PPT about the most common causes and management of strangulation of intestine

1. Department of Surgery
By:
Eslam Emad M.Fawzy

2. Bowel strangulation
 Definition :
Interference of Blood Supply of the involved Bowel segment with or /
without Blockage of the lumen leading to Congestion then Ischemia and
gangrene If not relieved within 6 hr.

3. Incidence
 The morbidity and mortality associated with strangulation are dependent on
the duration of ischemia and its extent.
 Elderly patients and those with comorbidities are more vulnerable to its effects.
 Although in strangulated external hernias the segment involved is often short, any
length of ischemic bowel can cause significant systemic effect secondary to sepsis and
obstruction proximal to the obstruction can result in significant dehydration. When
bowel involvement is extensive circulatory failure is common
 Strangulation occurs in nearly 10 to 20% of people with obstruction of the small
intestine
 Classification According to :
 Pathological Causes :
1. Twisting of Intestinal blood supply around itself “Volvulus”
2. Constriction of the blood supply by tight band or hernia
3. Thrombosis or Embolism of mesenteric vessels

4. - merckmanuals.com
- baily&love`s 26th

5. Lumen
1. Patent : Richter`s hernia, litter's hernia, MVO
2. Occluded: Strangulated external hernia, Volvulus, Intussusception
Motility
1. Dynamic obstruction : Mechanical causes e.g. Strangulated hernia,
Volvulus, Intussusception
2. A dynamic obstruction : e.g. MVO
Age
1.Neonate: Volvulus neonatorum, Intussusception
2.Infants: Strangulated hernia “commonest”
3.Adults: Tight adhesion bands “postoperative”, Strangulated hernia.
4.Elder: Strangulated hernia, MVO

6.  Pathology
 Ischemia from direct pressure on the bowel wall from a constricting band, such
as hernial orifice, is due to distention of bowel segment progress to congestion
and edema
 Distension of obstructed segment of bowel results in high pressure within the
bowel wall. This can happen when only part of the bowel is obstructed as seen
in Richter`s hernia.
 Venous return is compromised before the arterial supply. The resultant increase
in capillary pressure leads to impaired local perfusion and once the arterial
supply is impaired, hemorrhagic infarction occurs. As the viability of bowel is
compromised, translocation and systemic exposure to anaerobic organisms and
endotoxins occurs.
Baily&love`s 26th edition page 1182

7. Consequences of pathology
1. Bowel Gangrene: at first, venous occlusion strangulated loops &
mesentery become swollen and distended with gas and blood stained fluid.
Later, Arterial occlusion mucous membrane ulceration perforation
and peritonitis
2. Blood loss: From strangulated segment hypovolemic shock due to
dehydration & with PR shows “Red current jelly stool”
3. Toxic absorption: From peritoneal cavity General manifestation of
toxemia
 In closed Obstruction: Both ends are occluded, pressure inside lumen
increase interfering with blood supply Perforation & peritonitis
 A dynamic occlusion eg MVO: ischemia, ulceration, Sloughing & bleeding
bacterial translocation & toxemia due to peritonitis

8.  The list of signs and symptoms mentioned in various sources
for Bowel strangulation includes :
 General signs: Dehydration, Shock, Toxemia
 Abdominal or groin lump: due to the cause as, hernia, Tumour or
intussusception “sausage-shaped mass and emptiness in the right lower
quadrant (De Dance sign) “
 Pain: But spasm is more sever than intestinal obstruction and continuous
sharp pain & not relieve with NG Suction.
 Tenderness & Rebound tenderness with Rigidity
 Nausea & Vomiting :Repeated & Sever causes dehydration & shock
 Fever due to toxemia of peritonitis
 DRE: Red current Jelly stool or mass in Tumour or intussusception.
 Auscultation: Exaggerated intestinal sound followed by paralysis “silent
abdomen”
rightdiagnosis.com

9. General Complications of Stangulation
 Shock “Toxic & hypovolemic”
 Gastrointestinal bleeding
 Bowel obstruction & Gangrene
 Renal failure
Urgent necessary investigation
 CBC : Leucocytosis
 CT : 80 – 90% sensitivity in diagnosis
 U/s : Distended loops / mass of intussusception, Omega sign as in
sigmoid volvulus
 Plain x-ray erect position Erect “ multiple air fluid level”
 For Complications : KFT “pre-renal failure due to shock” , LFT, serum
electrolytes, CBC & serum lipase & amylase “raised”

