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1. INTESTINAL OBSTRUCTION
Presented by Dakane Maalim
Dr. Ogombe

2. O U T L I N E
1. Introduction and Epidemiology
2. Classification of intestinal obstruction
3. Risk factors
4. Pathophysiology
5.Clinical presentation
6.Investigations and imaging study
7.Management

3. INTRODUCTION
 Bowel obstruction occur when there is any form of
impedance of the normal flow of material through a
hollow viscous
(Garden, 6th
edition)
 Lead to dilatation of bowel proximally and disrupts
peristalsis
 Obstruction can be functional (due to abnormal
intestinal physiology) or due to a mechanical
obstruction, which can be acute or chronic.

4. Factors that may lead to increase risk developing IO :
 Abdominal or pelvic surgery which may cause adhesion
 Previous history of obstruction
 Crohn’s disease – cause intestinal walls to be thicken, narrowing the
passageway
 Cancer within abdomen especially history of removal abdominal
Tumor
 History of constipation – impacted faeces

5. EPEDEMIOLOGY
1% of all hospitalization
3% of emergency surgical admissions
More frequent in female patients because of gynecological-obstetric and pelvic
surgical operations are important etiologies for post operative adhesions
Adhesion is the most common cause of intestinal obstruction
80% of bowel obstruction due to small bowel obstruction and the most
common causes are adhesion—hernia---neoplasm while 20% due to colon
obstruction and the most common cause is CR-cancer 60-70% while 30% are
diverticular disease and volvulus
Mortality rate range between 3% for simple bowel obstruction to 30% when
there is strangulation or perforation
Recurrent rate vary according to method of treatment if conservative 12%
while the operation treatment recurrent rate 8-32%

6. INTRODUCTION

7. C L A S S I F I C A T I O N O F I N T E S T I N A L
O B S T R U C T I O N

8. DISTAL
PROXIMAL
LARGE BOWEL
SMALL BOWEL
Common Causes:
 Bilious
Vomiting
 Shorter onset
 Abdominal
Distension
 Fecaloid
vomitus
 Longer onset
A. LOCATION

9. A. LOCATION

10. B. DEGREE OF OBSTRUCTION
 Lumen narrowed but allow
transit some content
 Abdominal distension
 Presence of flatus
 Presence of bowel
movement Simple obstruction
(no vascular impairment)
 Lumen totally
obstructed
 Complete obstipation
Strangulation
Closed loop
(both ends are obstructed)
COMPLETE
PARTIAL
DEGREE OF
OBSTRUCTION

11. B. DEGREE OF OBSTRUCTION
Degree of obstruction is
based on degree of
collapse and amount of
residual contents distal
to obstruction.
OGILVIE SYNDROME

12. C. CAUSES
Peristalsis against a
mechanical obstruction
CAUSES
MECHANICAL /
DYNAMIC
FUNCTIONAL /
ADYNAMIC
EXTRAMURAL INTRAMURAL INTRALUMINAL
 Paralytic ileus
- Post op : 24-72 hour
- Infection
- Metabolic – uremic /
 Adhesions
 Hernias
 Congenital
bands
 Tumors
 volvulus
 Strictures :
inflammatory
(Crohn , TB )
 Tumors
 Intussusception
 Lymphomas
 Impacted
faeces
 Gallstones
 Bezoar
 Foreign
bodies
hypokalemia
 Pseudo-obstruction
Absent peristalsis due to
intestinal atony in
absence of mechanical
cause

13. INTESTINAL OBSTRUCTION

14. CAUSES
INTUSSUSCEPTION

15. INTESTINAL OBSTRUCTION
TRICHOBEZOARS AND PHYTOBEZOARS
 Trichobezoars (Undigested hair ball):
Due to persistent hair chewing or
sucking, and may be associated with
underlying psychiatric abnormality.
 Phytobezoars (Fruit/vegetable fibre):
Due to high fibre intake, inadequate
chewing, previous gastric surgery and
loss of the gastric pump mechanism.
Preoperative diagnosis is difficult
even with high resolution CT
scanning.
WORMS
 Ascaris lumbricoides may cause low
small bowel obstruction, particularly
in children.
 Diagnosis by: Worms in the stool or
vomitus, eosinophilia or the sight of
worms within gas-filled small bowel
loops on a plain radiograph.
 Occasionally, worms may cause a
perforation and peritonitis,
especially if the enteric wall is
weakened by such conditions as
ameobiasis.

