INTESTINAL OBSTRUCTION TYPES Classification I: Depending on Aetiopathology Dynamic. Adynamic Dynamic Outside the wall Hernia—25% Adhesions—40% Volvulus Intussusception

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INTESTINAL
OBSTRUCTION

2. INTESTINAL
OBSTRUCTION

3. INTESTINALOBSTRUCTION
TYPES
ClassificationI: Depending on
Aetiopathology
A. Dynamic.
B. Adynamic
Dynamic
Outside the wall
• Hernia—25%
• Adhesions—40%
• Volvulus
• Intussusception
In the wall
• Tuberculous stricture
• Crohn’s disease
• Malignancy
In the lumen
• Gallstones
• Roundworm
• Inspissatedfaeces
• Meconiumileus.
Adynamic
• Cessation of peristalsis
• Postoperative period
• Electrolyte imbalance
• Spinal injuries

4. • Uraemia
• Diabetes mellitus
• Retroperitoneal—
haematomas and surgeries
• Renal surgeries
• Mesentericischaemia
• Pseudo-obstruction
ClassificationII: Depending on
Type of Obstruction
1. Acute: Commonin small
bowel.
2. Chronic.
3. Acute on chronic:
Common in large bowel.
4. Closedloop obstruction.
ClassificationIII: Depending on
Site of Obstruction
1. Proximal Small bowel.
• Duodenumand Jejunum-
Proximal Small bowel.
• Causes
• Congenital
• Lipomas
• Leiomyomas
• Malignancy, Bands and
adhesions.
• Clinical Features
• Severe Vomitting
• Dehydration

5. • NO or Less Distention
• ColickyPain.
• SPECIAL FEATURES
• XRAY- Valvulae
conniventes.
2.Distal Small bowel;
• Ileum.
• Causes
• Tuberculosis Strictures,
• Maliganancy,
• Crohns
• Gallstones
• Hernias
• Round worms
• congenital.
• Clinical Features
• Central Distension,
• Vomiting
• Dehydration
• Central Abdominal
Pain.
• SPECIAL FEATURES
• XRAY- Central Fluid
level.
3. Large Bowel;
• Any where Large Intestine.
• Causes
• Malignancy
• TB Strictures

6. • Anorectal Malformation
• Volvulus
• Congenital
Malformation.
• Clinical Features
• Constipation
• Distension
• Late vomitting
• less pain
• SPECIALFEATURES
• XRAY-Dilatation,
Haustration.
ClassificationIV
A. Congenital.
B. Acquired.
Congenital
• Anorectal malformations
• Congenital megacolon
• Duodenal atresia
• Intestinal atresia (ileal)
• Bands and adhesions
Malrotation
• Volvulus neonatorum.

7. Acquired
• Hernia
• Postoperative
• Intussusception
• Roundworms
• Gallstones
• Tuberculosis
• Maliganancy
• Internal Hernias.
DYNAMICOBTRUCTION
DEFINITION
• It is mechanical blockage of
normal propulsion and
passage of intestinal
contents.

8. TYPES
• Obstructionmay be
• external/internal
• partial (incompleteor
subacute)/complete
• acute/acute on chronic/or
chronic
• simple/closed
loop/strangulation
• congenital/acquired
• proximal/distal.
CAUSES
• hernia
• adhesions
• Adhesions commonly cause
small bowel obstruction
thanlargebowel.
• 80% intestinal obstruction
occurs in small bowel; 20%
in colon. 70% of colonic
obstruction is due to
malignancy.
• Other 30%is due to
volvulus
• Diverticulitis

9. • inflammatorycauselike
tuberculosis, etc.
• Mortality is 3% in
obstruction without
strangulation
• 30% in obstructionwith
strangulation.
• Recurrent obstruction is
more commonin
adhesions
PATHOLOGY
• Changes proximal to the
bowel obstruction
↓
Intestinal obstruction
↓
Increasedperistalsis
↓
Becomes vigorous
↓
Obstructionnot relieved
↓
Peristalsis ceases - Flaccid,
paralysed, dilated bowel

