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Intestinal obstruction lecture

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Intestinal obstruction lecture

  1. 1. Intestinal Obstruction Dr. Faiez Alhmoud Albashir Hospital Amman-Jordan
  2. 2. WHAT’S INTESTINAL OBSTRUCTION ?
  3. 3. Intestinal Obstruction is: Restriction to the normal passage of intestinal contents or Luminal intestinal contents can’t pass through or Failure of propulsion of intestinal contents
  4. 4. CLASSIFICATION According to: - Type - Onset - Level - Nature
  5. 5. According to TYPE Intestinal obstruction may be classified into two types : 1• Dynamic or mechanical where peristalsis is working against a mechanical obstruction. 2• Adynamic or paralytic where the mechanical element is absent and may occur in two forms: Peristalsis may be absent (paralytic ileus) or non-propulsive form (mesenteric vascular occlusion or pseudo obstruction).
  6. 6. According to ONSET NATURE OF PRESENTATION ACUTE :sudden severe central colicky pain, central distention and early vomiting with late constipation(Usually small bowel) CHRONIC :lower abd. Pain with constipation followed by distenton of long duration (usually large intestine) ACUTE ON TOP OF CHRONIC :short history of distention with vomiting on longer history of pain & constipation SUBACUTE :incomplete or ON & OFF intestinal obstruction
  7. 7. According to LEVEL  High or Low  Proximal or Distal  Small or Large bowel  High (Proximal) or Low (Distal) small bowel
  8. 8. According to NATURE SIMPLE COMPLICATED
  9. 9. ETIOLOGY In both types there are :  CAUSES FROM OUTSIDE THE WALL (Extraluminal)  CAUSES FROM THE WALL (Intramural)  CAUSES IN THE LUMEN (Intraluminal)
  10. 10. ETIOLOGY DYNAMIC(MECHANICAL) FROM THE WALL 1- TB 2- CROHN’S 3- TUMORS 4-STICTURE 5- CONGENITAL ……… . .
  11. 11. ETIOLOGY MECHANNICAL IN THE LUMEN 1- GALL STONES 2- F.B 3- BEZOARS 4- WARMS 5- FECES ……….. GALL STONES BEZOARS WARMs FECES
  12. 12. ETIOLOGY MECHANICAL EXTRALUMINAL 1- BANDS 2- ADHESIONS 3- ABSCESS 4- HERNIAS 5-COMPRESSION …….. BANDS ABSCESS COMPRESSION HERNIA
  13. 13. ETIOLOGY Adynamic Intestinal Obstruction. 1- Peritonitis 2- Electrolytes’ Imbalance 3- Postoperative 4- Ischemia 5- Drugs 6- Retroperitoneal causes...
  14. 14. CLINCAL PICTURE HISTORY- INSPECTION- PALPATION-& AUSCULTATION -ABD. PAIN, DISTENTION, VOMITING ,CONSTIPTION - DEHYDRATION & LOSS OF SKIN TURGOR - TACHYCARDIA & HYPOTENTION - INCREASED OR ABSENT BOWEL SOUNDS - TENDERNESS ,REBOUND OR GUARDING - RECTUM SOMETIMES EMPTY 
  15. 15. DETAILS: MECHANICAL OBSTRUCTION WHERE PERISTALSIS WORKS AGAINST OBSTRUCTION
  16. 16. MOST COMMON CAUSES SMALL INTESTINE -ADHESIONS & - EXTERNAL HERNIAS (both are more than 75% of cases) - CROHN’S, TB, TUMORS, INTUS., CONGENITAL……… LARGE INTESTINE - TUMORS & - VOLVULUS (both are 90% of cases - DIVERTIDULITIS (rare) - ADHESIONS (extremely rare if at all)
  17. 17. CAUSES ACCORDING TO AGE BIRTH : Atresia, Meconium, NE, Volvulus,Hirschsprung’s 3 WEEKS : Pyloric stenosis 6-9MONTHS : Intussusception TEENAGE : Appendicitis , Meckel’s diverticulitis YOUNG ADULT : Adhesions , Hernia ADULT : Adhesions , Hernia, Appendicitis, Crohn’s, Carcinoma ELDERLY : Carcinoma, Diverticulitis, Sigmoid Volvulus , Feces
  18. 18. PATHOPHYSIOLOGY THE OBSTRUCTION COULD BE : - Simple - Closed loop - Strangulated
  19. 19. PATHOPYSIOLOGY SIMPLE OBSTRUCTION : 1-ABOVE THE OBSTRUCTION OBSTRUCTION  Peristalsis increases  Intstine dilates  Reduction in peristaltic strength  Flaccidity and paralysis (protective but late) 2- BELOW THE OBSTRUCTION NORMAL PERISTALSIS & ABSORBTION  Until it becomes empty  It contracts & becomes immobile
