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Intestinal obstruction


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Intestinal Obstruction - Small Intestine & Large Intestine

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Intestinal obstruction

  2. 2. Intestinal Obstruction  One of the common causes of acute abdomen  May lead to high morbidity and mortality if not treated correctly
  3. 3. INTESTINAL OBSTRUCTION DYNAMIC Intraluminal -faecal impaction -foreign body --bezoars -gall stones Intramural -stricture -malignancy -intussusception -volvulus Extramural - Bands/Adhesions -Hernia ADYNAMIC -Paralytic ileus -Pseudo obstruction
  4. 4. Causes Adhesions 40 inflammatory 15 Carcinoma 15 obstructed hernia 12 faecal impaction 8 pseudo-obstruction 5 Miscellaneous 5
  5. 5.  Dynamic Obstruction -peristalsis is working against a mechanical obstruction -can be acute or chronic
  6. 6.  Adynamic obstruction -no mechanical obstruction -peristalsis- absent or inadequate
  7. 7. Strangulation  Blood supply is compromised & bowel becomes ischaemic  Causes:- 1)Direct pressure on bowel wall -hernial orifices -adhesions/bands 2)Interrupted mesenteric blood flow -volvulus -Intussusception 3)Increased intraluminal pressure -closed loop obstruction
  8. 8.  Distention of the obstructed segment of bowel results in high pressure within the bowel wall  Venous return is compromised before the arterial supply  Increase in capillary pressure  Decreased local perfusion  Impaired arterial supply  Hemorrhagic infarction occurs  Viability of bowel compromised  Translocation & systemic exposure to anaerobic organisms and endotoxins occur
  9. 9.  Morbidity & mortality associated with strangulation--- depends on duration of ischaemia and its extend  Any length of ischemic bowel can cause significant systemic effects secondary to sepsis and significant dehydration  When bowel involvement is extensive – circulatory failure is common
  10. 10. Closed loop obstruction  Bowel is obstructed at both the proximal and distal points.  The distention is principally confined to the closed loop
  11. 11.  Carcinomatous stricture of colon with a competent ileocaecal valve:- -The inability of the distended colon to decompress itself into the small bowel results in an increase in luminal pressure, which is greatest at the caecum, with subsequent impairment of blood flow in the wall -Unrelieved, this results in necrosis and perforation
  13. 13. Internal hernia  Internal herniation occurs when a portion of the small intestine becomes entrapped in one of the retroperitoneal fossae or in a congenital mesenteric defect
  14. 14.  The following are potential sites of internal herniation - the foramen of Winslow; - a defect in the mesentery; - a defect in the transverse mesocolon; - defects in the broad ligament; - congenital or acquired diaphragmatic hernia; - duodenal retroperitoneal fossae – left paraduodenal and right duodenojejunal; - caecal/appendiceal retroperitoneal fossae – superior, inferior and retrocaecal;
  15. 15.  The standard treatment of an obstructed hernia is to release the constricting agent by division.
  16. 16. Obstruction from enteric strictures  Small bowel strictures usually occur secondary to tuberculosis or Crohn’s disease  Surgical management consists of resection and anastomosis.
  17. 17. Bolus obstruction  gallstones,food, trichobezoar, phytobezoar, stercoliths and worms.  Gall stones: -occur in the elderly secondary to erosion of a large gallstone directly through the gall bladder into the duodenum. -there is impaction about 60 cm proximal to the ileocaecal valve -reccurent attacks- ball-valve effect
  18. 18.  characteristic radiological sign of gallstone ileus is Rigler’s triad: 1)small bowel obstruction 2) pneumobilia and 3)Impacted gall stone # 2 signs are pathognomonic  Treatment – stone is milked proximally & crushed or either removed after opening intestine
  19. 19.  Food -Bolus obstruction may occur after partial or total gastrectomy -Fruit and vegetables
  20. 20. Trychobezoars and phytobezoars  undigested hair ball and fruit/vegetable fibre, respectively  When possible, the lesion may be kneaded into the caecum  otherwise open removal is required.  A preoperative diagnosis is difficult even with high resolution computed tomography (CT) scanning
  21. 21.  Stercoliths  These are usually found in the small bowel in association with a jejunal diverticulum or ileal stricture.  Presentation and management are identical to that of gallstones
  22. 22.  Worms -Ascaris lumbricoides -An attack may follow the initiation of antihelminthic therapy -At laparotomy, it may be possible to knead the tangled mass into the caecum; if not it should be removed.
