This document discusses intestinal obstruction, including its causes, symptoms, diagnosis, and treatment. It covers both dynamic and adynamic obstructions. Common causes of dynamic obstruction include adhesions, hernias, tumors, and gallstones blocking the intestines. Symptoms include pain, vomiting, distension, and constipation. Diagnosis involves physical exam, abdominal x-rays, and CT scans. Treatment depends on the cause but generally involves rehydration, draining the intestines, and surgically addressing the blockage or its underlying cause. More severe cases like strangulation or perforation require prompt surgery to prevent complications.

1. 1
Intestinal Obstruction
Dr Bina Ravi
Associate Professor and Consultant
Department of Surgery

2. 2
Abdomen- Bowel sound
 Present- Mechanical obstruction
Not present-
 Adynamic obstruction
 (no gas under diaphragm)
 Perforation
 (gas under diaphragm)

3. 3
Objectives
 Pathophysiology – dynamic, adynamic
 Cardinal features – history,
examination
 Causes – small, large gut obstruction
 Indications – contraindications for
conservative Mx

4. 4
Obstruction
 Dynamic – peristalsis, mechanical
obstruction
 Adynamic- paralytic ileus, non
propulsive Mesenteric vascular
obstruction or, pseudo obstruction

5. 5
Dynamic Obstruction
 Pain, distention, vomiting, absolute
constipation
 Two- small gut – high , low
 Large gut
 Acute , chronic, acute on chronic or,
sub-acute
 Simple – intact vascularity
 Strangulated – compromised
vascularity

6. 6
Intestinal obstruction:
Causes
Adhesion
Inflammatory
Carcinoma
Obstructed
hernia
Fecal
obstruction
Pseudoobstruc
tion
Misc

7. 7

8. 8
Causes –Dynamic obstruction
 Intra-luminal –impaction, FB, Bezoars,
gallstones
 Intramural- strictures, malignancy
 Extra-luminal- bands/adhesions, hernia,
volvulus, intussusception

9. 9
Adynamic obstruction-causes
 Paralytic ileus
 Mesenteric vascular occlusion
 Pseudo obstruction

10. 10
Pathophysiology
 Proximal gut dilates- altered motility
 Below the obstruction – normal motility,
immobile
 Proximal – increased peristalsis, dilates,
reduced peristalsis, flaccid
 Gas- bacteria. Aerobic/anaerobic, 90% N2
 Fluid- dig. Juices,

11. 11
Pathophysiology
 Dehydration and electrolyte imbalance
 Reduced intake
 Defective absorption
 Vomiting
 Sequestration in gut

12. 12
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

13. 13
Closed loop obstruction
 Strangulation
 Distention
 Necrosis
 perforation

14. 14

15. 15

16. 16
Acute Intestinal Obstruction-CP
 Location, age of obstruction,
pathology, ischemia
 Pain
 Vomiting
 Distension
 Constipation
 Dehydration, Hypokalemia, fever,
abdomen tenderness

17. 17
 Pain – severe, colicky, umbilical, lower
abdomen
 Increases with peristalsis, later reduces
 Severe pain - strangulation

18. 18
Vomiting
 High obstruction- violent
 Low obstruction- slow onset
nausea/vomit
 Gradually digestive food changes to
feculent material

19. 19
Distension
 Greater if distal obstruction
 Visible peristalsis
 Peristalsis delayed in colonic obstruction
 Absent in Mesenteric vascular obstruction

20. 20

21. 21
Constipation
 Absolute
 Relative
 Absent in – Richter’s hernia, gallstone,
MVO, Pelvic abscess, partial
obstruction

22. 22
Dehydration
 Vomiting, fluid sequestration
 Dry skin, poor venous filling, sunken
eyes, oliguria
 Raised blood urea, Hb, - secondary
polycythemia

23. 23
Hypokalemia
 K, amylase, LDH – strangulation, raised
TLC or, leucopenia
 Fever – indicates – ischemia,
perforation, inflammation
 Hypothermia – septic shock

