prevention is greater than cure

1. 1/26/2017 by:- Lemessa J. 1
Intestinal obstruction
By:- Lemessa Jira
December ,2016
Gondar ,Ethiopia

2. Session objective
Introduction to intestinal obstruction
Classification of intestinal obstruction
Causes of intestinal obstruction
Small bowel obstruction
Large bowel obstruction
Management of intestinal obstruction
Nursing intervention
Reference
Acknowledgment1/26/2017 by:- Lemessa J. 2

3.  Define intestinal obstruction
 Identify the type of intestinal obstruction
 List possible cause of intestinal obstruction
 Describe the clinical features of intestinal
obstruction .
 Describe the nursing intervention of IO.
 Understand the management of intestinal
obstruction
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4. Intestinal obstruction is blockage prevents
the normal flow of intestinal contents
through the intestinal tract.
It is potentially risky surgical emergency
associated with high morbidity and
mortality(Ullah S, et al 2010)
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5. The prevalence of intestinal obstruction was
21.8 % among patients admitted with the
acute abdomen conditions and 4.8 % among
total surgical admission patients(Soressa Uet al
,2016)
About 85 % of intestinal obstruction occurs
in the small bowel, while 15 % of occurs in
the large intestine (Kakoza R ,2010)
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Mechanical( Dynamic )
Functional( A dynamic)
Classification of intestinal
obstruction

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Mechanical obstructions is when something
physically blocks the intestine. It can be caused by :-
1. Intraluminal:- Fecal impaction, foreign bodies,
gallstones, Bezoars and parasites .
2. Intramural:- tumors, inflammatory strictures,
lymphomas and colonic carcinoma .
3. Extramural:- adhesion, hernias, volvulus,
intussusception, tumors.

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Intussusceptions: one part of the
intestine slips in to the another part
located below it like a telescope
shortening.
Adhesions: loops of the intestine
become adherent to areas that heal
slowly or scar after abdominal
surgery.(Thampi D et al ,2014)

9. Volvulus: bowel twist and turns upon it.
Hernias: protrusion of intestine through a
weakened area in the abdominal muscle or
wall.
Tumors, and neoplasm.
(Thampi D et al ,2014)
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10. It occurs due to muscles or nerves
within either the small or large
intestine function poorly.
This process is called paralytic ileus
if it’s an acute or self-limiting
condition.
(Brunner 11th edition )
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11. The intestines normally work in a coordinated
system of movement. If something interrupts
these coordinated contractions, it can cause a
functional intestinal obstruction.
Causes for paralytic ileus include:-
Muscular dystrophy,
endocrine disorders such as DM,
neurological disorders such as Parkinson’s
disease. (Brunner 11th edition. )
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12.  The obstruction can be partial or
complete.
Its severity depends:
On the region of bowel affected
The degree to which lumen is
occluded and especially the degree
to w/c vascular supply is disturbed.
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13. Most bowel obstructions (85%) occur
in the small intestine.
Adhesion is the most common cause of
SBO, followed by hernias and
neoplasms.
(Gn BB, et al ,2015)1/26/2017 by:- Lemessa J. 13

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Intestinal contents, fluid, and gas
accumulate above the intestinal
obstruction.
The abdominal distension and retention of
fluid reduce the absorption of fluids and
Stimulate more gastric secretion.
This caused edema, congestion, necrosis and
eventually rupture or perforation of the
intestinal wall, with resultant peritonitis
(Brunner 11th edition. ).

15. Reflux vomiting may be caused by
abdominal distension
Dehydration and acidosis develop from
loss of water and sodium.
 With acute fluid losses hypovolemic
shock may occur.
(Brunner 11th edition. )
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Initially crampy pain that is wavelike and colicky.
Blood and mucus may pass, but no fecal matter
and no flatus.
Abdomen becomes distended.
If obstruction is complete- the peristaltic wave
become reverse direction so intestinal content
come to the mouth.
If obstructions is in the ileum- fecal vomiting
takes place. (Thampi D et al ,2014)

17. First the patient vomits the stomach
contents then the bile stained contents of
the duodenum and the jejunum and
finally with each paroxysm of pain, the
darker, fecal like contents of the ileum.
(Thampi D et al ,2014)
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18.  Sign of DHN become evident
 Intense thirst
 Drowsiness
 Generalized malaise
 Abdominal distention
 Hypovolemic shock from DHN
 Constipation
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19. Patient Hx and P/E
plain abdominal X-ray
Barium Enema
Ultra sound
Laboratory studies (electrolyte studies
and CBC)
(Thampi D et al ,2014)
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20. Non operative management:- fluid
resuscitation, bowel decompression,
administration of analgesia and
antiemetic as indicated clinically
and administration of antibiotics.
Complete obstruction needs
surgical intervention (Brunner 11th
edition).
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21. Activity as tolerated:- With paralytic ileus, the
patient is encouraged to ambulate to enhance
return of peristalsis.
IV therapy to replace the depleted water, and
electrolyte before surgery .
Antiemetic agents:- For relief of nausea and
vomiting.
Prophylactic antibiotics .
Monitor intake and out put
Supportive care
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22. As in small bowel obstruction, large bowel
obstruction results in an accumulation of
intestinal contents, fluid and gas proximal to the
obstruction.
It is About 15% of intestinal obstruction.
The most common cause are carcinoma,
diverticulitis, inflammatory bowel diseases and
benign tumors ,mostly it occurs at sigmoid colon.
(Love M. Practice , 2013)
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23.  LBO differs clinically from small
bowel obstruction in that
Symptoms develop slowly relative
to SBO.
 Constipation (if obstruction in
sigmoid colon or the rectum).
 Abdomen becomes markedly
distended.1/26/2017 by:- Lemessa J. 23