  23. 23. Obstruction by adhesions and bands  Adhesions: -adhesions and bands are the most common cause of intestinal obstruction -The lifetime risk of requiring an admission to hospital for adhesional small bowel obstruction subsequent to abdominal surgery is around 4 % and the risk of requiring a laparotomy around 2 % -starts within hours of abdominal surgery
  24. 24.  Any source of peritoneal irritation results in local fibrin production, which produces adhesions between apposed surfaces.  Early fibrinous adhesions may disappear when the cause is removed or they may become vascularised and be replaced by mature fibrous tissue.
  25. 25.  Prevention of adhesions:  Factors that may limit adhesion formation include: - Good surgical technique - Washing of the peritoneal cavity with saline to remove clots - Minimising contact with gauze - Covering anastomosis and raw peritoneal surfaces
  26. 26.  Postoperative adhesions giving rise to intestinal obstruction usually involve the lower small bowel and almost never involve the large bowel
  27. 27.  Bands -Usually only one band is culpable. This may be: -congenital, e.g. obliterated vitellointestinal duct; - a string band following previous bacterial peritonitis; -a portion of greater omentum, usually adherent to the parietes.
  28. 28. Acute intussusception  when one portion of the gut invaginates into an immediately adjacent segment; almost invariably, it is the proximal into the distal  most common-children  peak incidence between 5-10 months of age  90% of cases are idiopathic  upper respiratory tract infection or gastroenteritis may precede the condition.
  29. 29.  hyperplasia of Peyer’s patches in the terminal ileum may be the initiating event  Weaning,  loss of passively acquired maternal immunity  common viral pathogens
  30. 30.  Children with intussusception associated with a pathological lead point such as Meckel’s diverticulum, polyp, duplication,Henoch– Schönlein purpura or appendix are usually older than those with idiopathic disease.  Adult cases are invariably associated with a lead point, -which is usually a polyp (e.g. Peutz–Jeghers syndrome), a submucosal lipoma or other tumour
  31. 31.  Pathology:  An intussusception is composed of 3 parts - 1)the entering or inner tube (intussusceptum); - 2)the returning or middle tube; - 3)the sheath or outer tube (intussuscipiens)  The part that advances is the apex, the mass is the intussusception and the neck is the junction of the entering layer with the mass.
  32. 32.  The degree of ischaemia is dependent on the tightness of the invagination, which is usually greatest as it passes through the ileocaecal valve.  CT scan- the target sign
  33. 33. Intussusception …..
  34. 34. Intussusception…..  Most common in children  Adult cases are secondary to intestinal pathology, e.g.polyp, Meckel’s diverticulum  Ileocolic is the most common variety  Adults – colocolic is more common  Can lead to an ischaemic segment  Radiological reduction is indicated in most paediatric cases  Adults require surgery
  35. 35. Volvulus  a twisting or axial rotation of a portion of bowel about its mesentery  The rotation causes obstruction to the lumen (>180° torsion)  if tight enough also causes vascular occlusion in the mesentery (>360° torsion).  Bacterial fermentation adds to the distention  increasing intraluminal pressure impairs capillary perfusion.  Mesenteric veins become obstructed as a result of the mechanical twisting and thrombosis results and contributes to the ischaemia.
  36. 36.  Volvuli may be primary or secondary.  The primary form occurs secondary to congenital malrotation of the gut, abnormal mesenteric attachments or congenital bands.  Examples include volvulus neonatorum, caecal volvulus and sigmoid volvulus.  A secondary volvulus, which is the more common variety, is due to rotation of a segment of bowel around an acquired adhesion or stoma
  37. 37. Volvulus….  May involve the small intestine, caecum or sigmoid colon;  neonatal midgut volvulus secondary to midgut malrotation is life-threatening  The most common spontaneous type in adults is sigmoid volvulus  Sigmoid volvulus can be relieved by decompression per anum  Surgery is required to prevent or relieve ischaemia
  38. 38. Sigmoid volvulus  Rotation nearly always occurs in the anticlockwise direction.  Causes:-
  39. 39.  Other predisposing factors - high residue diet and constipation.  Presentation can be classified as: - 1)Fulminant: sudden onset, severe pain, early vomiting, rapidly deteriorating clinical course; - 2)Indolent: insidious onset, slow progressive course, less pain,late vomiting.