10. Preoperative
1. Maintain I/V line with Cannula.
2. Draw blood samples for investigations.
3. Analgesia: Narcotic Analgesics. Inj. Nalbufin 10 mg + Inj. Marzine 10 mg I/V stat slow.
4. Start I/V Fluids. Inj. Ringer’s Lactate I/V to correct hydration status of the patient.
5. Start I/V Antibiotics. 1- Inj. ampicillin 500 mg I/V stat. 2- Inj. metronidazole 500 mg I/V
stat. 3- Inj. gentamycin 80 mg I/V stat.
6. Pass N/G tube and active suction & Urethral catheter to calculate urine outbut
7. Inform the REGISTRAR and Anesthetist and Theater Sister.
8. Admit the patient in the ward.
9. Take consent for operation.
10. Shift the patient to the Operation Theater as early as possible.
medicalopedia.org/1012/strangulated-inguinal-hernia
Treatment “ Urgent Surgery”

11. Treatment “ Urgent Surgery”
 Urgent Surgery according to the cause to avoid “ Perforation &
Gangrene “ under general anesthesia with long midline exploratory
incision except in strangulated hernia directly over it.
Exploration & determination of the level “ look for the caecum”
 if collapsed >> small bowel
 if distended >> large bowel

12. Treat the cause
Reduction & repair of hernia or untwisting of the volvulus or division of adhesions if
viable bowel

13. Right hemicolectomyResection and 1ry anastomosis in
Prepared colon or with GI stapling
device dorsal lithotomy position. This
allows for the possibility that an
unexpectedly low anastomosis may
be required end-to-end anastomosis
(EEA) stapler. The perineum remains
draped until it is time to pass the
stapling device.
Hartman`s Procedure
(rapid resection with an end colostomy)
is preferred. The patient is placed in a
supine position,
and a low midline incision is made
The proximal divided end of the colon is
mobilized sufficiently to create a tension-
free end colostomy. The distal stapled end
of the bowel remains in the pelvis
Medscape.com

14. Video : Dynamic Compression Anastomosis

15. Dynamic Compression Vs. Stapling

16. Post operative
 Sedation
 NPO
 Ryle suction & IV fluids
 Antibiotics
 Drain
 close monitoring of blood pressure and hemoglobin level to evaluate for sepsis or
hemorrhage.
Complications : Possible postoperative complications include the following:
 Surgical wound infection
 Anastomotic leakage
 Colocutaneous fistula
 Abdominal or pelvic abscess
 Sepsis

17. 1. Bands of Adhesion
 Caused Strangulation outside the wall.
 Etiology:
 Congenital : obliterated vitellointestinal duct
 Acquired “ common” Postoperative ,
 Inflammatory e.g. TB enteritis, Irritation by Powder of gloves.
 C/P
 Typical picture of Intestinal obstruction but
with past history of operation or other causes
 Investigations as pervious .
 Treatment : Adhesolysis or Lateral
anastomosis in extensive adhesion as in TB
Baily&love`s 26th edition page 1184

18. 2.Intussusception
 Intussusception is a serious condition in which part of the intestine slides into
an adjacent part of the intestine. This "telescoping" often blocks food or fluid
from passing through. Intussusception also cuts off the blood supply to the
part of the intestine that's affected, which can lead to a tear in the bowel
(perforation), infection and death of bowel tissue.
 Intussusception is the most common cause of intestinal obstruction in children
younger than 3. The cause of most cases of intussusception in children is
unknown but there are theories.
 Though rare in adults, most cases of adult intussusception are the result of an
underlying medical condition, such as a tumor.
 In children, the intestines can usually be pushed back into position with an X-
ray procedure. In adults, surgery is often required to correct the problem.
mayoclinic.org/diseases-conditions/intussusception

19. Definition: Invagination of a segment of bowel into the lumen of adjoining &
usually lower segment.
 Types:
1. Infantile type “most common”
2. Adult type
Infantile type : Always acute, occur in
healthy male, maximally between 5 – 9 months
due to weaning & teething or following G.E.
Etiology: No organic cause, but pdf as :-
1. Mobile caecum & ascending colon so terminal ileum enter into it.
2. Bulky ileocaecal valve forming the apex of Intussusception.
3. Weaning & Teething are associated with G.E >> exaggerated peristalsis
4. Maximal aggregation of lymphoid follicles at terminal ileum.
5. Only 5% have organic cause as polyp or Meckel's diverticulum.

