intestinal 0bstruction

2. INTESTINAL
OBSTRUCTION
ASSOC. PROFESSOR
COL. (R) DR. NISAR AHMED
MBBS (Army Medical College)
FCPS(SURGERY)
FCPS(ORTHOPAEDICS)
ARS (MALAYSIA), CHPE (NUMS)

3. LEARNING OBJECTIVES:
 Pathophysiology – dynamic, adynamic
 Cardinal features – history, examination
 Causes – small, large gut obstruction
 Indications for surgery and other treatment
options in bowel obstruction
 Contraindications for conservative Management

4. CLASSIFICATION:
 Dynamic – peristalsis, mechanical obstruction
 Adynamic- paralytic ileus, non propulsive Mesenteric
vascular obstruction or, pseudo obstruction

5. CAUSES OF DYNAMIC OBSTRUCTION:
 Intra-luminal –impaction, FB, Bezoars, gallstone
 Intramural- strictures, malignancy
 Extra-luminal- bands/adhesions, hernia, volvulus,
intussusception

6. CAUSES OF ADYNAMIC OBSTRUCTION:
 Paralytic ileus
 Mesenteric vascular occlusion
 Pseudo obstruction

7. Common causes of obstruction and their relative frequencies

8. PATHOPHYSIOLOGY:
 Proximal gut dilates- altered motility
 Below the obstruction – normal motility, immobile
 Proximal – increased peristalsis, dilates, reduced
peristalsis, flaccid
 Gas- bacteria. Aerobic/anaerobic, 90% Nitrogen
 Fluid- dig. Juices
 Dehydration and electrolyte imbalance
 Reduced intake
 Defective absorption
 Vomiting
 Sequestration in gut

9. 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

10. CLOSED LOOP OBSTRUCTION:
Strangulation
Distention
Necrosis
Perforation

11. CLINICAL FEATURES:
 Pain
 Vomiting
 Distension
 Constipation
 Dehydration
 Hypokalemia, fever, abdomen tenderness

12. PAIN:
 Severe, colicky, umbilical, lower abdomen
 Increases with peristalsis, later reduces
 Severe pain – strangulation

13. VOMITING:
 High obstruction- violent
 Low obstruction- slow onset nausea/vomit
 Gradually digestive food changes to feculent material

14. DISTENTION:
 Greater if distal obstruction
 Visible peristalsis
 Peristalsis delayed in colonic obstruction
 Absent in Mesenteric vascular obstruction

15. CONSTIPATION:
 Absolute
 Relative
 Absent in – Richter’s hernia, gallstone, Pelvic abscess,
partial obstruction

16. DEHYDRATION:
 Vomiting, fluid sequestration
 Dry skin, poor venous filling, sunken eyes, oliguria
 Raised blood urea, Hb, - secondary polycythemia

17. HYPOKALEMIA:
 K, amylase, LDH – strangulation, raised TLC or, leucopenia
 Fever – indicates – ischemia, perforation, inflammation
 Hypothermia – septic shock
ABDOMINAL TENDERNESS:
 Localized – ischemia
 Peritonitis – infarction or, perforation

18. 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

19. RADIOLOGY:
 Supine/ erect plain abdomen films
 Small gut- central, transverse, no/minimal gas in colon
 Jejunum- valvulae connivantes
 Ileum- featureless
 Cecum- round gas in RIF
 Large gut- haustral folds

20. SMALL GUT OBSTRUCTION
supine position erect position

21. SIGMOID VOLVULUS:
 Dilated, no haustral pattern
 Small gut- air and fluid levels
 More the fluid levels, more distal the lesion

22. INTUSSUSCEPTION:
 Plain film – absent caecal gas
 Barium enema- claw sign
 CT scan

23. ADHESIONS AND BANDS:
 Commonest
 Fibrin – adhesions- fibrinous, fibrous
 Appendectomy , gynecological op.
 Bands- congenital, bacterial peritonitis,
greater omentum causing band

24. CT SCAN ABDOMEN:
 It is widely used investigation in all forms of intestinal
obstruction.
 It is a highly accurate and its only limitations are in
diagnosing ischemia.
 Reduced bowel wall enhancement on CT Scan increases
the probability of strangulation.
 Absence of mesenteric fluid decreases the probability of
strangulation.

25. ULTRASOUND:
 Ultrasound may be helpful in detecting intra-abdominal
collection like abscess and ascites.
 It may also detect pathology in other solid abdominal
organs.
BARIUM ENEMA:
 It maybe helpful in children to diagnose ileo-cecal
intussusception.
 It can also be helpful in reducing the intussusception.

26. LAB INVESTIGATIONS:
 Blood CP
 ESR
 Blood Group
 LFTs
 RFTs
 Serum Electrolytes
 Serum Amylase
 CRP
 HBSAG
 Anti-HCV

27. FLOOD AFFECTED AREAS 2022:

33. TREATMENT OF ACUTE INTESTINAL OBSTRUCTION:
Conservative:
 NG Tube drainage
 Electrolyte and water replacement
 Antibiotics
Surgical Intervention:
 Timing of surgical intervention depends on the clinical picture.
 Early Surgical Intervention
1. Obstructed external hernia
2. Suspicion of intestinal strangulation
3. Obstruction in virgin abdomen
 Management of segment at the site of obstruction
 The distended proximal bowel
 Underlying cause of obstruction

34. SURGICAL PROCEDURES ACCORDING TO CAUSE
OF OBSTRUCTION AND GUT CONDITION:
 Adhesions/bands
Conservative 72 hours
Surgical Release
Serosal Tears Repair
Laparoscopic Adhesiolysis
 Internal Hernias
Release the ring and reduce the hernia
 Enteric Strictures
Stricturoplasty

35.  Acute Intussusception
Operative Reduction

36.  Caecal Volvulus
Clockwise female
Laparotomy/Laparoscopy
Untwist/Resection if gangrene

37.  Sigmoid Volvulus
Flexible sigmoidoscopy/rigid
Laparotomy-untwisting
Viable fixed to the peritoneum
Resection- gangrene
Sigmoid colectomy/ Hartmann’s procedure later
anastomosis

38.  Large Bowel Obstruction by Carcinoma
Resectable
Right hemi colectomy
Extended Right hemi colectomy
Left hemi colectomy

39. Unresectable
Colostomy
Self expanding metal stent (SEMS)

40. ADYNAMIC OBSTRUCTION:
 Paralytic ileus
It is defined as a state in which there is failure of
transmission of peristaltic waves secondary to neuro-
muscular failure leading to accumulation of fluid and gas
within the bowel which results in distention, vomiting,
absence of bowel sounds and absolute constipation.
 Varieties:
1. Post-operative
2. Infection
3. Reflex ileus
4. Metabolic

41.  Clinical Features:
 Absent bowel sounds
 No passage of flatus
 Abdominal distention
 Effortless vomiting
 Gas filled loops with multiple fluid levels
 Management:
 NPO
 Nasogastric suction
 Electrolyte and fluid balance
 Antibiotics
 Treat the underlying cause
 Surgery

43. Q No.1
Which of the following is the most typical
symptom of a small bowel obstruction?
a) Sharp left lower quadrant pain
b) Non-localized cramping abdominal pain
c) High volume watery diarrhea
d) Melena

44. Q No.2
Which of the following examination signs
indicates that ischemia may be developing?
a) Percussion tenderness
b) Abdominal distension
c) Cachexia
d) Tinkling bowel sounds

45. Q No.3
Which measurement in an arterial blood gas is
most indicative of bowel ischemia?
a) Metabolic alkalosis
b) High lactate
c) Hyponatraemia
d) Hypercapnia