Dr Praveen Choudhary
When there is pathological interference with
the normal progression of the intestinal
luminal contents distally, the condition is
called intestinal obstruction.
Intestinal obstruction may be classified into two types:
1. Dynamic/Mechanical obstruction.
2. Adynamic obstruction.
I.Intraluminal (obstruction in the human).
II.Intramural (lesion of bowel wall).
III.Extramural (lesion extrinsic to the bowel).
Peristalsis may be absent e.g. paralytic ileus.
Peristalsis may be present in a non propulsive form.
I. Intraluminal Obstruction
c) Gall stones.
d) Polypoid Tumour of bowel.
f) Impaction of barium/worms/foreign
Classification of Intestinal obstruction can be
made as follow: 1. Simple mechanical obstruction.
2. Strangulated obstruction.
3. Closed loop obstruction.
Clinically obstruction may be classified into two
Small Bowel obstruction – high or low
Large Bowel obstruction
Presentation may be :1. Acute.
3. Acute on Chronic.
Increased bowel motility
Does not relieve
Clinical Features Of Strangulation
v Pain is never completely absent.
In early stage „visible peristalsis is the only sign.
Abdominal distension is the late sign.
Hernial orfices, surgical scars must be inspected.
During colic there may be muscle guarding. Slight tenderness may be present
between attacks of pain.
Tenderness and rigidity at the sight of obstruction usually indicates strangulation.
Only reveals resonant note of gaseous distension of bowel.
Presence of loud borborygmi, conciding with intestinal colic is very diagnostic.
In case of intestinal obstruction “Silent abdomen” suggests paralytic ileus.
Presence of mass on rectal examination within or
outside the lumen will give a clue to diagnosis.
Presence or absence of feaces in rectum should be
noted. Absence means obstruction is higher up. If
present it should be studied for presence of occult
blood, which include mucosal lesion e.g. cancer,
intussusception or infarction. Sigmoidoscopy should
be done if colonic obstruction is suspected.
(1) Blood Examination
(2) Radiological Examination
There are three main measures: 1. Gastrointestinal drainage.
2. Fluid and electrolyte replacement.
3. Relief of obstruction (surgical).
Fluid And Electrolytic Replacement
Cause for Adhesions
2. Foreign material
3. Infection & Inflammation
4. Radiation enteritis
Cause for Bands
A string band following previous bacterial peritonitis.
A portion of greater omentum usually adherent to
Initial management of Adhesions And Bands is based
on I.V. rehydration and nasogastric decompression.
When obstruction is caused by an area of multiple
adhesions, they should be freed by sharp dissection.
To prevent recurrence the bare area should be covered
with omental grafts.Following release of band
obstruction, the constriction sites that have suffered
direct compression should be carefully assessed
Recurrent Obstruction Due
Repeat adhesiolysis (enterolysis) alone.
Noble‟s plication operation.
Charles – Phillips transmesentric
Special Types Of
1. Internal Hernia
2. Obstruction From Enteric Strictures
3. Bolus Obstruction
4. Acute Intussusception
Internal herniation occurs where a portion of
the small intestine becomes entrapped in one
of the retroperitoneal fossae or into a
congenital mesenteric defect.
Treatment : The standard treatment for a hernia
is to release the constricting agent by division.
Small bowel strictures usually occur secondary to
tuberculosis or Crohn‟s disease presentation is usually
subacute or chronic.
Treatment : Standard surgical management consist of
resection and anastomosis.
Bolus obstruction in small bowel may be caused by
food, gallstone, Bezoars, stercolith and worms.
Treatment : In case of stone or food, after milking the
stone proximally, crush the stone if possible. If not, the
intestine is opened and the gallstone disimpacted, milked
back and removed. In case of Bezoars or stercolith,
Lesion may be kneaded, if possible otherwise open
removal is required.
When one portion of the gut invaginates into
immediately adjacent loop, the condition is called
Hydrostatic Reduction : Barium enema
be used for hydrostatic reduction of
After preoperative rescescitation a midline incision is
used for proper exposure.Reduction is achieved by
squeezing the most distal part.
Cope,s method is used in difficult cases
A volvulus is a twisting or axial rotation of a portion of bowel
about its mesentry. When complete it forms a closed loop of
obstruction with resultant ischemia secondary to vascular
1. Primary Volvulus
1. Congential malrotationof gut.
2. Abnormal mesentric attachments.
3. Congential bands.
Example : Volvulus neonatorum, caecal & sigmoid volvulus.
Cause:Actual rotation of a piece of bowel around an acquired
adhesion or stoma.
It is predisposed to by arrested gut rotation with a resultant
narrow mesentry of small bowel and caecum. Surgical
Operation consist of reduction by untwisting and division of
any secondary obstructive lesions such as transduodenal band
Volvulus of small intestine
This may be primary or secondary & usually occurs in lower
Treatment: Treatment consist of reduction of the twist and is
than directed to underlying cause.
May occur as a part of volvulus neonatorum or denavo.
At operation the volvulus should be reduced. Further
management consist of either fixation of caecum to right iliac
fossa(caecopaxy) or a caecostomy.
It occurs mainly due to band of adhesions.
Flexible sigmoidoscopy or rigid sigmoidoscopy and insertion
of a flatus tube should be carried out to allow deflation of gut.
Also known as ileosigmoid knotting. The long pelvic
mesocolon allow the ileum to twist around the sigmoid colon
resulting in gangrene of either or both segments of bowel.
At operation decompression, resection and anastomosis are
It may be defined as a state in which there is failure of
transmission of peristaltic waves secondary to neuromuscular
Following varieties are recognised :
2. Infection: Intra-abdominal sepsis
3. Reflex ileus
4.Matabolic: Uraemia & Hypokalaemia are commonest
The essence of treatment is prevention with the use of
nasogastric suction and restriction of the oral intake untill
bowel sounds and passage of flatus return.Treatment is
according to cause
but following general principle apply:1. Primary cause must be removed.
2. Gastrointestinal distension must be relieved.
3. Close attention to fluid and electrolyte balance is essential.
4. Use of peristalsis stimulant is recommended only in
5. If paralytic ileus is prolonged, a laparotomy should be
considered to exclude a hidden cause and facilitate bowel
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