20. Pathology: The Intussusception is formed of 3 layers
1. Outer layer = intussuscepiens
2. Middle layer & Inner layer = intussusceptum
3. Apex = Distal end of intussusception
Pathological changes :
- As apex advances, the mesentery is pulled and
the veins are constricted at the neck >> edema &
gangrene >> Perforation & Peritonitis may occur.
- Spontaneous cure may occur by spontaneous
reduction or sloughing of the Intussusception.
Anatomical types
1.Ileocaecal 75% 2.Ileoileal 3.Ileoileocaecal
4.Ileocolic 5.Colicocolic
mayoclinic.org/diseases-conditions/intussusception

21. The patient with intussusception is usually an infant, often one who has had an
upper respiratory infection, who presents with the following : symptoms:
1.Vomiting: Initially, vomiting is nonbilious and reflexive, but when the intestinal
obstruction occurs, vomiting becomes bilious
2.Abdominal pain: Pain in intussusception is colicky, severe, and intermittent
3.Passage of blood and mucus: Parents report the passage of stools, by affected
children, that look like currant jelly; this is a mixture of mucus, sloughed mucosa,
and shed blood; diarrhea can also be an early sign of intussusception
4.Lethargy: This can be the sole presenting symptom of intussusception, which
makes the condition’s diagnosis challenging
5.Palpable abdominal mass
emedicine.medscape.com/article/930708

22. Physical examination
The hallmark physical findings in intussusception are a right hypochondrium
sausage-shaped mass and emptiness in the right lower quadrant (Dance sign). This
mass is hard to detect and is best palpated between spasms of colic, when the
infant is quiet.
Abdominal distention frequently is found if the obstruction is complete.
DRE : Red Current Jelly Stool
peritonitis can be suggested on the basis of rigidity and involuntary guarding.
Investigations :
Imaging studies used in the diagnosis of intussusception include the following:
Radiography: Plain abdominal radiography reveals signs that suggest
intussusception in only 60% of cases
emedicine.medscape.com/article/930708

23. Ultrasonography: Hallmarks of ultrasonography
include the target and pseudokidney signs
Contrast enema: This is the traditional and most
reliable way to make the diagnosis of
intussusception in children by Claw sign.
Treatment : As there are signs of Strangulation
there is no role of conserve by hydrostatic
reduction for example.
So ttt is Urgent Surgical according to loops viability
In healthy loops
*Reduction insitu *Reduction outside the abdomen
In unhealthy loops >> Resection & Anastomosis
*Terminal ileum : Rt hemicolectomy
*Lt colon Preparation then Hartman`s procedure or
Stapling device or resection and 1ry anastomosis
*Laparoscopy
mayoclinic.org/diseases-conditions/intussusception

24. Adult Type
affect adults, may be acute, subacute, chronic.
Etiology: Usually there is Organic cause as:
1. Benign or malignant tumour
2. Mechel`s Diverticulum
3. Parasite
4. Follow long period of starvation
Clinically
Typical signs & symptoms of intestinal obstruction.
Palpaple mass
Barium enema is diagnostic showing striate filling defects surrounded by a
shell of barium ( Claw sign)
Treatment
Operable >> Reduction & Exploration for cause
Inoperable or gangrenous >> Resection

25. 3.Volvulus
Definition: Abnormal twisting of a portion of
the gastrointestinal tract, usually the intestine,
Around its mesenteric axis which can impair blood
flow.
 Volvulus can lead to gangrene and death of the
involved segment of the gastrointestinal tract.
 It occurs due to a birth defect known as intestinal
malrotation which generally occurs during the
tenth week of gestation. However, Volvulus can
also affect individuals who do not have an
intestinal malrotation. It usually develops within
the first year of life.
medicinenet.com
medlineplus.gov/ency