24.  Acute obstruction:- usually in small
bowel and obstruction with severe
colicky central abdominal pain,
distension, early vomiting and
constipation.
 Chronic obstruction: -usually in large
bowel which is lower abdominal
colic & constipation followed by
distension.1/26/2017 by:- Lemessa J. 24

25. 1. abdominal pain
2. vomiting
3. distension
4. constipation
Vary according to
• location of obstruction
• Duration of obstruction
• underlying pathology
• intestinal ischemia
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26. Abdominal pain
 colicky in nature, around the umbilicus in SBO
while in the lower abdomen in LBO.
 if it becomes continuous, think about
perforation or strangulation.
 does not usually occurs in paralytic ileus.
Vomiting
 starts early in SBO and late in LBO
 As obstruction progresses vomitus alters from
digested food to feculent due to enteric bacterial
overgrowth .1/26/2017 by:- Lemessa J. 26

27. Distension
 more with lower obstruction
 Loops of large bowel becomes visibly
outlined through the abdominal wall.
 Eventually, Crampy lower abdominal
pain .
 Dehydration occurs more slowly than
in the small intestine.
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28. 1/26/2017 by:- Lemessa J. 28
Dehydration
o More common in small bowel
obstruction due to repeated vomiting .
Pyrexia
Onset of ischemia.
Intestinal perforation.
Inflammation associated with intestinal
obstruction .

29. Acute cholecytitis
Perforated peptic ulcer disease
Ectopic pregnancy
Ovarian cyst
PID
Appendicitis
Acute pancreatitis
Peritonitis
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30. Based on symptoms
P/E
X-ray studies (show distended
colon)
Imaging abdominal CT
MRI findings reveal
(Thampi D et al ,2014)
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31. Vital signs
 Signs of dehydration :- tachycardia,
hypotension ,dry mucus membrane,
decreased skin turgor, decreased urine
output.
Inspection : distension, scars, masses,
hernia.
Palpation : Rebound tenderness, rigidity,
psoas sign and Rovsing sign ???????????1/26/2017 by:- Lemessa J. 31

32. Percussion : tympanic abdomen.
Auscultation : Increased frequency of
bowel sounds occur in diarrhea and
mechanical intestinal obstruction
 Reduced or absent bowel sounds occur
in paralytic ileus and generalized
peritonitis
(Thampi D et al ,2014).
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33. Colonoscopy may be performed to
untwist and decompress the bowel.
Rectal tube to decompress.
A nasogastric tube should be
considered for patients with severe
colonic distention and vomiting.
(Brunner 11th edition).
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34. The usual Rx, however, is surgical
resection to remove the
obstructing lesion
Colostomy /surgical opening of the
cecum / may be performed.
(Brunner 11th edition )
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35. Nausea, distension, and pain related to
gastrointestinal obstructive process.
Desired outcome:
Patient relates a reduction in discomfort and
does not exhibit signs of uncontrolled pain.
Intervention : Implement comfort measures to
provide pain relief like distraction, backrubs,
conversation and relaxation therapy.
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36. Implement comfort measures to
provide pain relief: distraction,
backrubs, conversation, relaxation
therapy.
Administer prescribed analgesics
and antiemetic agents as indicated.
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37. Maintain patency and proper
functioning of the gastric tube.
Monitor in put & out put .
Take special note of the amount of GI
aspirate.
Appropriate IV fluids at the prescribed
rate.
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38. Provide adequate fluid resuscitation and NG
suctioning non-operative management suggest it
to be successful in 65-81% of partial small-bowel
obstruction cases without peritonitis (Goyal SK,et al
2016).
CT scan of abdomen and pelvis should be
considered in all patients with IO because it can
provide incremental information over plain films
in differentiating grade, severity, and etiology of
IO that may lead to changes in management
(Adippah, et al 2010 )
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39. Patients with IO should generally be admitted to a
surgical service because this has been shown to
be associated with a shorter length of stay, less
hospital charges, and lower mortality compared
with admission to a medical service(Mbbs MD,
2015).
Rectal tube should stay at least for 48 hrs. and
Enema is contradicated for all patients who have
intestinal obstruction(Dickman R., 2013).
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40. 1. Soressa U, Mamo A, Hiko D, Fentahun N. Prevalence , Causes And Management Outcome Of
Intestinal Obstruction In Adama Hospital , Ethiopia. BMC Surg [Internet]. BMC Surgery;
2016;1–8. Available From: Http://Dx.Doi.Org/10.1186/S12893-016-0150-5
2. Gn BB, Naresh Y, Shivakrishna G. A Prospective Study On Adhesive Intestinal Obstruction In A
Tertiary Care Centre , South India. 2015;2(10):178–81.
3. Thampi D, Tukka Vn, Bhalki N, Ss A. ISSN ( O ): 2321 – 7251 A Clinical Study Of Surgical
Management Of Acute Intestinal Obstruction. 2014;(1).
4. Ullah S, Khan M, Mumtaz N, Naseer A. Original Article Intestinal Obstruction : A Spectrum Of
Causes. :188–92.
5. Thampi D, Tukka VN, Bhalki N, Ss A. ISSN ( O ): 2321 – 7251 A Clinical Study Of Surgical
Management Of Acute Intestinal Obstruction. 2014;(1).
6. 5 Kakoza R, Iii HMS, Lieberman G. Mechanical Small Bowel. 2010;(may).
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41. 41
 Any question???
1/26/2017by:- Lemessa J.
Thank
you!