5. DEFINITION
• Bowel obstruction is any condition
that interferes with normal
movement and passage of intestinal
contents. This can involve the small
bowel, colon or both small and colon
as in generalized ileus
•Intestinal obstruction is a blockage
that keeps food or liquid from passing
through the small or large intestines
(colon)
6. EPIDEMIOLOGY
It comprises of the following:
•1% of all hospitalized patients
•3% of all emergency surgical admissions
and operations
•More frequent in female patients
because of gynecological-obstetric and
pelvic surgical operations which are a
predisposing factor for post operative
adhesions
•Adhesions are the most common cause
of intestinal obstruction
7. EPIDEMIOLOGY CT…
•80% of bowel obstruction are due to small
bowel obstruction and the most common
causes are adhesion, hernias, and
neoplasms (tumors) while 20% are due to
colon obstruction and the most common
cause is Colon-rectal cancer which is 60-
70% while 30% are diverticular disease
and volvulus
8. EPIDEMIOLOGY CT…
•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 surgical treatment is 8 to 32%
9. CAUSES
•Fibrous bands of tissue (adhesions) in the
abdomen that form after surgery
•Hernias
•Colon cancer
•Certain medications or strictures from an
inflamed intestine caused by certain
conditions, such as Crohn's disease or
diverticulitis
10. CAUSES- SMALL BOWEL
Extra luminal
Intramural
Luminal
Postoperative
adhesions
Congenital
adhesions
Hernia
Volvulus
Neoplasims
lipoma
polyps
leiyomayoma
hematoma
lymphoma
carcimoid
cacinoma
secondary Tumors
Crohns
TB
Stricture
Intussusception
Congenital
Foreign Body
Gall stone
Food Particles
11.
12.
13. CLASSIFICATION
Cause of obstruction : mechanical or
functional ( Ileus )
•Duration of obstruction: acute or chronic
•Extent of obstruction : partial or complete
•Type of obstruction : simple or complex
(closed loop and strangulation)
14. MECHANICAL OBSTRUCTION
There is physical blockage of intestinal
lumen due to:
1. Intramural (within wall) : congenital,
tumors, hematoma and inflammation
2. Extramural (outside wall): adhesion,
volvulus, hernia, abscess, hematoma
3. Luminal (within lumen) obstruction:
stone, foreign body, impaction (stool
orworms)
15. MECHANICAL OBSTRUCTION CT…
This mechanical obstruction can be partial (
lumen narrowed but allow transit of some
contents) or complete ( lumen - totally
obstructed)
When lumen is totally obstructed can be
classified as:
1. Simple obstruction (no vascular
impairment)
2. Closed loop ( both ends are obstructed
e.g volvulus)
3. Strangulation obstruction
16.
17. SMALL BOWEL ADHESIONS
Accounts for 60-70% of All Small Bowel
Obstruction:
• Results from peritoneal injury, platelet
activation and fibrin formation
• Associated with intra-peritoneal sepsis,
haemorrhage and wash with irritant
solutions iodine and other foreign
bodies
• Colon or rectal Surgery 25%
• Gynaecological 20%
• Appendectomy 14%
18. HERNIA
Accounts for 20% of Small Bowel
Obstruction
Commonest are:
1. Femoral hernia
2. Inguinal hernia
3. Umbilical hernia
Others:
4. Incisional hernia
19. HERNIA CT…
• The site of obstruction is the neck of the
hernia. The compromised viscus is within
the sac
• Ischemia occurs initially by venous
occlusion, followed by oedema and
arterial compromise
• Strangulation is noted by:
• Persistent pain
• Discolouration
• Tenderness
20.
21.