26. VOLVULUS TYPES
This disorder is divided into several types according to the location:
 VOLVULUS NEONATORUM
 GASTRIC VOLVULUS
 INTESTINAL VOLVULUS
 CECAL VOLVULUS
 TRANSVERSE VOLVULUS
 SIGMOID VOLVULUS “ THE MOST COMMON’
 SPLENIC FLEXURE VOLVULUS
 COMPOUND VOLVULUS OR ILEOSIGMOID KNOT: It occurs when the ileum
enwraps the base of sigmoid, passes beneath itself to form a knot.
primehealthchannel.com/volvulus.html

27. CECAL AND SIGMOID VOLVULUS
 These types of the condition can result from various GIT disorders, such as
constipation, that cause the large intestine to overstretch. The
overstretched intestine can easily get twisted around itself and lead to the
disorder.
 Incidence: Affect both male and female, but more common in elder
males. Occur in long pelvic colon with high residual diet.
 Predisposing factors:
1. Abnormal elongation of pelvic colon.
2. Narrow attachment by mesocolon
3. Constipation by feces increase overload in colon
4. Adhesion at apex of sigmoid, which facilitate twisting

28.  Pathology:
 Chronic constipation lead to an overloaded sigmoid
colonic loop. The weight of this loaded sigmoid colon
makes it susceptible to torsion along the axis of
the elongated mesentery.
 The base of the sigmoid mesocolon becomes
foreshortened. The associated mild, chronic
inflammation at the base of the mesentery
and the two limbs of the sigmoid colon loop leads to
the formation of adhesive tissue. This causes the sigmoid
loop to become chronically fixed into a paddlelike
configuration, which, in turn,
The upper loop Rotate around the lower loop
Anticlockwise ½ turn Upton 1 ½ turn leading to:
 Occlusion of veins >> congestion & distension
 Occlusion of Arteries >> Gangrene & Perforation with peritonitis

29.  Clinical Features
 More than 60-70% of patients present with acute symptoms; the remainder present with
subacute or chronic symptoms. A history of chronic constipation is common. The patient may
describe previous episodes of abdominal pain, distention, and obstipation, which suggest
repeated subclinical episodes of volvulus.
 The symptoms of this disease are caused by two principal mechanisms:
 Bowel obstruction
 Reduction in blood flow (Ischemia)
 The symptoms generally vary depending on what form of Volvulus a patient is suffering from.
The common symptoms include:
 Abdominal distension “Sudden onset” is commonly massive and characteristically tympanitic
over the gas-filled, thin-walled colon loop.
 Abdominal pain “ colicky”
 Constipation “ Absolute”
 Rapid heart rate & breathing And Shock
 Vomiting greenish yellow material delayed 1-2 days
 DRE: Empty rectum, Passage of blood

30.  Investigations
 Laboratory tests include a complete blood count (CBC) with differential
and a comprehensive metabolic profile. An elevated white blood cell
(WBC) count and left shift indicate bowel ischemia, peritoneal infection,
or systemic sepsis.
 Bowel obstruction may cause significant changes in electrolyte levels.
 diagnostic studies include plain abdominal radiography, computed
tomography (CT), barium enema, and sigmoidoscopy or colonoscopy.
emedicine.medscape.com/article/2048554-workup

31. Plain X-ray
 Massive dilation of the sigmoid colon loop arising from the
pelvis and extending to the diaphragm is a typical finding of
sigmoid volvulus. The walls of the loop are evident as three
bright lines converging in the pelvis to create a beaklike
appearance.
 Cecal volvulus produces large- and small-bowel obstruction.
Radiographic findings reveal a markedly distended loop of
bowel extending from the right lower quadrant upward to
the left upper quadrant. The small bowel is distended,
whereas the distal colon is decompressed.
 Omega sign , Colonic obstruction and exaggerated or lost
haustrations

32. CT of Abdomen and Pelvis
 Computed tomography (CT) is not often needed, because the plain
radiographic findings typically suffice for diagnosis of sigmoid volvulusIn such
cases, CT can delineate the exact site of the torsion and reveal evidence of
ischemia.
 Upward displacement of the appendix with large-bowel obstruction is a
definitive sign of cecal volvulus. Additionally, decompressed transverse and
descending colon are apparent.
Barium Enema
 A contrast enema should be performed in patients
who show no evidence of peritonitis and in whom
plain abdominal radiographs are not diagnostic.
 The contrast study typically demonstrates a beaklike termination at the point of
the sigmoid volvulus .

