está palestra contem todo o conteúdo importante para conhecer na área médica sobre oclusão intestinal

1. INTESTINAL OCCLUSION:
mechanical and adynamic ileus
UCM Beira – Bloco 4.5- Ano 2018 Drª Maria Antonia Marongiu

2. Intestinal occlusion is a blockage that
keeps food, liquid or gas from passing
through small or large intestine.
DEFINITION

3. INTESTINAL OCCLUSION
Mechanical ileus : real bowell obstruction from
intestinal contents progress.
Adynamic (paralitic) ileus: missed intestinal
contents progression for peristaltic inability,
leading to functional obstruction

4. MECHANICAL ILEUS
INTRALUMINAL OBSTRUCTION CAUSES
• Foreign bodies
• Bezoar
• Gallstone
• Parassites
• Enteroliths
• Intussusception
• Inspissated faeces

5. foreign bodies
inspissated faeces
parassites
bezoar
(egagropilo)

6. Cherry stones
Enteroliths:
an intestinal calculus formed of layers of
minerals salts surrounding a nucleus of
some hard body suche as a swallod fruit
stone or otehr indigestibl substance

7. Intussuscepted colon with colonic ischemia
Small bowel intussusception
Intussusception

8. Gallstones
Gallbladder stone
Cholecysto – duodenal fistula formation *
*
*
*

9. MECHANICAL ILEUS
INTRAMURAL OBSTRUCTION CAUSES (lesions intrinsic to the intestinal wall)
• Congenital : atresia,
stenosis,
malrotation,
intestinal duplication
• Inflammatory process: crohn disease,
diverticulitis,
tuberculosis,
actinomicosis,
• Neoplasms: primary neoplasm ( benign or malignant)
secondary neoplasm (metastatic)
• Traumatic: intramural hematoma
• Miscellaneus: endometriosis,
radiation enteritis / stricture
post-ischemic stricture

10. Intestinal atresia
Stenosis
The pictures show a stricure, which
can result from intestinal inflammatory
diseases.

11. Intestinal neoplasm
evolution
Intestinal neoplasm
causing obstruction

12. MECHANICAL ILEUS
EXSTRINSIC OBSTRUCTION CAUSES
• Adhesions
• Hernias : external, internal
• Volvulus
• External mass effect: extraintestinal neoplasms, intra-abdominal abscess

13. Adhesions
Hernias
Plain abdomen X-ray
Internal hernia
Exsternal
strangulated
hernia

14. Volvulus
External mass
Plain abdome X-ray
(coffee bean sign)
*
*

15. ADYNAMIC ILEUS
Factors implicated
in the development
and persistence of
ileus
• Neurogenic: spinal cord lesione or injury
retroperitoneal process
ureteral colic
Parkinson’s disease
• Metabolic: hypokalemia
uremia
Ca⁺⁺, Mg⁺⁺ imbalance
hipothyroidism
diabetic coma or ketoacidosis
• Pharmacologic: opiates
neuroletic medications
anticholinergics
calcium channel blockers
• Infectius: peritonitis
pneumonia
tetanus
bacterial overgrowth of bowel
herpes zoster
• Laparotomy
CAUSES

16. Pathophysiology
• Intestinal gas accumulation
• Intraluminal fluid accumulation
• Intestinal flora alteration
• Changes in intestinal blood flow
• Changes in intestinal motility: mechanical ileus , at first increase of intestinal and
contractile activity; later progressive decrease of
peristatic activity
adynamic ileus, from the beginning progressive
deacrease of peristaltic activity
INTESTINAL OCCLUSION

17. • bacterial endotoxins ↑ fluid intraluminally
• ↑ secretory stimulation of the intestinal mucosa
• ↓ absorptive activity of the intestinal mucosa
• ↑ intraluminal distention and pressure
• ↓ myolectrical function of the gut
• Electrolyte imbalance : ↓ Natremia
↓ Cloremia
↓ Kalaemia
promote decrease of peristaltic activity
atony of the wall
Funcional obstruction

18. Clinical presentation
• ABDOMINAL PAIN
• VOMITING
• OBSTIPATION (inability to pass gas o stool)
• ABDOMINAL DISTENSION
• DEHYDRATION
INTESTINAL OCCLUSION

19. ABDOMINAL PAIN
Mechanical ileus
Adynamic ileus
At first
Intermittent
Colicky
Intense
Related to peristalsis*
After
Continuous with fresh outbreak
Gradual disappearance
(progressive decrease
of peristaltic activity)
* Intestinal motility increase to propel luminal contents
Less intense and
vague
severe evolution

20. VOMITING:
Present in mechanical and adynamic ileus
Mechanical ileus
Obstruction in proximal small bowel : early and bilious
Obstruction in distal small bowel and colon: late and progressively feculent
Vomiting is earlier in higher obstruction, late in distally obstruction

21. OBSTIPATION
(inability to pass gas o stool)
Mechanical ileus
Total retention of gas and stools.
Total or partial retencion of gas and
stool for emptying dowenstream of
the obsturction
Adynamic ileus

22. ABDOMINAL SIGNS
Abdominal distention.
Absent peristaltic sounds
(silent abdomen).
Hyperresonance to percussion.
Adynamic
tinkling bowel sounds
silent abdomen
severe situation
Mechanical ileus
Abdominal distention.
Hyperresonance to percussion.