16. ADHESION
 Most commonly occurs due to previous abdominal
surgery.
 Risk of acquiring adhesion subsequent to abdominal
surgery is 4% and that after laparotomy is 2%
 Adhesions start to form within hours of abdominal
surgery.
 Classified into 2 types: early (fibrinous) and late
(fibrous)
 Post-operative adhesions giving rise to intestinal
obstruction usually involve the lower small bowel
and almost never involve the large bowel

17. ADHESION

18. HERNIA
 Most common cause of small bowel obstruction in patients
with no prior history of surgery is hernia.
 Careful search for inguinal, femoral and umbilical hernia must
be made. Consider internal hernia too.
 Internal herniation occurs when a portion of the small
intestine becomes trapped in one of the retroperitoneal
fossae or in a congenital mesenteric defect

19. HERNIA

20.  This occur when the bowel is obstructed at both the proximal and distal points
 It is present in many cases of intestinal strangulation
 When gangrene of the strangulated segment is imminent, retrograde thrombosis of
the mesenteric vein result in distension of both sides of the strangulated segment
CLOSED LOOP IO

21. STRANGULATED IO
 Strangulation occurs in nearly 25% of people with small bowel obstruction.
 Usually, strangulation results when part of the intestinal becomes trapped in an
Abnormal opening such in diagram above.
 Gangrene can develop in as few as 6 hours.
 Mortality rate : 10-35%
Gangrene  the intestinal wall dies  usually causing rupture  peritonitis, shock
And if untreated, death

22. Acute intestinal obstruction in a newborn
Neonatal intestinal obstruction has many potential causes.
 Congenital atresia and stenosis are the most common.
 Intestinal malrotation with midgut volvulus.
 meconium ileus, Hirschprung’s disease, imperforate anus, necrotising enterocolitis

23. PATHOPHYSIOLOGY
 Irrespective of aetiology or acuteness of onset, in dynamic (mechanical)
obstruction the bowel proximal to the obstruction dilates and the bowel
below the obstruction exhibits normal peristalsis and absorption until it
becomes empty and collapse.
 Initially, proximal peristalsis is increased in an attempt to overcome the
obstruction. If the obstruction is not relieved, the bowel continue to
dilate, ultimately there is a reduction in peristaltic strength, resulting in
flaccidity and paralysis.

24. PATHOPHYSIOLOGY
The distension of proximal to an obstruction is caused by two factors:
 Gas : there is significant overgrowth of both aerobic and anerobic
organism, resulting in considerable gas production. Following the
reabsorption of oxygen and carbon dioxide, the majority is made up of
nitrogen (90%) and hydrogen sulphide.
 Fluid : this is made up of the various digestive juice (Saliva 500mL, bile
500mL, pancreatic secretion 500mL, gastric secretion 1Litre- in all per
24 hours.) this accumulate in the guts lumen as absorption by the
obstructed gut is retarded. Dehydration and electrolyte loss are
therefore due to:
- reduced oral intake
- defective intestinal absorption
- sequestration in the bowel lumen
- transudation of fluid into the peritoneal cavity

25. CLINICAL FEATURES
Cardinal features
1. Colicky pain
2. Vomiting
3. Abdominal
distension
4. Constipation
Other features
1. Dehydration
2. Hypokalemia
3. Pyrexia
4. Abdominal tenderness

26. I N V E S T I G A T I O N S

27. TYPES
 ABDOMINAL X-RAY ( SUPINE )
 CONTRAST ABDOMINAL X-RAY
 CT SCAN

28. ABDOMINAL X-RAY
 Supine (Most of diagnosis made by this
position)
 Erect (May be requested when in doubt)
 (3/6/9 rule) : 3cm for the small bowel, 6cm forthe
colon and 9cm for the caecum

29. RADIOLOGICAL FEATURES OF
IO
OBSTRUCTED SMALL BOWEL
 Characterized by straight segments that are generally
central and lie transversely
 No/minimal gas is seen in the colon
JEJUNUM
Characterized by its valvulae conniventes, which
completely pass across the width of the bowel and are
regularly spaced, giving a ‘concertina’ or ladder effect

30. RADIOLOGICAL FEATURES OF
IO
ILEUM
The distal ileum has been described bywangensteen as
featureless
CAECUM
A distended caecum is shown by a rounded gasshadow in the
right iliac fossa
LARGE BOWEL
Except for the caecum, shows haustral folds, whichare
spaced irregularly & do not cross the whole diameter of
the bowel.