33.  Treatment
 1. Improve general condition : Iv fluids , Rectal tube “can be ttt in early non
strangulated” & antibiotics
 The patient is resuscitated with intravenous isotonic crystalloid solution to
correct fluid deficits and hypovolemia. This is performed while the patient is
being examined and arrangements are being made to attempt endoscopic
reduction of volvulus. Laboratory tests and plain radiographs of the
abdomen are obtained in the emergency department.
 Broad-spectrum antibiotics with anaerobic coverage are given to patients in
whom peritonitis, ischemic bowel, or sepsis is evident. A Foley catheter is
inserted to assess fluid balance, and a nasogastric tube is placed if the
patient has been vomiting. Because pressure on the inferior vena cava may
compromise venous return, the patient is placed in the left lateral position
to improve venous return.

34. 2.Approach Considerations
Surgery is the definitive treatment of
sigmoid and cecal volvulus.
The decisions regarding timing of
surgery and choice of procedure
depend on the clinical presentation.
Endoscopic Detorsion and Decompression
Recognition of radiologic findings of a volvulus on
plain radiography is followed by emergency
sigmoidoscopy or colonoscopy for detorsion and
decompression of the volvulus.
The sigmoidoscope is advanced into the rectum
under direct vision. The rectum is insufflated to
provide good visibility and facilitate identification of
the apex of the volvulus. Occasionally, the pressure
of the air causes detorsion, reducing the volvulus.

35.  Sigmoid Colectomy for Sigmoid Volvulus
 After successful endoscopic decompression of
sigmoid volvulus, the surgical approach that is
simplest and has the lowest rate of recurrence is
sigmoid colectomy with primary anastomosis.
 The patient is placed in a dorsal lithotomy position.
This allows for the possibility that an unexpectedly
low anastomosis may be required, which can be
accomplished through transanal passage of an end-
to-end anastomosis (EEA) stapler. The abdomen and
perineum are prepared and draped separately. The
perineum remains draped until it is time to pass the
stapling device.
 In the event of a failed sigmoidoscopic reduction or
a suspected ischemic bowel, the divided bowel is
carefully inspected to ensure good supply.

36. Hartmann Procedure for Sigmoid Volvulus
 If fecal peritonitis is present or the patient is
hypotensive, a Hartmann procedure(rapid resection
of the volvulus with an end colostomy) is preferred.
 The patient is placed in a supine position, and a low
midline incision is made. The omega loop of the
sigmoid colon is resected. The proximal divided end
of the colon is mobilized sufficiently to create a
tension-free end colostomy. The distal stapled end of
the bowel remains in the pelvis .
 A Hartmann procedure is also a good option in a
severely debilitated, bedridden patient who requires
long-term care.

37. Right Hemicolectomy for Cecal Volvulus
 The preferred surgical procedure for the
treatment of patients with cecal volvulus
is right hemicolectomy.

The patient is placed in a supine position,
and the abdomen is prepared and draped. A
low midline incision is made. The area of the
volvulus and the terminal ileum are
exteriorized. The volvulus is reduced through
counterclockwise detorsion, because the
torsion occurs in a clockwise direction.

38. Complications
 Postoperative care includes continued fluid resuscitation and
antibiotic therapy as guided by the patient’s clinical
condition. Possible postoperative complications include the
following:
 Surgical wound infection (8-12%)
 Anastomotic leakage (3-7%)
 Colocutaneous fistula (2-3%)
 Abdominal or pelvic abscess (1-7%)
 Sepsis (2%)