  20. 20. PATHOPHYSIOLOGY Distention of the intestine is caused by accomulation of: 1- GAS 2- FLUIDS gas fluids Distention fluids
  21. 21. PATHPYSIOLOGY Gas in the intestine is due to: 1. Swallowed air 2. Bacterial overgrowth 3. Diffusion from blood
  22. 22. PATHOPHYSILOGY Fluids come from : 1. Ingested fluids 2. Saliva 3. Gastric and intestinal juice 4. Bile & Pancreatic secretions
  23. 23. PATHOPHYSIOLOGY Dehydration caused by : 1. Reduced intake 2. Reduced absorption 3. Increased loss (Vomiting & sequesration)
  24. 24. PATHOPHYSIOLOGY Systemic Effects of Obstruction : 1. Water and electrolyte losses (lead to hypovolemia) 2. Toxic materials and toxemia(lead to sepsis) 3. Cardiopulmonary dysfunction(atelectasis) 4. Renal failure 5. Shock and death
  25. 25. PATHOPHYSIOLOGY Strangulation leads to impaired venous return  Increased congestion  -free peritoneal fluid -edema of intestinal wall -blood in the lumen -impaired arterial blood supply -ischemia and gangrene
  26. 26.  Pathophysiology : (1) Proximal segment •Hyperperistaltic phase •Antiperistaltic phase •Stage of dilatation •Fluid accumulation •Gas accumulation •Increased tension •Ischemia (2) Distal segment Collapsed
  27. 27. ADYNAMIC OBSTRUCTION causes Either localized or generalized Small intestine - Postoperative - Intra-abdominal abscess or peritonitis - Mesenteric embolism or thrombosis Large intestine - Retroperitoneal hematoma - Drugs - Hypokalemia - Idiopathic
  28. 28. DIAGNOSIS History Clinical examination Paraclinical examination
  29. 29. SYMPTOMS & SIGNS Pain Distention Vomiting Constipation and obstipation
  30. 30. THE PAIN In small bowel obstruction is central & colicky  In large bowel obstruction is dull & peripheral  In strangulation is continuous & severe  In paralytic ileus is absent
  31. 31. THE VOMITING Time of onset : Early: High small bowel obstruction Late: Low small bowel obstruction Delayed or absent: Large bowel obstruction Nature of vomitus Clear gastric: Pyloric obstruction Bilious: High small bowel obstruction Feculent: Low small bowel obstruction or late colonic
  32. 32. CONSTIPATION Incomplete Complete (Obstipation)
  33. 33. DISTENTION  High obstruction: Little and central distention if at all  Low obstruction: Great distention to the whole abdomen
  34. 34. CLINICAL EXMINATION Inspection: dehydration, distention, visible peristalsis, hernias, scars Palpation: mases, tenderness, guarding, rigidity, obstructed hernia Percution: tympani, tenderness Auscultation: frequent, metalic (high pitched), borburigmi, absent Digital rectal examination: impaction, masses, blood, empty rectum
  35. 35. PARACLINICAL EXAM.  Plain abdominal X-ray :  erect & supine  CT Scan  CBC  KFT
  36. 36. LATE MANIFISTETIONS  Oliguria.  Dehydration: dry tongue & skin, sunken eyes and poor venous filling  Hypovolemic shock  Fever  Respiratory embarrassment  Peritonism
  37. 37. RADIOLOGICAL PICTURE  Small Bowel Obstruction - Central distention (GAS) - Valvulae conniventes - “Ladder-like dilatation” - Small diameter  Large Bowel Obstruction - Peripheral distention “Picture frame” - More gross distention - Haustral indentation & large diameter
  38. 38. DIAGNOSIS ? Hernia
  39. 39. DIAGNOSIS ? Paralytic Ileus
  40. 40. DIAGNOSIS Small bowel obstruction Large bowel obstruction
  41. 41. DANGEROUS SIGNS (Red Flags)  Constant pain  Absent bowel sounds  Tenderness with rigidity  Leukocytosis  Fever and tachycardia  Shock
  42. 42. Do not take to OR if: Post-op Carcinomatosis Recurrent adhesive bowel obstruction Post radiotherapy
  43. 43. MANAGEMENT OF ACUTE CASE (Plan)  I.V Fluids and electrolytes rescusitation for all  N.G 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
  44. 44. Thank you

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