22. FUNCTIONAL OBSTRUCTION
•These are obstructions secondary to
factors caused by either paralysis or
dysmotility of intestinal peristalsis
•Postoperative ileus is the most common
form of functional bowel obstruction
•Postoperative ileus present to some extent
after most intra-abdominal operation
23. FUNCTIONAL OBSTRUCTION CT…
•Postoperative ileus is associated with
degree of surgical trauma and type of
operation e.g. radiation surgery, chronic
obstruction or severe peritonitis have
more prolonged Post operative ileus
•Different anatomic segments of GIT also
recover at different rates after
manipulation and trauma such as:
- Small bowel within hours after
operation
- Stomach may take 1-2 days
- Colon 3-5 days post op
24. ETIOLOGY OF FUNCTIONAL OBSTRUCTION
Ther are three types:
A. Vascular occlusion ileus.
B. Spastic ileus. ( intestine remain
contracted and not propellent)
causes are:
1. Uremia
2. Heavy metal poison
25. FUNCTIONAL OBSTRUCTION CT…
C. Adynamic or inhibition ileus :
1. Post operation mostly after
abdominal surgery
2. Metabolic causes: Diabetic Keto
Acidosis - hyponateremia-
hypokalemia – hypomagnesaemia
3. Drugs: morphine, antacid and
anticonvulsant
4. Intra-abdominal inflammation
such as sepsis or wound infection
5. Some conditions such as
Pneumonia, renal stones,
retroperitoneal hematoma,
fracture spine and ribs
26. PATHO-PHYSIOLOGY
•In normal circumstances isotonic fluid
received by the small intestines (saliva,
stomach, duodenum, pancreas and
hepatobiliary, most of it is absorbed. The
remaining fluid enters the large intestine
and about 200 ml is excreted in faeces. On
the other hand air in the bowel which
results from swallowed air ( O2 & N2) and
bacterial fermentation in the colon ( H2,
Methane & CO2), is released through flatus
27. PATHOPHYSIOLOGY CT…
•When there is obstruction to the bowel,
fluid and gas can not pass through inorder
to be excreted in faeces or flatus, this
causes proximal bowel to be filled with
fluid and gas, hence the bowel dilates. The
dilatation and built up of gas and fluid
increases intra-luminal pressure resulting
in increased pressure on the bowel wall,
when pressure on wall increases-pressure
in the capillaries is also increased leading
to reduction of blood supply to the bowel
wall
28. PATHOPHYSIOLOGY CT…
•This causes ischemia, gangrene,
perforation of the bowel which leads to
bowel contents to enter into the
abdominal cavity causing peritonitis
•In addition, enteric bacteria consist of
coliforms, anaerobes and streptococci
faecalis releases toxins which causes gas
accumulation in the intensities
29. PATHO-PHYSIOLOGY CT…
•when this happens, there is distension of
the abdomen due to gas or fluid
accumulation. This exerts hydrostatic
pressure in the intestines which could
weaken intestinal wall and leads to rupture
of the intestines leading to intestinal
contents oozing into the abdominal cavity
leading to irritation and infection called
peritonitis
30. PATHO-PHYSIOLOGY CT…
•If mucosal barrier is broken it may result in
penetration of bacteria and toxins into the
blood stream leading to bacteremia,
septicaemia and toxaemia
Obstruction results in:
1. Initially there is increased peristalsis in
order to overcoming the obstruction
2. Increased intraluminal pressure by
accumulation of fluid and gas
3. Vomiting
31. PATHO-PHYSIOLOGY CT…
1. Flow of fluid into the lumen from the
surrounding circulation
2. Lymphatic and venous congestion
resulting in oedematous tissues
3. Hypovolaemia and electrolyte
imbalance
4. Localised anoxia, mucosal depletion,
necrosis and perforation and peritonitis
5. Bacteria over growth with translocation
of bacteria and it’s toxins causing
bacteraemia and septicaemia
32. RISK FACTORS
•Diseases and conditions that can increase
risk of intestinal obstruction include:
•Abdominal or pelvic surgery, which often
causes adhesions
•Crohn's disease, which can cause the
intestine's walls to thicken, narrowing the
passageway
•Cancer in the abdomen
33. CLINICAL MANIFESTATIONS
•Crampy abdominal pain that comes and
goes
•Loss of appetite