39. 4.Strangulated Hernia
 A strangulated hernia is a life-threatening medical condition. Fatty tissue or a
section of the small intestines pushes through a weakened area of the abdominal
muscle. The surrounding muscle then clamps down around the tissue, cutting off
the blood supply to the small intestine. This strangulation of the small intestine can
lead to intestinal perforation, shock, or gangrene (death) of the protruding tissue.
Incidence:
1. The commonest cause of intestinal obstruction in developing countries
2. Adult more liable than infants because stronger muscles.
3. Varies according to hernia type “ 25-30% in femoral, 15-20% in paraumblical, 3-
5% in incisional, 2-4% in Inguinal.
4. Although femoral is higher but strangulated inguinal hernia more than 50% of all
strangulated external hernias
5. The content more commonly intestine than omentum
Kasr El-einy book

40. Causes:
1. Sharp edge of the defect such as;
 Edge of external & internal rings in oblique inguinal hernia.
 Edge of lacunar ligament in femoral hernia.
 Defect of the linea alba in paraumblical hernia.
2. Narrow neck in relation to large content:
3. Irreducibility, inflammation, obstruction predispose for strangulation.
4. Repeated attempts at reduction, producing edema.
Pathology:
1.The constricting agent: any resistant structure outside sac or bands of adhesions
within sac
2.The contents: Venoconstrivtion >> Congestion >> serous transudate.
Arterial obstruction >> ischemia >> Gangrene “stares at ring of obstruction >>
blood exudates >> Perforation & Peritonitis >> septic shock
3. Distended sac loses its luster & Inflamed covering

41. Clinical picture: “Pain+Tense+No Impulse”
 Hernia is painless condition unless complicated
 History pf painless swelling become painful “ colicky or stabbing due to ischemia
& Colic will disappear after perforation >> Generalized Pain due to peritonitis &
Finally septic shock.
 Picture of intestinal obstruction “ Vomiting, absolute constipation, Distension”
 Strangulation without obstruction can occur in :
1. Strangulated omentum
2. Strangulated Richter`s hernia
3. Strangulated Meckel`s diverticulum

42. Examination
 General Examination
 Dehydration / Hypovolemic or even septic shock
 Local Examination
 Gives no expansile impulse on cough
 Irreducible
 Tense “ Full of exudate or transudate” & Tender
 Sudden enlargement

43. Treatment “ Urgent operation after preparation”
Preoperative
1. Maintain I/V line with Cannula.
2. Draw blood samples for investigations.
3. Analgesia: Narcotic Analgesics. Inj. Nalbufin 10 mg + Inj. Marzine 10 mg I/V stat slow.
4. Start I/V Fluids. Inj. Ringer’s Lactate I/V to correct hydration status of the patient.
5. Start I/V Antibiotics. 1- Inj. ampicillin 500 mg I/V stat. 2- Inj. metronidazole 500 mg I/V
stat. 3- Inj. gentamycin 80 mg I/V stat.
6. Pass N/G tube and active suction & Urethral catheter to calculate urine outbut
7. Inform the REGISTRAR and Anesthetist and Theater Sister.
8. Admit the patient in the ward.
9. Take consent for operation.
10. Shift the patient to the Operation Theater as early as possible.
medicalopedia.org/1012/strangulated-inguinal-hernia/

44.  Intraoperative
 General anesthesia
 Wide exploratory incision
 Open the sac “at the fundus in
inguinal/femoral & near the neck in
paraumblical”
 Evacuate it from toxic fluid before division
of constriction ring, grasp the intestinal
loop & examine it “viable or not” then
deal with contents:
 Omentum = excision even viable or not
 Intestine = “viable or not”

45. Post operative
 Sedation
 NPO
 Ryle suction & IV fluids
 Antibiotics
 Drain

46. 5. Acute Mesenteric Ischemia
 Definition: Acute mesenteric ischemia (AMI) is a syndrome caused by inadequate blood flow
through the mesenteric vessels, resulting in ischemia and eventual gangrene of the bowel wall.
 Classification:
 AMI may be classified as either arterial or venous. AMI as arterial disease may be subdivided
into nonocclusive mesenteric ischemia (NOMI) and occlusive mesenteric arterial ischemia
(OMAI); OMAI may be further subdivided into acute mesenteric arterial embolism (AMAE) and
acute mesenteric arterial thrombosis (AMAT). AMI as venous disease takes the form of
mesenteric venous thrombosis (MVT).
 The four types of AMI have somewhat different predisposing factors, clinical pictures, and
prognoses. A secondary clinical entity of mesenteric ischemia occurs as a consequence of
mechanical obstruction (eg, from internal hernia with strangulation, volvulus, or
intussusception). Tumor compression, aortic dissection and postangiography thrombosis are
other reported causes. Occasionally, blunt trauma may cause isolated dissection of the superior
mesenteric artery (SMA) and lead to intestinal infarction.
emedicine.medscape.com/article/189146-overview