  40. 40. Compound volvulus/Ileosigmoid knotting  The long pelvic mesocolon allows the ileum to twist around the sigmoid colon, resulting in gangrene of either or both segments of bowel.  patient presents with acute intestinal obstruction  Xray- reveals distended ileal loops in a distended sigmoid colon  At operation- decompression, resection and anastomosis
  41. 41. CLINICAL FEATURES  Dynamic obstruction -classic quartet-pain, distension, vomiting and absolute constipation.  Obstruction may be classified clinically into two types: 1) small bowel obstruction – high or low; 2) large bowel obstruction
  42. 42.  Features of obstruction:  high small bowel obstruction- vomiting occurs early, is profuse and causes rapid dehydration. Distension is minimal with little evidence of dilated small bowel loops on Xray  low small bowel obstruction- pain is predominant with central distension. Vomiting is delayed. Multiple dilated small bowel loops are seen on xray  large bowel obstruction- distension is more. -Pain is less severe and vomiting and dehydration are later features. -The colon proximal to the obstruction is distended on Xray.
  43. 43.  Cardinal clinical features of acute obstruction 1) Abdominal pain 2) Distension 3) Vomiting 4) Absolute constipation  Presentation will be further influenced by whether the obstruction is: # simple – in which the blood supply is intact; # strangulating/strangulated – in which there is interference to blood flow.
  44. 44.  severe pain – strangulation  Constipation -absolute (i.e. neither faeces nor flatus is passed) -relative (where only flatus is passed)  The administration of enemas should be avoided in cases of suspected obstruction
  45. 45.  Late manifestations of intestinal obstruction: dehydration, oliguria, hypovolaemic,shock,pyrexia, septicaemia, respiratory difficulty and peritonism
  46. 46. Other manifestations  Hypokalemia  Abdominal tenderness  Bowel sounds: -High-pitched bowel sounds- majority of patients with intestinal obstruction - Normal bowel sounds are of negative predictive value -scanty or absent if the obstruction is long-standing and the small bowel has become inactive
  47. 47.  Clinical features of strangulation - Constant pain, severe pain - Tenderness with rigidity and peritonism - Shock  When strangulation occurs in an external hernia: -the lump is tense, tender and irreducible and there is no expansile cough impulse. -Skin changes with erythema or purplish- underlying ischaemia
  48. 48.  Clinical features - intussusception -the ‘redcurrant jelly’ stool -feeling of emptiness in the right iliac fossa (the sign of Dance) -On rectal examination- blood-stained mucus  If unrelieved, progressive dehydration and abdominal distension from small bowel obstruction will occur, followed by peritonitis secondary to gangrene
  49. 49. Imaging  Xray abdomen-erect : Multiple air fluid levels -In adults,normally two inconstant fluid levels – -one at the duodenal cap -other in the terminal ileum  In the small bowel, the number of fluid levels is directly proportional to the degree of obstruction and to its site (the number increases- the more distal the lesion)  Fluid levels may also be seen in-non-obstructing conditions such as gastroenteritis, acute pancreatitis, intra-abdominal sepsis.
  50. 50.  Colonic obstruction is usually associated with a large amount of gas in the caecum
  51. 51. Radiological features of obstruction (on plain x-ray)  Obstructed small bowel-straight segments that are generally central and lie transversely  No/minimal gas is seen in the colon  The jejunum- valvulae conniventes,which completely pass across the width of the bowel and are regularly spaced, giving a ladder effect  Ileum – the distal ileum has been featureless  Caecum – a distended caecum is shown by a rounded gas shadow in the right iliac fossa  Large bowel, except for the caecum, shows haustral folds, spaced irregularly, do not cross the whole diameter of the bowel and do not have indentations placed opposite one another
  52. 52. Imaging in intussusception  Xray- shows small or large bowel obstruction with an absent caecal gas shadow in ileocolic cases.  A barium enema-to diagnose ileocolic intussusception (the claw sign)  USG- ‘doughnut’ appearance of concentric rings in transverse section  CT scan -most sensitive radiologic method to confirm intussusception-‘target’ or ‘sausage’- shaped soft-tissue mass with a layering effect, mesenteric vessels within the bowel lumen are
  53. 53. Imaging in volvulus - In caecal volvulus, caecal dilatation (98–100%), single air-fluid level (72–88%), small bowel dilatation (42–55%) and absence of gas in distal colon (82%)  In sigmoid volvulus- coffee bean sign
  54. 54. Sigmoid volvulus-coffee bean sign
  55. 55.  Treatment of acute intestinal obstruction - Gastrointestinal drainage via a nasogastric tube - Fluid and electrolyte replacement - Relief of obstruction  Principles of surgical intervention for obstruction -Management of: 1) The segment at the site of obstruction 2) The distended proximal bowel 3) The underlying cause of obstruction
  56. 56.  Indications for early surgical intervention - Obstructed external hernia - Clinical features suspicious of intestinal strangulation - Obstruction in a ‘virgin’ abdomen
  57. 57.  If there is complete obstruction, but no evidence of intestinal ischaemia, it is reasonable -to defer surgery until the patient has been adequately resuscitated.  Where obstruction is likely to be secondary to adhesions, conservative management may be continued for up to 72 hours in the hope of spontaneous resolution
  58. 58.  If the site of obstruction is unknown, adequate exposure is best achieved by a midline incision.  Assessment is directed to: - the site of obstruction; - the nature of the obstruction; - the viability of the gut.