•Constipation (Inability to have a bowel
movement or pass gas)
•Vomiting
•Abdomen distention
34. DIAGNOSTIC PROCEDURES
History taking and physical examination:
1. Ask for four important symptoms:
(pain, vomiting, distension and
constipation)
2. Proximal obstruction earlier
symptoms with prominent vomiting
and less distension while vomiting
uncommon in colon obstruction till
late stage
3. Location and characteristic of pain
differentiates between mechanical
obstruction and ileus. Severe, cramp
and localized (mid abdomen) pain in
mechanical while in ileus pain is
diffuse and mild
35. DIAGNOSTIC PROCEDURES CT…
Examination :
•Vital signs (Temperature, pulse rate,
respirations & blood pressure)
•Hydration status
•Abdominal and rectal examinations
Laboratory investigations:
•Full Blood Count: increased packed
cell volume (dehydration ) and
increased in WBC (infection)
•Kidney Function Test: increase in Blood
Urea Nitrogen and creatinine
36. DIAGNOSTIC PROCEDURES CT…
•Lactate concentration-amylase-lactic
dehydrogenase useful but not
sensitive in evaluations of bowel
obstruction especially to rule out
necrosis
•Serum concentration to identify
presence of intestinal cell necrosis
but the specificity and sensitivity still
not accurate
37. DIAGNOSTIC PROCEDURES CT…
Radiological :
A.Upright Chest X-Ray with supine and
upright abdominal
1. CHEST X-RAY
1. Detect extra-abdominal
condition present with bowel
obstruction e.g. pneumonia
2. Presence of pneumoperitoneum
indicates perforated abdominal
lining
2. ABDOMINAL X-RAY
•Small bowel considered dilated
when diameter more than 3 cm
while proximal colon 9 cm and the
sigmoid 5 cm
38. DIAGNOSTIC PROCEDURES CT…
•Dilated small bowel tends to be in
the central portion of abdomen
while dilated colon tends to be in
the periphery of abdomen (can be
diagnostic in 50-80% of patients)
The cause of bowel obstruction can
often be determined eg presence of
pneumobilia suggest ileus while
presence of sigmoid and cecal
volvulus
39. DIAGNOSTIC PROCEDURES CT…
Contrast studies:
•Indications are controversial.
Identify site and often the cause of
obstruction
Differentiates between colonic and
distal small bowel obstruction
Differentiates between ileus-partial
and complete obstruction
40. DIAGNOSTIC PROCEDURES CT…
Computed tomography:
Recently become valuable in Bowel
Obstruction especially when plain
films failed to diagnose suspected
strangulation
Sensitivity 93% and specificity 100%
Accuracy 94% in diagnosis of Bowel
Obstruction
42. Role of CT
SCAN
• Used with iv contrast, oral and
rectal contrast (triple
contrast).
• Able to demonstrate
abnormality in the bowel wall,
mesentery, mesenteric vessels
and peritoneum.
• It can define
• the level of obstruction
• The degree of obstruction
• The cause: volvulus,
hernia, luminal and mural
causes
• The degree of ischaemia
• Free fluid and gas
• Ensure: patient vitally stable
with no renal failure and no
previous alergy to iodine
43. MANAGEMENT
CONSERVATIVE
• Resuscitation: Air way, breathing nd
Circulation (ABC)
• Air way (O2 60-100%)
• Insert 2 lines if necessary
• Collect blood for lab investigations
• Inform a senior member in the team
• NPO
• Decompress abdomen with Naso-gastric
tube and secure in position
44. CONSERVATIVE MANAGEMENT
CT…
• Insert a urinary catheter (hourly urinary
measurements) and start a fluid input
and output chart
• Intravenous antibiotics prophylactic
• Follow-up lab results and correction of
electrolyte imbalance
45. CONSERVATIVE
MANAGEMENT CT…
• The patient should be nursed in HDU
• Rectal tubes should only be used in
Sigmoid volvulus
• Correct electrolyte abnormalities
• Recognise strangulation and
perforation
46. INDICATIONS FOR SURGERY
1. Generalized or localized
peritonitis
2. Perforation
3. Irreducible hernia
4. Strangulated hernia
5. Palpable mass
6. Closed loop
7. Failure to improve
47. COMPLICATIONS
•Untreated, intestinal obstruction can cause
serious, life-threatening complications,
including:
•Tissue death: Intestinal obstruction can cut
off the blood supply to part of the intestine.