24. 24
Abdomen tenderness
 Localized – ischemia
 Peritonitis – infarction or, perforation

25. 25
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

26. 26
Radiology
 Supine/ erect plain abdomen films
 Small gut- central, transverse, no gas-
colon
 Jejunum- valvulae connivantes
 Ileum- featureless
 Cecum- round gas in RIF
 Large gut- haustral folds

27. 27
Supine

28. 28

29. 29
Sigmoid volvulus
 Dilated, no haustral pattern
 Small gut- air and fluid levels
 More the fluid levels, more distal the
lesion

30. 30

31. 31
Inv:
 Plain x ray- impacted foreign body
 Fluid levels – non obstructing
conditions – inflammatory bowel
disease, acute pancreatitis, abdominal
sepsis

32. 32
Treatment
 3 measures
 Intestinal drainage
 Fluid and electrolyte replacement
 Relief of obstruction

33. 33
Surgical Mx
 Mx of segment at the site of
obstruction
 The distended proximal bowel
 Underlying cause of obstruction

34. 34
Supportive
 NG tube drainage
 Na , water replacement
 Antibiotics

35. 35
Large gut
 Ca or diverticular disease
 Contrast study – pseudo-obstruction
 Caecal perforation- caecostomy,
ileostomy

36. 36
Adhesions/bands
 Commonest
 Fibrin – adhesions-fibrinous, fibrous
 Appendectomy , gynaecological op.
 Bands- congenital, bacterial peritonitis,
greater omentum causing band
 Mx- conservative – 72 hrs –lap
adhesiolysis

37. 37
Special obstructions
 Int. hernia – foramen of Winslow, hole in
the mesentery, hole in transverse
colon, defects in broad ligament, cong
diaphragmatic hernia, paraduodenal
fossae, intraperitoneal fossae
 Mx- release the ring, reduction of
hernia

38. 38
Enteric strictures
 TB, Crohn’s, Ca, lymphomas,
stricturoplasty
 Bolus obstruction – food, gall stone,
trichobezoars, phytobezoars,
stercoliths, worms

39. 39
Ac Intussusception
 Proximal gut enters distal gut
 Adults – lead point, polyp, submucosal
lipoma, tumor,
 Colo-colic – adults
 Pathology- inner tube, outer tube,
returning of middle tube
 Strangulating obstruction- ileoileal,
ileocaecal, ileocolic

40. 40

41. 41
Clinical picture
 Severe attacks of pain – lasts few
minutes
 Later - red currant jelly stool
 Exam –between episodes-50-60%
sausage shaped lump – empty RIF –
Sign de Dance
 P/R – blood stained finger
 Later vomit, distension

42. 42

43. 43
Radiology
 Plain film – absent caecal gas
 Ba enema- claw sign
 CT scan
 Mx- Hydrostatic reduction with enema
 Operative reduction
 Recurrent – 5%- anchorage of ileum to
ascending colon

44. 44

45. 45

46. 46
Differential diagnosis
 Acute enterocolitis
 Henoch Schoenlein perpura
 Rectal prolapse

47. 47
Volvulus
 Axial rotation of bowel at its
mesentery
 Congenital or secondary
 Small intestine, caecum, sigmoid-
common
 Small gut- spontaneous, vegetable
consumption – untwist
 Caecal – clockwise- females- lap .
Untwist, resection if gangrene

48. 48
Sigmoid
 Anticlockwise
 Bands, overloaded colon, large
mesocolon, narrow pelvic mesocolic
attachment

49. 49

50. 50

51. 51

52. 52
Treatment
 Flexible sigmoidoscopy/ rigid
 Laparotomy- untwisting
 Viable – fixing to retroperitoneum
 Resection – Paul Mickulikz- gangrene
 Sigmoid colectomy/ Hartmann’s
procedure later re-anastomosis

53. 53
Compound volvulus
 Rare, ile-osigmoid knotting
 Gangrene
 Laparotomy - Decompression,
resection and anastomosis

54. 54

55. 55
Thanks

56. 56