10. ↓
Fluid collects just proximal to
the obstructionwhichis
derivedfromsaliva, stomach,
pancreasand intestine
↓
Because of oedema and
inflammationabsorption
decreases
↓
sequestrationof fluidfromthe
circulation intothe lumen
occurs and bacteria
↓
(E. coli, Klebsiella, anaerobes,
bacteroides and other
organisms)
↓
multiply, toxins are released—
toxaemiaoccurs.
↓
This leads to severe dehydration,
electrolyte imbalance.
↓
Proximal to the collected
fluid, air accumulates

11. ↓
(derived fromswallowedair
(70%),
↓
Diffusion fromblood intothe
lumen(20%)
↓
Fromdigested product and
bacterial action (10%))
↓
in which, maincomponentis
nitrogen (90%) and also
hydrogensulphide.
↓
During vigorous peristalsis, air
enters the distal fluid
↓
results in churning, is the reason
to cause multiple air-fluidlevels
in plainX-ray abdomen
↓
Defective absorption, decreased
fluid intake, loss of fluidby
vomiting, sequestrationof fluid
intothebowel lumen

12. ↓
leads into severe dehydration,
fluid and electrolyte imbalance
• Inflammatory response in
thebowel wall (intramural
inflammation)
↓
causes accumulation of activated
neutrophils and macrophages in
the muscle wall
↓
whichrelease reactive enzymes
and cytokines
↓
Thesesubstances damage
secretory and motor processof
muscle
↓
leading into dilatationof the
bowel.
↓
Increasedrelease of nitric oxide
in muscle wall and
↓
production of intramural
reactive oxygen metabolites alter
gut motilityand
permeability.

13. • Intestinal wall hypoxia is
also the cause for dilatation.
↓
In first 12 hours of obstruction
↓
there is only decreased
absorption
↓
whichcauses accumulation of
fluid and electrolytes in the
lumen.
↓
After 12 hours, there is also
increasedintestinal secretion
↓
causing further accumulation
of the fluid.
↓
Accumulationof bacterial
toxins, bile salts,
prostaglandins, and mucosa-
derivedfree radicals, VIP
↓
all increase theluminal
secretion of fluidin obstructed
bowel.
• Dilatation of bowel wall

14. ↓
increases intraluminal pressure
↓
whichexceeds the bowel wall
venous pressure
↓
causing ischaemia
↓
whichcauses further dilatation
and ischaemic injury
↓
This leads intoeventual blockage
of arterial perfusion causing
bowel wall necrosis/gangrene.
↓
Increasedbacterial colony in the
bowel (Normal flora is less than
106 colonies/ml in jejunumand
108 colonies /ml in the ileum)
↓
due to alteredluminal content
and environment
↓
multiplication
↓
toxins
↓
further mucosadamage

15. ↓
disrupted mucosal
defense/barrier/integrity
↓
translocation of bacteria across
mucosainto submucosaand
also absorptionof bacterial and
other toxins into the circulation
↓
bacteraemia/toxaemia/
septicaemia/SIRS/MODS.
FACTORScausing systemic
problems in intestinal
obstruction™
• Dilatation of the bowel ™
• Decreasedabsorptionacross
mucosa ™
• Increasedsecretion into the
lumen ™
• Intramural inflammation
and hypoxia ™
• Increasedintraluminal
pressure ™
Venous congestion
• increasedvenous
pressure ™

16. • Disruptedmucosal barrier
→ bacterial translocation
PATHOLOGYCHANGESIN
THE SITE OF OBSTRUCTION
Initially venous return is
impaired
↓
Congestion, oedema of bowel
wall occurs which turns purple.
↓
Laterthis jeopardizes the arterial
supply.
↓
Loss of shineness, blackish
discolouration, loss of peristalsis.
↓
Gangrene.
↓
Perforationoccurs.
↓
Bacteria and toxins migrateinto
the peritoneum.
↓
Peritonitis.

