of recurrent subacute obstruction.  The diagnosis is made by the exclusion of a mechanical cause. Treatment consists of initial correction of any underlying disorder. Metoclopramide and erythromycin may be of use. This may occur in an acute or a chronic form. presents as acute large bowel obstruction. Abdominal radiographs show evidence of colonic obstruction, with marked caecal distension being a common feature. AXR shows colonic obstruction with marked caecal distension Confirmation of absence mechanical cause by colonoscopy or single contrast water soluble barium enema or CT. Once confirmed, treated by colonoscopic decompression
    • 34. ACUTE MESENTERIC OCCLUSION • ACUTE ISCHEMIC OF MESENTERIC VESSEL. COMMONLY SMA • CAUSES: AF, MURAL THROMBOSIS, ATHEROMATOUS PLAQUE FROM AORTIC ANEURYSM AND VALAVE VEGETATION FROM ENDOCARDITIS • FEATURES: -SUDDEN ONSET OF SEVERE ABD. PAIN IN PT WITH AF AND ATHEROSCLEROSIS -PERSISTENT VOMITING AND DEFECATION THEN PASSAGE OF ALTERED BLOOD -HYPOVOLUMIC SHOCK • INVESTIGATIONS: - NEUTROPHIL LEUKOCYTOSIS - ABD XRAY: ABSENCE OF GAS IN THICKENED SMALL INTESTINES • TREATMENT: - ANTI-COAGULANT - EMBOLECTOMY - REVASCULARIZATION