  59. 59.  Operative decompression should be performed whenever possible.  Following relief of obstruction, the viability of the involved bowel should be carefully assessed
  60. 60.  If in doubt, the bowel should be wrapped in hot packs for 10 minutes with increased oxygenation and then reassessed. -The state of the mesenteric vessels and pulsation in adjacent arcades should be sought. -Viability is also confirmed by colour, sheen and peristalsis. - If at the end of this period, there is still uncertainty about gut viability, the gut should
  61. 61. Treatment of adhesions  Initial management is based on intravenous rehydration and nasogastric decompression; occasionally, this treatment is curative.  Although an initial conservative regimen is considered appropriate, regular assessment is mandatory to ensure that strangulation does not occur.  Conservative treatment should not usually be prolonged beyond 72 hours.  When laparotomy is required, although multiple adhesions may be found, only one may be causative.  If there is absolute certainty that this is the cause of the obstruction, this should be divided and the
  62. 62. Treatment of intussusception  In the infant with ileocolic intussusception, after resuscitation - non-operative reduction can be attempted using an air or barium enema  Successful reduction- free reflux of air or barium into the small bowel, together with resolution of symptoms and signs in the patient  Non-operative reduction-contraindicated if there are signs of peritonitis or perforation,a known pathological lead point or in the presence of profound shock.  Perforation of the colon during pneumatic or hydrostatic reduction is a recognised hazard, but is rare  Recurrent intussusception occurs in up to 10 %
  63. 63.  Surgery is required-radiological reduction has failed or is contraindicated.  Reduction is achieved by gently compressing the most distal part of the intussusception toward its origin  The viability of the whole bowel should be checked  An irreducible intussusception/one complicated by infarction/a pathological lead
  64. 64. Intestinal atresia  Duodenal atresia and stenosis are the most common forms of intestinal obstruction in the newborn  Jejunal or ileal atresias are next in frequency, whereas colonic atresia is rare.  The possibility of multiple atresias makes intraoperative assessment of the whole small and large bowel mandatory.
  65. 65.  There are 4 major types of jejunoileal atresia: 1)Type I consists of a membrane completely occluding the lumen with the intestine intact. 2)Type II is a gap in the intestine with a fibrous cord between the proximal and distal segments of intestine. 3)Type IIIA is a mesenteric gap without any connection between the segments. Type IIIB is jejunal atresia with absence of the distal superior mesenteric artery; the distal small bowel is coiled like an apple peel, and the gut is short. 4)Type IV consists of multiple atretic segments (a string of sausages) The obstructed proximal bowel is at risk of perforation, which may happen prenatally causing meconium peritonitis in the fetus.
  66. 66.  Small bowel atresias present with intestinal obstruction soon after birth.  Bilious vomiting is the dominant feature in jejunal atresia  Abdominal distension is more prominent with ileal atresia
  67. 67.  Surgery: -Duodenal atresia is corrected by a duodenoduodenostomy. -In most cases of jejunal/ileal atresia, the distal end of the dilated proximal small bowel is resected and a primary end-to-end anastomosis is possible -ocasionally, a temporary stoma is required before definitive repair.