23. Abdominal examination should be undertaken, with
careful inspection of the entire abdomen and inguino-
femoral region for signs of either surgical scars or
hernia.
Digital rectal examination may
reveal an anal or rectal tumor or
impacted feces
Never forget

24. DIAGNOSIS
• ANAMNESIS
• SYMPTOMS
• CLINICAL EXAMINATION
• DIGITAL RECTAL EXAMINATION
• LABORATORIAL TESTS
• RADIOLOGICAL DIAGNOSIS

25. LABORATORIAL TESTS
• Complete blood count : ↑ hematocrit
↑ red blood cell
↑ white blood cell
• Blood biochemical tests : potassium (K)
sodium (Na)
calcium (Ca)
chloride (Cl)
creatinine
urea
• Coagulation parameters
• Urine
dehydration
Necrosis ?

26. multiple air fluid levels
Mechanical ileus Adynamic ileus
gaseous distention
PLAIN ABDOMEN X-RAY

27. ABDOMINAL COMPUTED TOMOGRAPHY
( CT )
Small-bowel obstruction due to a bezoar
bezoar
dilated small bowel loops
(egagropilo)

28. Crohn’s disease
CT

29. Foreign body obstruction at the terminal ileum with small bowel dilatation
CT
Foreign body removed by enterotomy
Foreign body

30. Dilated large bowel loops loaded with faeces
CT
faeces

31. Ogilvie’s Syndrome
(acute colonic pseudo-obstruction)
It is a clinical entity in which signs and symptoms of bowel
obstruction are present without an actual mechanical obstruction
Symptoms: abdominal distension
pain
nausea and vomiting
obstipation
or
50% flatus or diarrhea
peritonitis, if perforated only (luminal diameter of colon > 10 -12 cm)
At first non operative treatment: nasogstric tube
correction of fluid and electrolyte imbalances
rectal tube
Neostigmina administration
Usually resolves in more than 75% of cases
May occur in hospitalized patient
with severe illness , after surgery
or in metabolic imbalance

32. Mechanical intestinal obstruction
TREATMENT
• Nasogastric tube: decompression
• Intravenous fluid : isotonic saline solution, lactated Ringer’s
+ potassium chloride if needed
• Urine moritoring : Foley catheter
• Central venosus assessment : in severe dehydration
• Broad-spectrum antibiotics
Non operative management
Operative management
Vigilant management of fluid and electrolyte status

33. Abdominal disconfort, distention, constipation
Steady pain Colic
Absent bowel sounds Active bowel sounds
X-ray nonspecific X-ray, air-fluid levels
Suspect adynamic ileus Suspect mechanical obstruction
(mechanical ileus)
Especting observation
Intravenous fluids, nasogstric tube, serial evalustions
Improvement No change Deterioration
Clamp tube Not tolerated Colic
White blood cells
Mass
Tenderness
Tolerated, passes flatus Continued expectant
and stool management
Nasogastric tube removed Gradual Non resolution Laparotomy
Diet advanced evolution

34. Bibliography
• http://www.radiologytutorials.com/main.cgi?tut=/main.cgi&frame=main&tt=1&t=135&s=2
• Lazar J. Greenfield, Micheal W. Muholland, Keith T. Oldham, Gerald B. Zelenock, Keith D. Lillemoe ,
SURGERY, Scientific principles and practice, third edition, Lippincott Williams & Wilkins Ed. 2001,
Philadelphia, USA
• C. M.Townsend, R. D. Beauchemp, B. M. Evers, K. L. Mattox, Sabiston Textbook of surgery, 18th Ed., 2008-
Philadelphia
• https://www.mayoclinic.org/diseases-conditions/intestinal-obstruction/symptoms-causes/syc-20351460
• https://www.researchgate.net/figure/Surgical-findings-in-a-patient-with-gallstone-ileus-A-An-impacted-
gallstone-was-found_fig2_291421810
• https://www.pedsradiology.com/Historyanswer.aspx?qid=47&fid=1
• https://medical-dictionary.thefreedictionary.com/enterolith
• https://www.everydayhealth.com/crohns-disease/symptoms/dealing-with-strictures-in-crohns-disease/
• https://viverepiusani.it/cosa-bisogna-sapere-sul-cancro-al-colon/
• https://www.unmedicopertutti.it/cancro_colon.htm
• https://pmj.bmj.com/content/75/887/559
• http://www.gastrosurgery.co.uk/intestinal-adhesions-treatment-london/
• I. lópez blasco, S. Paz Maya, D. Soriano Mena, J. P. Ruiz
• Gutierrez, A. Llanes Rivada, D. Dualde-Beltrán, R. Dosdá-Muñoz,J. Palmero; Valencia/ES, How to diagnose a
bezoar: imaging findings in CT, European Society of Radiology – electronic presentation
• Merck Manual - https://www.merckmanuals.com/professional/gastrointestinal-disorders/acute-abdomen-
and-surgical-gastroenterology/intestinal-obstruction

35. • https://www.semanticscholar.org/paper/Durian-seed-causing-small-bowel-obstruction.-Shelat-
Tan/744565e8e00a14e15c98f20efbf658a 153cc98ee/figure/0
• https://www.uptodate.com/contents/acute-colonic-pseudo-obstruction-ogilvies-syndrome
• Journal of Clinical Case Reports online