Lack of blood supply would lead to death of
the wall of the intestinal
• Tissue death can result in a tear
(perforation) in the intestinal wall, which
can lead to infection
48. COMPLICATIONS CT…
•Infection: Peritonitis is the medical term for
infection in the abdominal cavity. It's a life-
threatening condition that requires
immediate medical and often surgical
attention
49. Gradable assignment in groups
• Mr. GG 60 years old is admitted in male
surgical ward with complaining of
constipation for 5 days, abdominal pain
and distension. He is also experiencing
repeated episodes of vomiting. His vital
sign are stable on examination abdomen
is distended with diffuse tenderness and
bowel Sounds are hyperactive. Plain
abdominal x-ray was taken on admission
50. SUBMISSION MONDAY NEXT WEEK at 10 AM
•Formulate all possible nursing diagnoses
and their interventions
51. GASTROINTESTINAL REVIEW
•The gastrointestinal tract is comprised of
several segments: stomach, small intestine,
large intestine, rectum and anus
•It is a complex system with many functions,
but the fundamental function is to ensure
that food is available in a form that allows
cells to use it
•It consists of four main layers: mucosa,
submucosa, muscle and peritoneum
•The mucosa consists of epithelial cells and
secretory glands that aid in absorption and
secretion
52. GASTROINTESTINAL REVIEW CT…
•The submucosa is a thick layer of
connective tissue that joins the mucosa to
the muscle layer
•It also contains blood vessels, nerves and
glands
•The muscle layer is comprised of two
smooth muscle layers, a circular inner
sheet and a longitudinal outer sheet
53. GASTROINTESTINAL REVIEW CT…
•It is innervated by the autonomic nervous
system and is responsible for peristalsis
(propulsive and mixing movements) while
the peritoneum is a layer of connective
tissue that covers most of the
gastrointestinal tract in the abdomen
54. GASTROINTESTINAL REVIEW CT…
•The large intestine (colon) is approximately
four to five feet in length and is wider in
diameter than the small intestine
•It connects the end of the ileum to the anal
canal. It consists of several distinct
segments: cecum, ascending colon,
transverse colon, descending colon, sigmoid
colon, rectum and anal canal. Its functions
include:
55. GASTROINTESTINAL REVIEW CT…
sodium and water absorption, secretion of
mucous to lubricate and aid in defecation
and storage of feces until defecation
•Fecal matter is 75% water and 25% solid
waste. The average person defecates five
to seven times a week. Those who eat a
diet rich in fiber will produce more stool in
a quicker transit time
56. COLOSTOMY
•A colostomy is a surgically created opening
in the abdomen where a portion of the
colon is brought through to allow
feces/stool to pass. It can be either
temporary or permanent depending on the
reason for its creation
•A temporary colostomy will allow the
affected bowel a chance to rest and heal.
