Intestinal obstruction

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Intestinal Obstruction
Dr Bina Ravi
Associate Professor and Consultant
Department of Surgery

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Abdomen- Bowel sound
 Present- Mechanical obstruction
Not present-
 Adynamic obstruction
 (no gas under diaphragm)
 Perforation
 (gas under diaphragm)

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Objectives
 Pathophysiology – dynamic, adynamic
 Cardinal features – history,
examination
 Causes – small, large gut obstruction
 Indications – contraindications for
conservative Mx

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Obstruction
 Dynamic – peristalsis, mechanical
obstruction
 Adynamic- paralytic ileus, non
propulsive Mesenteric vascular
obstruction or, pseudo obstruction

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Dynamic Obstruction
 Pain, distention, vomiting, absolute
constipation
 Two- small gut – high , low
 Large gut
 Acute , chronic, acute on chronic or,
sub-acute
 Simple – intact vascularity
 Strangulated – compromised
vascularity

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Intestinal obstruction:
Causes
Adhesion
Inflammatory
Carcinoma
Obstructed
hernia
Fecal
obstruction
Pseudoobstruc
tion
Misc

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Causes –Dynamic obstruction
 Intra-luminal –impaction, FB, Bezoars,
gallstones
 Intramural- strictures, malignancy
 Extra-luminal- bands/adhesions, hernia,
volvulus, intussusception

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Adynamic obstruction-causes
 Paralytic ileus
 Mesenteric vascular occlusion
 Pseudo obstruction

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Pathophysiology
 Proximal gut dilates- altered motility
 Below the obstruction – normal motility,
immobile
 Proximal – increased peristalsis, dilates,
reduced peristalsis, flaccid
 Gas- bacteria. Aerobic/anaerobic, 90% N2
 Fluid- dig. Juices,

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Pathophysiology
 Dehydration and electrolyte imbalance
 Reduced intake
 Defective absorption
 Vomiting
 Sequestration in gut

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Strangulation
 Blood supply compromised
 Venous return first affected, arterial
 Hemorrhagic infarction
 Translocation and systemic exposure
to microbes/ toxins
 Morbidity/ mortality- age, extent,
Peripheral vascular failure

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Closed loop obstruction
 Strangulation
 Distention
 Necrosis
 perforation

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Acute Intestinal Obstruction-CP
 Location, age of obstruction,
pathology, ischemia
 Pain
 Vomiting
 Distension
 Constipation
 Dehydration, Hypokalemia, fever,
abdomen tenderness

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 Pain – severe, colicky, umbilical, lower
abdomen
 Increases with peristalsis, later reduces
 Severe pain - strangulation

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Vomiting
 High obstruction- violent
 Low obstruction- slow onset
nausea/vomit
 Gradually digestive food changes to
feculent material

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Distension
 Greater if distal obstruction
 Visible peristalsis
 Peristalsis delayed in colonic obstruction
 Absent in Mesenteric vascular obstruction

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Constipation
 Absolute
 Relative
 Absent in – Richter’s hernia, gallstone,
MVO, Pelvic abscess, partial
obstruction

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Dehydration
 Vomiting, fluid sequestration
 Dry skin, poor venous filling, sunken
eyes, oliguria
 Raised blood urea, Hb, - secondary
polycythemia

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Hypokalemia
 K, amylase, LDH – strangulation, raised
TLC or, leucopenia
 Fever – indicates – ischemia,
perforation, inflammation
 Hypothermia – septic shock

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Abdomen tenderness
 Localized – ischemia
 Peritonitis – infarction or, perforation

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Strangulation
 Diagnosis is clinical
 Features of obstruction
 Persistent pain, Shock, local tenderness
 Non-responsive to conservative Mx
 Hernia strangulation – tender, irreducible,
absent cough impulse, recent increase in
size

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Radiology
 Supine/ erect plain abdomen films
 Small gut- central, transverse, no gas-
colon
 Jejunum- valvulae connivantes
 Ileum- featureless
 Cecum- round gas in RIF
 Large gut- haustral folds

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Supine

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Sigmoid volvulus
 Dilated, no haustral pattern
 Small gut- air and fluid levels
 More the fluid levels, more distal the
lesion

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Inv:
 Plain x ray- impacted foreign body
 Fluid levels – non obstructing
conditions – inflammatory bowel
disease, acute pancreatitis, abdominal
sepsis

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Treatment
 3 measures
 Intestinal drainage
 Fluid and electrolyte replacement
 Relief of obstruction

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Surgical Mx
 Mx of segment at the site of
obstruction
 The distended proximal bowel
 Underlying cause of obstruction

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Supportive
 NG tube drainage
 Na , water replacement
 Antibiotics

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Large gut
 Ca or diverticular disease
 Contrast study – pseudo-obstruction
 Caecal perforation- caecostomy,
ileostomy

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Adhesions/bands
 Commonest
 Fibrin – adhesions-fibrinous, fibrous
 Appendectomy , gynaecological op.
 Bands- congenital, bacterial peritonitis,
greater omentum causing band
 Mx- conservative – 72 hrs –lap
adhesiolysis

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Special obstructions
 Int. hernia – foramen of Winslow, hole in
the mesentery, hole in transverse
colon, defects in broad ligament, cong
diaphragmatic hernia, paraduodenal
fossae, intraperitoneal fossae
 Mx- release the ring, reduction of
hernia

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Enteric strictures
 TB, Crohn’s, Ca, lymphomas,
stricturoplasty
 Bolus obstruction – food, gall stone,
trichobezoars, phytobezoars,
stercoliths, worms

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Ac Intussusception
 Proximal gut enters distal gut
 Adults – lead point, polyp, submucosal
lipoma, tumor,
 Colo-colic – adults
 Pathology- inner tube, outer tube,
returning of middle tube
 Strangulating obstruction- ileoileal,
ileocaecal, ileocolic

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Clinical picture
 Severe attacks of pain – lasts few
minutes
 Later - red currant jelly stool
 Exam –between episodes-50-60%
sausage shaped lump – empty RIF –
Sign de Dance
 P/R – blood stained finger
 Later vomit, distension

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Radiology
 Plain film – absent caecal gas
 Ba enema- claw sign
 CT scan
 Mx- Hydrostatic reduction with enema
 Operative reduction
 Recurrent – 5%- anchorage of ileum to
ascending colon

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Differential diagnosis
 Acute enterocolitis
 Henoch Schoenlein perpura
 Rectal prolapse

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Volvulus
 Axial rotation of bowel at its
mesentery
 Congenital or secondary
 Small intestine, caecum, sigmoid-
common
 Small gut- spontaneous, vegetable
consumption – untwist
 Caecal – clockwise- females- lap .
Untwist, resection if gangrene

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Sigmoid
 Anticlockwise
 Bands, overloaded colon, large
mesocolon, narrow pelvic mesocolic
attachment

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Treatment
 Flexible sigmoidoscopy/ rigid
 Laparotomy- untwisting
 Viable – fixing to retroperitoneum
 Resection – Paul Mickulikz- gangrene
 Sigmoid colectomy/ Hartmann’s
procedure later re-anastomosis

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Compound volvulus
 Rare, ile-osigmoid knotting
 Gangrene
 Laparotomy - Decompression,
resection and anastomosis

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Thanks

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