17. • Closedloop obstruction:
↓
Whenthere is obstruction in the
large bowel, with ileocaecal valve
competence (40%)
↓
pressure increases in the
caecum.
↓
Stercoral ulcer in the caecum.
↓
Gangrene.
↓
Perforation.
↓
Peritonitis (Faecal).
↓
Perforationalso can occur at
the site of obstructiondue to
the malignant growth
↓
Closedloop obstruction also
can occur whenbowel get
obstructed
↓
at both proximal and distal
parts of the loop of the bowel.

18. ↓
It can occur in external or
internal hernias, volvulus, etc.
↓
Necrosis and perforationare
bothcommonat obstructedsite
↓
and over the convex summit of
the bowel content.
↓
Bowel distal to the obstructionis
inactive and collapsed.
CLINICALFEATURES
• Abdominal pain:
Initially colicky and
intermittent: later
continuous and severe.
• painsuggests
strangulation.
• Painbegins usually
aroundumbilicus in
small bowel obstruction

19. • In small bowel obstruction,
• it is crampy,
• recurrent paroxysms
occurring as short
crescendo/decrescendo
episodes (of 30 seconds)
• In large bowel obstruction,
• it is of longer episodes of
minutes (In
paralytic/adynamic
ileus, painis diffuse and
mild).
• Vomiting:
• In jejunal obstruction, it
is earlyand persistent.
• In ileal obstruction, it is
recurrent occurring at
an interval
• initially bilious later
faeculent.
• In large bowel
obstruction, vomiting is
a late feature.

20. • Distension
• It is absent or minimal
in case of jejunal
obstruction
• Obvious withvisible
intestinal peristalsis (VIP)
and borborygmi sounds in
case of ileal obstruction—
Step ladder peristalsis. It is
enormous in case of large
bowel obstruction.
• Features of toxaemia and
septicaemia:
• Tachycardia, tachypnoea,
fever, sunken eyes, cold
periphery.
• Constipation:
• It is absolute, i.e. neither
faeces nor flatus is
passed.
• Dehydration: Leads to
oliguria → renal failure

21. • Abdominal tenderness:
• It is initially localisedbut
later becomes diffuse—is
a feature of intestinal
obstruction.
• Reboundtenderness
• and guarding will not
be present in simple
obstructions which are
features of
strangulation
Features of strangulation:
• Continuous severe pain
• Shock
• Tenderness
• rebound tenderness
(Blumberg’s sign)
• Guarding and rigidity
• absence of bowel sounds.

22. • In case of strangulated
hernia, a swelling which is
tense, tender, rigid,
irreducible, no expansile
impulse on coughing and
history of recent increasein
size is seen.
• Temperature:
• Fever signifies
inflammationin the
bowel wall/
ischaemia/perforation.
• Hypothermia can occur
when septicaemia
develops due to lack of
pyrogenicresponse.
• It suggests poor
prognosis.
• Bowel sounds:
• They are increased—
high-pitched metallic
(rushes and groans)
sounds followed by
metallic tinkling sounds
of dilatedbowel.

23. • Eventually oncefatigue
occurs or gangrene develops,
bowel sounds are not
heard—silentabdomen of
peritonitis develops (in
paralyticileus, there are only
continuous metallic sounds
of dilatedbowel).
• Per-rectal examination
• Shows empty, dilated
rectum, often with
tenderness. If rectal growth
is the causefor obstruction,
it may be palpable.
CARDINALFEATURES
• Colickyabdominal pain
• Vomiting
• Distension
• constipationlater.
• In high jejunn—no
distension(scaphoid
abdomen),

24. • severeal obstruction
• bilious vomiting, no
peristalsis, without
constipation
• In ileal obstruction
• central moderate
distension
• bilious and faeculent
vomiting
• intermittent crescendo
colicky pain
• step ladder peristalsis
• constipationat a later
period.
• In low/colonic obstruction
• variable colickypain
• rightto left peristalsis
• markedenormous
distension
• constipationto begin with,
late feculent vomiting.
INVESTIGATION
PlainX-rayabdomen:
• (initially supine abdominal
X-rayis taken; later if
needed, X-rayin erect
posture is takenif
perforationis suspected).