  68. 68. Meconium ileus  Cystic fibrosis (AR)- Most common underlying cause -Meconium is normally kept fluid by the action of pancreatic. -In meconium ileus, the terminal ileum becomes filled with thick viscid meconium, resulting in progressive intestinal obstruction. -A sterile meconium peritonitis may have occurred
  69. 69.  gene mutation analysis- CFTR gene mutation; Chr.7  a sweat test, which shows elevated sodium chloride levels (>70 mmol/L).  Surgical procedures-intestinal resection and temporary stoma formation, resection and primary anastomosis,  In uncomplicated cases-enterotomy and irrigation of the bowel.  The Bishop–Koop operation with its irrigating stoma is now only rarely used.
  70. 70. TREATMENT OF ACUTE LARGE BOWEL OBSTRUCTION  an underlying carcinoma or diverticular disease  Acute or chronic  Distension of the caecum will confirm large bowel involvement.  Identification of a collapsed distal segment of the large bowel and its sequential proximal assessment will readily lead to identification of the cause
  71. 71.  When a removable lesion is found in the caecum, ascending colon, hepatic flexure or proximal transverse colon, an emergency right hemicolectomy should be done  A primary anastomosis is safe if the patient’s general condition is reasonable.  If the lesion is irremovable,a proximal stoma (colostomy or ileosotomy- if the ileocaecal valve is incompetent) or ileotransverse bypass should be considered.  Obstructing lesions at the splenic flexure should be treated by an extended right hemicolectomy with ileodescending colonic anastomosis
  72. 72.  For obstructing lesions of the left colon or rectosigmoid junction,immediate resection  In the absence of senior surgeon, it is safest to bring the proximal colon to the surface as a colostomy.  When possible,the distal bowel should be brought out at the same time(Paul–Mikulicz procedure) to facilitate subsequent closure.  In the majority of cases, the distal bowel is closed and returned to the abdomen (Hartmann’s procedure).  A second-stage colorectal anastomosis can be planned when the patient is fit.
  73. 73. Treatment of caecal volvulus  At operation,if the volvulus is ischaemic – needs resection If, viable- the volvulus should be reduced.  Sometimes, this can only be achieved after decompression of the caecum using a needle. Further management consists of fixation of the caecum to the right iliac fossa (caecopexy) and/or a caecostomy
  74. 74. Treatment of sigmoid volvulus  Flexible sigmoidoscopy or rigid sigmoidoscopy and insertion of a flatus tube should be carried out to allow deflation of the gut.  The tube should be secured in place with tape for 24 hours and a repeat x-ray taken to ensure that decompression has occurred.  Successful deflation, as long as ischaemic bowel is excluded, will resolve the acute problem
  75. 75.  In young patients, an elective sigmoid colectomy is required.  It is reasonable not to offer any further treatment following successful endoscopic decompression in the elderly as there is a high death rate (~80 per cent at two years) .  In elderly patients with comorbidities and recurrent episodes of volvulus, the options are resection or two point fixation with combined endoscopic/percutaneous tube insertion.  Failure results in an early laparotomy, with untwisting of the loop and per anum decompression  When the bowel is viable, fixation of the sigmoid colon to the posterior abdominal wall may be a safer
  76. 76.  A Paul–Mikulicz procedure is useful, particularly if there is suspicion of impending gangrene  an alternative procedure is a sigmoid colectomy and,  when anastomosis is considered unwise, a Hartmann’s procedure with subsequent reanastomosis can be carried out
  77. 77. CHRONIC LARGE BOWEL OBSTRUCTION  The causes of obstruction may be organic: - 1)intraluminal (rare) : faecal impaction - 2)intrinsic intramural : strictures (Crohn’s disease, ischaemia,diverticular), anastomotic stenosis; - 3)extrinsic intramural (rare) : metastatic deposits (ovarian),endometriosis, stomal stenosis - 4) functional: Hirschsprung’s disease, idiopathic megacolon, pseudoobstruction.
  78. 78.  Constipation appears first- relative early and then absolute, associated with distension.  In the presence of large bowel disease, the point of greatest distension is in the caecum, and this is heralded by the onset of pain.  Vomiting is a late feature and therefore dehydration is less severe.  Rectal examination may confirm the presence of faecal impaction or a tumour.