31. LARGE BOWEL OBS. SMALL BOWEL OBS.

32.  In intestinal obstruction, fluid levels appear later than
gas shadows as it takes time for gas and fluidto
separate. (Most prominent on an erect film)
 When fluid levels are pronounced, the obstructionis
advanced.
 In the small bowel, the number of fluid levels is
directly proportional to the degree of obstructionand
to its site, the number increasing the more distal the
lesion.

33. CONTRAST ABD X-RAY
BARIUM STUDIES
 Done in patients without evidence of strangulation
 Adhesive small bowel obstruction
 Predicts resolution of small bowel obstruction
 Contraindicated in acute obstruction

35. CT SCAN
 Widely used nowadays
 Highly accurate
 Limitation : cannot
diagnose ischemia

36. IMAGING IN
INTUSSUSCEPTION
1. Plain X-ray : evidence of small or large bowel obstruction
with an absent caecal shadow in ileocecal cases
2. Barium enema : shows claw sign in ileocolic
intussusception
3. CT scan : shows a target or sausage-shaped soft tissue
mass with a layering effect ( mesenteric vessels within bowel
lumen )
4. Ultrasound : shows a doughnut appearance of concentric
rings in transverse section

38. IMAGING IN VOLVULUS
CAECAL VOLVOLUS
Characterised with
 Caecal dilatation (98-100%),
 Single air-fluid level (72–88 %),
 Small bowel dilatation (42–55 %)
 Absence of gas in distal colon (82
%)

39. IMAGING IN VOLVULUS
SIGMOID VOLVULUS
 Shows massive colonic
distension.
 The classic appearance: two
twisted loops with a central
doubled wall component. ( On
plain xray)
 Coffee bean sign

40. GALLSTONES ILEUS
 Rigler’s triad
1. Pneumobilia
2. Small bowel obstruction
3. Atypical mineral shadow
 2 of these 3 signs are
pathognomic of gallstone ileus.

41. M A N A G E M E N T
N

42. DANGEROUS SIGNS
 Constant pain
 Absent bowel sounds
 Tenderness with rigidity
 Leukocytosis
 Fever and tachycardia
 Shock

43. ACUTE INTESTINAL
OBSTRUCTION
It involves:
i. Conservative management
ii. Surgical management
 Some cases will settle by using conservative regimen, other
need surgical intervention
 Surgery should be delayed till resuscitation is complete unless
signs of strangulation and evidence of closed-loop obstruction
 Cases that show reason for delay should be monitored
continuously for 72 hours in hope of spontaneous resolution

44. ACUTE INTESTINAL
OBSTRUCTION
SUPPORTIVE MANAGEMENT
 Nasogastric aspiration by Ryle's tube
 IV fluid
 NPO
 Urinary catheter
 Check temperature and pulse 2 hourly
 Abdominal temperature 8 hourly
 Broad spectrum antibiotics initiated early

45. ACUTE INTESTINAL
OBSTRUCTION
SURGICAL MANAGEMENT
Principles:
 Management of segment at site of obstruction
 Management of distended proximal bowel
 Management of underlying cause of obstruction

46. ACUTE INTESTINAL
OBSTRUCTION
If the site of obstruction is unknown, laparotomy assessment is directed to:
i. The site of obstruction
ii. The nature of obstruction
iii. The viability of gut
INDICATION FOR SURGERY
 Failure of conservative management
 Tender and irreducible hernia
 Strangulation
 Virgin abdomen

47. SURGICAL TREATMENT
The type of surgical procedure depend upon the cause of
obstruction via division of bands, adhesiolysis, excision, or bypass
Once obstruction relieved, the bowel is inspected for viability, and
if non-viable, resection is required
IN DIC ATION FOR NON -VIABIL ITY
 Absent peristalsis
 Loss of normal shine
 Loss of pulsation in mesentery
 Green or black color of bowel
 Absent mesenteric pulsations