47.  Etiology
 Causes of AMAE (embolic AMI) include the following :
1. Cardiac emboli - Mural thrombus after myocardial infarction, auricular thrombus associated with
mitral stenosis and atrial fibrillation, or septic emboli from valvular endocarditis (less frequent)
2. Emboli from fragments of proximal aortic thrombus due to a ruptured atheromatous plaque
3. Atheromatous plaque dislodged by arterial catheterization or surgery (eg, aortic aneurysm
resection)
 Acute mesenteric arterial thrombosis
Causes of AMAT (thrombotic AMI) include the following:
1. Atherosclerotic vascular disease (most common)
2. Aortic aneurysm
3. Aortic dissection
4. Arteritis
5. Decreased cardiac output from MI or CHF (thrombotic AMI may cause acute decompensation)
6. Dehydration from any cause

48.  Causes of NOMI include the following:
1. Hypotension from CHF, MI, sepsis, aortic insufficiency, severe liver or renal disease, or
recent major cardiac or abdominal surgery
2. Vasopressors
3. Ergotamines
 Case reports have documented celiac artery compression syndrome (CACS) as a cause of
mesenteric ischemia through external compression of the celiac artery, usually by the median
arcuate ligament or the celiac ganglion.
Causes of MVT include the following (>80% of patients with MVT are found to have predisposing
conditions):
 Hypercoagulability antithrombin III deficiency, dysfibrinogenemia, polycythemia vera (most
common), thrombocytosis, sickle cell disease pregnancy, and oral contraceptive
 Tumor causing venous compression or hypercoagulability (paraneoplastic syndrome)
 Infection, usually intra-abdominal (eg, appendicitis, diverticulitis, or abscess)
 Venous congestion from cirrhosis (portal hypertension)

49. Pathology Damage result from Ischemia & Reperfusion
 Ischemia leading to:
1. Within 3 hr : complete vascular block affect first the mucosa which is the most
sensitive layer leading to ischemia, ulceration, slaughing and bleeding into the
lumen.
2. Bacterial translocation: Bacteria get access to blood vessles through damaged
mucosal barrier.
3. Within 6 hr : Whole thickness is affected >> gangrene & serous discharge
4. Fluid containing toxins collect in peritoneum >> Toxemia
5. Bowel is paralyzed and cyanosed & proximal loops become distended with fluid
and gases “peritonitis & paralytic ileus >> more distension
Reperfusion: Return of blood flow spontaneously or by surgery >> release of O2
free radicals to circulation >> cell membrane damage

50.  Clinical picture:
 Type of patient : Common in elderly due to thrombosis on top of atherosclerosis
 May occur in young pt due to embolism as “AF”
 Clinical features:
 Sudden sever abdominal pain, not relieved by narcotics or nasogastric suction
 Vomiting
 Bleeding per rectum, detected by DRE
 Later, Hypovolemic shock from blood loss
 Peritonitis due to Perforation
 Patient may become partially shocked with collapse & pallor and distension
rigidity, tenderness and rebound tenderness.
 Manifestation of toxemia
 DRE >> Red current Jelly stool

51.  Complications
1. The following are potential complications of AMI:
2. Bowel necrosis necessitating bowel resection
3. Sepsis and septic shock
4. Multiple organ dysfunction syndrome (MODS)
5. Death
Deferential diagnosis
1. Acute pancreatitis : Increase serum amylase
2. Other causes of intestinal strangulation
3. Neglected Perforated peptic ulcer

52. Investigations “No specific test”
1.CBC :
 Leucocytosis > 20,000
 Anemia decrease Hemoglobin
2.Serum amylase : to exclude acute pancreatitis
3.Aspiration of Peritoneal fluid with chemical “amylase, Lipase” & Bacterial
4.Plain X-ray in erect position shows:
 Multiple air-Fluid levels
 Necrosis >> intraluminal & intramural gas
 Gas in portal venous system
5.Abdominal U/s >> Fluid & Distended loops
6.CT Multiple studies have cited sensitivities of 96-100% and specificities of 89-94%.
7.Angiography “CONTROVERSED”
 Pre-operative if MAE is diagnosed