Once the bowel has healed, the colostomy
will be reversed (closed)
57. COLOSTOMY CT…
•Part of the intestine that has been brought
to the outside of the abdominal war is
referred to as a stoma
•A temporary stoma usually remains in
place for 3 to 6 months
•A permanent colostomy is required when
the disease affects the lower end of the
intestine and/or rectum, or the patient has
significant problems that would place them
at a higher risk if they had reversal surgery
58. COLOSTOMY CT…
•The most common colostomies are the
sigmoid colostomy located in the lower
left quadrant, transverse colostomy
located in the upper right and left
quadrants near the midline and an
ascending colostomy located on the
right side of the abdomen
61. INDICATIONS FOR COLOSTOMY
•Colon or rectal cancer, chronic
inflammatory bowel diseases, diverticular
disease, radiation damage and trauma are
among the top health issues that lead to the
need for a temporary or permanent
colostomy
62. OSTOMY POUCH/COLOSTOMY BAG
•After surgery a person will be using
colostomy bags stack on top of the stoma
to receive foecal mater. The pouches are
waterproof and come in different types
and shape
•There are 2 types reusable and disposable
65. CARE OF COLOSTOMY
•Colostomy care refers to colostomy
management
•The purpose of colostomy care is for skin
protection and prevention of stoma related
complications
• The pouch should be emptied when it is
about half full of either air or stool. This will
prevent the pouch from getting too full and
pulling off (detached from the skin) before
emptying because if too full it will be heavy
66. CARE OF COLOSTOMY CT…
•Place toilet paper in the toilet to prevent
splashing when pouring contents from the
pouch into the toilet
•Then, sit down and empty the pouch
between legs. If an individual chooses to
empty the pouch whilst standing then
stand facing the toilet to empty the pouch
•If pouch is reusable, clean the end of the
pouch with toilet paper, then fold up the
closure at the bottom of the pouch
67. CARE OF COLOSTOMY CT…
•Colostomy Pouch need to be changed
routinely twice a week, and when any of
the following occur:
• Leakage, Itching under the pouch, Burning
under the pouch
Changing the pouch
•Assemble the following: Scissors,
Measuring guide, Wash cloths or soft
paper towels, a bowl of clean water
68. CARE OF COLOSTOMY CT…
•Towel Paste or ring (optional), Paper
towel rolled into a wick
•Remove the old pouch gently by lifting up
on tape while pressing underneath on
skin
•Do not rip or tear the pouch off, as this
can irritate the skin. If pouch is sticking
too well, use a wet wash cloth to press on
the skin behind the barrier
69. CARE OF COLOSTOMY CT…
•Clean the skin with a wet washcloth or soft
paper towel tipped in clean tap water and
clean the skin around the stoma
•Allow skin to dry well. Do not use wipes
that have lotion in them. Check skin around
the stoma for any changes. Measure the
stoma before applying pouch, remeasure
the stoma with a guide Make a note of the
new size opening. Trace the new opening
on the back of the wafer and cut it out
70. CARE OF COLOSTOMY CT…
•For the first 2 months after surgery,
measure the stoma whenever changing the
pouch
•Adjust the size as needed
•Prepare wafer/pouch by removing the
paper backing from the barrier wafer
71. CARE OF COLOSTOMY CT…
•Paste, ring or strip paste may be used on the
sticky side of the wafer/barrier around the
opening edge or wherever minor creases are
to fill in, making a flat surface. This will
improve the fit and seal of the pouch
• Center the opening in the wafer/barrier
around the stoma and apply the sticky side
to the skin
•Press down to make sure all edges are
sealed
72. CARE OF COLOSTOMY CT…
•To close the bottom of the pouch, fold up
the lower edge 3 times and pinch to close
Treatment of irritated skin
1. Remove the pouch gently
2. Cleanse with a wet wash cloth
3. Gently dry surrounding skin
4. Sprinkle ostomy protective powder on
reddened skin
73. CARE OF COLOSTOMY CT…
5. Dust off excess powder with a dry cloth.
The powder should stick only to areas where
the skin is irritated. The powder provides a
dry surface so the wafer is able to stick well
6. Recheck the size of the stoma opening
used and be sure the opening in the wafer is
the same size as the stoma
7. Prepare and apply wafer and pouch as
usual
74. CARE OF COLOSTOMY CT…
•It is important to have equipment that fits
and works well and allows the person to
lead a normal, active life
•Observe the following any time stoma care
is done if present visit the hospital
•Unusual bulging around stoma (there was
no bowel movement for more than 2 days)
•Any unusual problems with abdominal pain
or continuous nausea and vomiting
75. CARE OF COLOSTOMY CT…
•Skin irritation lasting for more than a few
days (redness, itching or burning) or if a
person has any questions or problems with
pouching or leakage or questions about
activities of daily living
Other important tips
•Carry an extra pouch already cut to fit the
stoma when leaving home. This will make
one feel more secure if leaking occurs
•It is also important to bring an extra pouch
any time one visits the hospital
76. REFERENCE
Huether, S.E and Mc Cance, K.L (2013).
Understanding pathophysiology. (5th
Ed.) St. Louis: Elsevier.
Stellenberg, E. & Bruce, J. (2007). Nursing
practice: Medical-Surgical