48. SURGICAL TREATMENT
VIABLE NON-VIABLE
CIRCULATION
Dark color becomes lighter Dark color remain
Visible pulsation in mesenteric
arteries
No detectable pulsation
GENERAL
APPEARANCE
Shiny Dull and lusterless
INTESTINAL
MUSCULATURE
Firm Flabby, thin and friable
Peristalsis may be observed No peristalsis

49. SURGICAL TREATMENT
IN CASE OF SMALL BOWEL OBSTRUCTION
 The first maneuver is to deliver the distended small bowel into the wound
 The small bowel should be covered with moist swabs and the weight of the
fluid filled bowel supported so that the blood supply to the mesentery is not
impaired
 Operative decompression should be performed whenever possible. This
reduces pressure on the abdominal wound, reducing pain and improving
diaphragmatic movement
 This is done via large bore orogastric tube and milking the bowel content in
retrograde manner to the stomach for aspiration
 All volumes of fluid removed should be accurately measured and appropriately
replaced
 Following relief of obstruction, the viability of the involved bowel should be
carefully assessed

50. PLAN
 IV fluids and electrolytes resuscitation for all
 NG tube if repeated vomiting
 Antibiotics for all
 Hernia –> Operation
 Adhesions –> Conservative first
 Obstruction –> Remove
 Volvulus –> Derotate and/or operate
 Mesenteric ischemia –> Operate
 Abscess or peritonitis –> Drain and treat
 Intussusception –> Pneumatic or barium reduction
or operate

51. SURGICAL TREATMENT
IN CASE OF ACUTE LARGE BOWEL OBSTRUCTION
 After full resuscitation the abdomen should be opened
through a midline incision
 Distension of caecum will confirm large bowel involvement.
Identification of a collapsed distal segment of large bowel and
its sequential proximal assessment will readily lead to
identification of the cause
 When a removable lesion is found in the caecum, ascending
colon, hepatic flexure or proximal transverse colon, an
emergency right hemicolectomy should be performed
 If the lesion is irremovable, a proximal stoma or
ileotransverse bypass should be considered

52. SURGICAL TREATMENT
IN CASE OF ACUTE LARGE BOWEL OBSTRUCTION
 Obstructing lesions at the splenic flexure should be treated
by an extended right hemicolectomy with
ileodescending colonic anastomosis
 For obstructing lesions of left colon or rectosigmoid
junction, immediate resection should be considered
unless there are clear contraindications
CONTRAINDICATIONS TO IMMEDIATE RESECTION INCLUDE:
i. Inexperienced surgeon
ii. Moribund patient
iii. Advanced disease

53. MANAGEMENT
DYNAMIC VS ADYNAMIC
SMALL INTESTINE VS LARGE INTESTINE
SIMPLE VS COMPLICATED

54. DYNAMIC VS ADYNAMIC
DYNAMIC ADYNAMIC
 Peristalsis is working against
mechanical obstruction
 May be in acute and chronic form
a  Peristalsis is absent or inadequate
where there is no obstruction
Causes:
 Intraluminal
 Intramural
 Extramural
Causes:
 Paralytic ileus
 Pseudo-obstruction
 Abdominal pain
 Abdominal distension
 Vomiting
 Absolute constipation
Paralytic ileus:
 Clinical significance after 72 hours
 Absence of bowel sound and no
passing out flatus
 Abdominal distension becomes
more marked and tympanic
 Effortless vomiting

55. DYNAMIC OBSTRUCTION
ADHESIVE OBSTRUCTION
 NG decompression and rehydration
 Not prolonged beyond 72 hours
 Divide the causative adhesion(s) and limit the dissection
 Repair serosal tears, resect areas of doubtful viability
 Laparoscopic adhesiolysis in expert surgeon’s hands
CONSERVATIVE MANAGEMENT
SURGICAL MANAGEMENT

56. DYNAMIC OBSTRUCTION
INTUSSUSCEPTION
NG drainage, resuscitation with IV fluids, antibiotics
Air OR barium enema performed if there are no signs of
peritonitis, perforation
 Reducible intussusception
 Irreducible intussusception – resection with primary
anastomosis
CONSERVATIVE MANAGEMENT
NON OPERATIVE MANAGEMENT
OPERATIVE MANAGEMENT