  79. 79.  Investigation  Plain abdominal radiography confirms the presence of large bowel distension.  All such cases should be investigated by a subsequent single-contrast water-soluble enema study, CT scan
  80. 80.  Organic disease requires decompression with either a laparotomy or stent.  Stomal stenosis can usually be managed at the abdominal wall level.  Functional disease requires colonoscopic decompression in the first instance and conservative management
  81. 81. INTESTINAL OBSTRUCTION DYNAMIC Intraluminal -faecal impaction -foreign body --bezoars -gall stones Intramural -stricture -malignancy -intussusception -volvulus Extramural - Bands/Adhesions -Hernia ADYNAMIC -Paralytic ileus -Pseudo obstruction
  82. 82. ADYNAMIC OBSTRUCTION  Paralytic ileus -This may be defined as a state in which there is failure of transmission of peristaltic waves secondary to neuromuscular failure (i.e. in the myenteric (Auerbach’s) and submucous (Meissner’s) plexuses). - The resultant stasis leads to accumulation of fluid and gas within the bowel, with associated distension, vomiting, absence of bowel sounds and absolute constipation
  83. 83.  The following varieties are recognised: 1) Postoperative. A degree of ileus usually occurs after any abdominal procedure and is self-limiting, with a variable duration of 24–72 hours. Postoperative ileus may be prolonged in the presence of hypoproteinaemia or metabolic abnormality. 2) Infection. Intra-abdominal sepsis may give rise to localised or generalised ileus. 3) Reflex ileus. This may occur following fractures of the spine or ribs, retroperitoneal haemorrhage or even the application of a plaster jacket. 4) Metabolic. Uraemia and hypokalaemia are the most
  84. 84.  Clinical features Paralytic ileus takes on a clinical significance if, 72 hours after laparotomy: - there has been no return of bowel sounds on auscultation; - there has been no passage of flatus.  Abdominal distension becomes more marked and tympanitic.  Colicky pain is not a feature.  Distension increases pain from the abdominal wound. In the absence of gastric aspiration, effortless vomiting may occur.  Radiologically, the abdomen shows gas filled loops of
  85. 85.  Management:  use of nasogastric suction and restriction of oral intake until bowel sounds and the passage of flatus return.  Electrolyte balance must be maintained.  Specific treatment is directed towards the cause, but the following general principles apply: - If a primary cause is identified, this must be treated. - Gastrointestinal distension must be relieved by decompression. - Close attention to fluid and electrolyte balance is essential. - There is no place for the routine use of peristaltic
  86. 86.  If paralytic ileus is prolonged- CT scan  The need for a laparotomy - if it lasts for more than 7 days or if bowel activity recommences following surgery and then stops again
  87. 87. Pseudo-obstruction  This condition describes an obstruction, usually of the colon,that occurs in the absence of a mechanical cause or acute intraabdominal disease
  88. 88. pseudo-obstruction Metabolic Diabetes Hypokalaemia Uraemia Myxodoema Intermittent porphyria Severe trauma especially to the lumbar spine and pelvis Shock Burns Myocardial infarction Stroke Idiopathic Septicaemia Postoperative (for example, fractured neck of femur) Retroperitoneal irritation Blood Urine Enzymes (pancreatitis) Tumour Drugs Tricyclic antidepressants Phenothiazines Laxatives Secondary gastrointestinal involvement Scleroderma Chagas’ disease
  89. 89. Small intestinal pseudo- obstruction -This condition may be primary (i.e. idiopathic or associated with familial visceral myopathy) or secondary -The clinical picture consists of recurrent subacute obstruction. The diagnosis is made by the exclusion of a mechanical cause. -Treatment consists of initial correction of any underlying disorder.
  90. 90. Colonic pseudo-obstruction  an acute or a chronic form.  The former, also known as Ogilvie’s syndrome, presents as acute large bowel obstruction.  Abdominal radiographs show evidence of colonic obstruction, with marked caecal distension (diameter >10cm) being a common feature.  caecal perforation is a complication.  The absence of a mechanical cause requires urgent confirmation by colonoscopy or a single- contrast water-soluble barium enema or CT.  Once confirmed, pseudo-obstruction requires treatment of any identifiable cause.
  91. 91.  Caecal perforation can occur in pseudo- obstruction.  Abdominal examination-tenderness and peritonism over the caecum and as with mechanical obstruction, caecal perforation is more likely if the caecal diameter is 14 cm or greater.  Surgery is associated with high morbidity and mortality and should be reserved for those with impending perforation when other treatments have failed or perforation has occurred.