53. Treatment “Urgent laparotomy key of survival”
Initial Resuscitation and Stabilization
1. Shock >> Blood transfusion
2. Restore blood volume by IV fluids as isotonic sodium chloride solution
3. Decompression by NG suction
4. IV antibiotics for toxemia broad-spectrum
5. Oxygen should be provided to maintain a saturation between 96-99%
6. Urethral catheter for calculate urinary output
7. any arrhythmia, congestive heart failure (CHF), or myocardial infarction (MI)
should be treated.
8. Adequate pain control should be provided (e.g. with parenteral opioid
analgesics) while stable blood pressure is maintained.

54. Inpatient medications that may be used include the following:
1. Papaverine
2. Heparin/low-molecular-weight heparin (LMWH)
3. Warfarin
4. Broad-spectrum antibiotics and pain medications
5. Thrombolytics
 Because timing is essential in preventing bowel necrosis with its
attendant severe morbidity and mortality, patients should be
transferred only if the primary hospital lacks adequate services for
diagnosing and treating the patient. Patients should be optimally
resuscitated before transfer. Appropriate services must be available at
the receiving hospital.

55. In 2000, the American Gastroenterological Association released recommended
algorithms for the diagnosis and management of mesenteric ischemia

56. Surgical Intervention “urgent laparotomy”
*Gangrenous small intestine or Rt colon = Resection & 1ry anastomosis.
*Infarction of large intestine “rare” due to embolization of middle colic artery >>
Resection of transeverse colon with exteriorization “paul mickulicz`s technique”
Second look operation in 1ry anastomosis after 24-48 hr :
1. If Further pathology clinically detected.
2. To check viability of intestine
Avoid 1ry anastomosis in case of
1. Friable tissue in peritonitis
2. Bad general condition
3.Doubtful Viability of remaining intestine
So in these cases do 2 barrel colostomy till general & local condition improve

57. In case of Viable Intestine
 Reversible ischemia = Revascularization by:
 In Mesentric artery embolism
1. Embolectomy by Fogarty`s catheter
 In Mesentric artery thrombosis
1. Bypass graft
2. Post operative anticoagulant for 3 months

58. Post Operative Care
1. close monitoring of blood pressure and hemoglobin level to evaluate for sepsis or
hemorrhage.
2. Heparin anticoagulation should be continued postoperatively to reduce thrombotic
events.
3. Antibiotics should be continued postoperatively to prevent any septic events.
4. Papaverine may be administered to reduce vasospasm.
5. (ECG) should be obtained to evaluate for myocardial dysfunction.
6. Echocardiography should be considered to identify any for valvular vegetations.
7. A workup for a hypercoagulable state
8. Postoperative ileus due to bowel reperfusion should be expected and appropriately
managed.
9. Nasogastric suction
10.IV fluids

59. 6.Closed loop obstruction
 Closed loop obstruction is a specific type of
obstruction in which two points along the course of
a bowel are obstructed at a single location thus
forming a closed loop.
 Occur when both ends are occluded, Pressure inside
the lumen increase interfering with the blood supply
>> Perforation and peritonitis
 Example : Cancer Rt colon as the ileocecal valve act
as some sort of obstruction “ abnormal presentation
of cancer colon”
 Investigation: X-ray , CT
 Treatment of the cause after resusitaion
 Ex. Cancer Rt colon = Rt sided hemi colectomy

60. REFERENCES
 - baily&love`s 26th From pg. 1180 to 1185
 - merckmanuals.com
 rightdiagnosis.com
 medicalopedia.org/1012/strangulated-inguinal-hernia/
 Kasr Eleiny book
 mayoclinic.org/diseases-conditions/intussusception
 emedicine.medscape.com/article/930708
 medicinenet.com
 medlineplus.gov/ency
 primehealthchannel.com/volvulus.html
 emedicine.medscape.com/article/2048554-workup
 emedicine.medscape.com/article/189146-overview