57. DYNAMIC OBSTRUCTION
VOLVULUS
 If viable, volvulus should be reduced
achieved after decompression of caecum using needle
 Further management consists of fixation of caecum to right iliac
fossa (caecopexy) or caecostomy
CAECAL VOLVULUS

58. DYNAMIC OBSTRUCTION
VOLVULUS
 Flexible sigmoidoscopy or rigid sigmoidoscopy & insertion of a
flatus tube should be carried out to allow deflation of gut
 The tube should be secured in place with tape for 24 hours and
a repeat X-Ray taken to ensure that decompression has
occurred
 This will resolve the acute problem
SIGMOID VOLVULUS

59. DYNAMIC OBSTRUCTION
VOLVULUS
FURTHER TREATMENT
 YOUNG: Elective sigmoid colectomy is required
 ELDERLY: If endoscopic decompression is successful, it is
reasonable to not offer further treatment as 80% death rate
If it’s recurrent, the options available are:
i. Resection
ii. Two point fixation with combine endoscopic /
percutaneous tube insertion
 Failure results in an early laparotomy with untwisting of the
loop and per anum decompression
SIGMOID VOLVULUS

60. ADYNAMIC OBSTRUCTION
PARALYTIC ILEUS
Failure of transmission of peristaltic waves secondary to
neuromuscular failure
Post operative, infection, reflex ileus, metabolic
 NG suction, fluid replacement
 Use prokinetics (domperidone/erythromycin) in resistant case
 Laparotomy – if inactivity persists > 7 days, only after
confirmation of abdominal sepsis / mechanical obstruction
CAUSES
MANAGEMENT

61. ADYNAMIC OBSTRUCTION
PSEUDO-OBSTRUCTION
Obstruction in absence of mechanical cause or acute intra-abdominal disease
Metabolic, severe trauma, shock, retroperitoneal irritation
 Radiographs show colon obstruction and distension
 If no obstruction, confirm by colonoscopy & barium enema
 Treat the identifiable cause
 IV Neostigmine 1mg
 Repeat with second dose after few minutes if first dose is ineffective
 Colonoscopic decompression
 Surgery is associated with high mortality and morbidity
ASSOCIATIONS
MANAGEMENT

62. SBO VS LBO
HIGH SMALL BOWEL LOW SMALL BOWEL LARGE BOWEL
 Vomiting occurs early and
profuse
 Vomitus contain
undigested food
 Rapid dehydration
 Minimal distension
 Upper abdominal
discomfort
 Little evidence of dilated
small bowel loops
 Pain is predominant with
central distension
 Vomiting is delayed
 Vomitus may contain
feaculant material
 Multiple small bowel
loops is dilated
 Distension is early and
pronounced
 Less severe pain
 Vomiting and dehydration
present later
 Obstipation indicates
complete obstruction
 History of constipation
 The proximal colon and
caecum are distended on
abdominal radiography
 Presence of haustral folds
 The small bowel is dilated
if ileocecal valve is
incompetant

63. SIMPLE VS COMPLICATED OBSTRUCTION
SIMPLE OBSTRUCTION COMPLICATED OBSTRUCTION
 Blood supply is intact
 The obstruction occludes the lumen
only
 Strangulation occurs when there is
interference with the blood flow
 Obstruction with strangulation impairs
the blood flow leading to necrosis to
intestinal wall
CLINICAL FEATURES
 Vomiting
 Abdominal distension
 Abdominal pain
 Constipation
CLINICAL FEATURES
 Fever
 Constant severe pain
 Generalized tenderness with rigidity
 Shock
PLAIN X RAY CT SCAN
 Dilated small bowel loops with air fluid  Thickening of bowel wall
levels  Air in the bowel wall / portovenous
CT SCAN system
 Shows a discrepancy in the caliber  Absence of mesenteric fluid
between distended proximal bowel  Intrapertoneal free air indicated
and collapsed distal intestine perforation

64. REFERENCE
 Bailey and Love 26th
Edition
 UpToDate
 MedTube.Net
 MSDManuals

65. THANK YOU