25. • Multiple air-fluidlevels.
Proximal the obstruction→
Lesser the air fluid level.
Distal the obstruction→
More the air fluid level
• Normally, three fluidlevels
can be seenin plain X-ray
film—at fundus of
stomach, at duodenumand
often at caecum
• Jejunumshows concertina
effectdue to valvulae
conniventes (Herring bone
pattern)—by the valves of
Kerckring.

26. • Ileumis smoothand
characterless(by Wangen
steen). Large bowel shows
haustration.
• Pneumobilia (gasin biliary
tree)may be due to gall-
stone ileus. Distended
caecumis shownas round
gas shadowin the right iliac
fossa. Dilatedcaecum
signifies large bowel
obstruction.
• CT scan
• Barium(micro bar solution)
enema or gastrografin
contrast enema X-ray is
useful in intussusception.
[Bariummeal is usually
contraindicatedin acute
intestinal obstruction
• Haematocrit, blood urea
and serumcreatinine;
arterial blood gas analysis
(acidosis is common), LFT,
plateletcount (insevere
sepsis, there will be altered
LFT withthrombocytopenia).

27. • Serumelectrolytes
estimation.
• Hypokalaemia is common
• Total countis increased. But
can be significantly low in
severestage of sepsis
• US abdomen is useful to see
dilatedbowel and fluidin
the peritoneal cavity. It is
better than X-ray but not as
good as CT scan.
COMPLICATION
• Peritonitis
• Hypovolaemicand septic
shock
• Renal failure
• ARDS
• Intra-abdominal abscess
formation
• Moribundstatus
DIFFERENTIAL DIAGNOSIS
• Paralyticobstruction
• Pseudo-obstruction
• Ascites

28. TREATMENT
• Nasogastricaspiration: To
reduce toxic effects, to
reduce bowel distension
whichindirectlyimproves
pulmonary ventilationand
to reduce possibilityof
aspirationpneumonia.
• Replacement of fluid and
electrolytes.
• Antibiotics: Ampicillin,
gentamicin, metronidazole,
cephalosporins.
• Blood transfusion:
• ICUcritical care: Systemic
management of
complications like ARDS,
DIC, SIRS are important.
• If there is hypotension,
dopamine/dobutamine are
also needed.
• CVP for fluid and
monitoring

29. SURGERY
• Surgery: Immediate
laparotomy is done and the
site
• Warm-saline soakedmop is
placed over the doubtful area
with 100%oxygeninhalation
for 20 minutes; if colour
becomes normal with
peristalsis thenbowel is
viable. On table Doppler
studymay be useful.
• Small bowel can be
decompressedusing Savage’s
decompressor.
• In case of right-sidedcolonic
obstruction, right
hemicolectomywithileocolic
anastomosis is done
• In case of left-sidedcolonic
obstruction, left hemicolec
tomy (resection) and colo-
colic anastomosis is done
witha defunctioning
colostomy(right-sided
transverse) which is closed
after 6 weeks.

30. • Obstructiondue to
rectosigmoid growthwith
patient being severely ill—
Hartmann’s operationcan
be done .
REFERENCE
1. SRB's Manual of Surgery
by SriramBhat M
2. A Manual on Clinical
Surgeryby Das
3. A Concise textbookof
Surgeryby Das

31. A
Special Thanks
To A Very
Special Doctor