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Management Of Intestinal Obstruction

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General & specific management of obstructed cases in acute abdomen.

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Management Of Intestinal Obstruction

  1. 1. Intestinal Obstruction
  2. 3. <ul><li>Assessment </li></ul><ul><li>Investigations </li></ul><ul><li>Treatment </li></ul>
  3. 4. <ul><li>History -Onset, acute/chronic, bleeding, constipation, weight loss, anorexia, changes in bowel habits, associated features, previous surgery, drug usage. </li></ul><ul><li>Physical examination- General physical, vital signs, abdominal distention/mass, tenderness/guarding, auscultation (Bowel sounds)-high pitched, tinkling sounds. </li></ul>
  4. 5. <ul><li>Complete blood count- A raised white cell count will indicate an infection. A raised hematocrit may indicate hemoconcentration while a decreased hematocrit will signify blood loss. </li></ul><ul><li>Serum Urea & electrolytes- Derangements may be seen with vomiting & diarrhea. Dehydration will be reflected in raised serum urea & creatinine. </li></ul>
  5. 6. <ul><li>Liver function test- Elevated serum bilirubin & alkaline phosphatase point towards an obstructed cause. </li></ul><ul><li>Serum amylase </li></ul><ul><li>It is a non-specific test & may be raised in cases of small intestinal obstruction. </li></ul>
  6. 7. <ul><li>Erect chest x-ray- Free air under the diaphragm, without recent abdominal surgery, shows perforated viscus. </li></ul><ul><li>Supine abdominal x-ray- It may show abnormal bowel pattern (dilation of bowel loops in case of obstruction or sentinel loop). It may also show masses. </li></ul><ul><li>Erect Film- It shows fluid levels in case of obstructed bowel. </li></ul>
  7. 8. <ul><li>Ultrasound - It is less useful but may indicate presence of intraparitoneal fluid or mass. It can also detect gallstones or other biliary diseases. </li></ul><ul><li>CT - It is performed with oral or Intravenous contrast. Lower abdomen CT is useful in detection of acute appendicitis, acute diverticulitis, intestinal obstruction, aortic aneurysm & mesentric ischaemia. </li></ul>
  8. 9. <ul><li>Supportive </li></ul><ul><li>NPO </li></ul><ul><li>Rehydration & urine output monitoring </li></ul><ul><li>Cross-match blood & transfusion if required </li></ul><ul><li>Pass NG tube( diagnostic/therapeutic purpose) </li></ul><ul><li>I.V antibiotics if indicated </li></ul><ul><li>Symptomatic </li></ul><ul><li>Analgesia after confirming diagnosis </li></ul><ul><li>Specific </li></ul><ul><li>Therapy directed at underlying disease </li></ul>
  9. 11. <ul><li>Investigations - Plain X-ray </li></ul><ul><li>Duodenal obstruction- stomach & proximal duodenum are distended- “double bubble” </li></ul><ul><li>Jejunal & ileal obstruction- air fluid levels present </li></ul>
  10. 12. <ul><li>Treatment : </li></ul><ul><li>Correct electrolyte & fluid deficits </li></ul><ul><li>Duodenal atresia requires duodenojejuostomy & spliting of the anastomosis with a feeding tube. </li></ul><ul><li>Atretic segments in the jejunum or ileum may produce dilated proximal loops that require tapering prior to anastomosis. </li></ul>
  11. 13. <ul><li>Investigation: </li></ul><ul><li>Plain x-ray of the small bowel gas shows malrotation & level of obstruction. </li></ul>
  12. 14. <ul><li>Treatment: </li></ul><ul><li>The volvulus is reduced, the transduodenal band(Ladd’s band) divided, the duodenum mobilised & the mesentry freed. </li></ul><ul><li>Appendicectomy is routinely performed to avoid diagnostic difficulty with appendicitis in the future. </li></ul><ul><li>Infarcted bowel necessitates resection. </li></ul>
  13. 15. <ul><li>Investigation </li></ul><ul><li>Differential white cell count is raised </li></ul><ul><li>A Merkel’s radioisotope scan will reveal acid producing gastric mucosa. </li></ul>
  14. 16. <ul><li>Treatment: </li></ul><ul><li>Excision of the inflammed diverticulum </li></ul><ul><li>Presence of gastric mucosa requires the resection of the ileal loop containing the diverticulum to ensure complete excision of all acid producing mucosa. </li></ul>
  15. 17. <ul><li>Plain x-ray </li></ul><ul><li>Shows small dilated bowel loops </li></ul><ul><li>Gastrograffin enema (in the absence of acute obstruction) shows up the meconium & excludes Hirshsprung’s disease. </li></ul>
  16. 18. <ul><li>Treatment: </li></ul><ul><li>Colonic washouts may restore patency </li></ul><ul><li>Proximal ileum is anastomosed end to side to the colon with a distal ileostomy to clear the obstruction. </li></ul>
  17. 19. <ul><li>Gastrograffin enema demonstrates unhindered flow of contrast upto the cecum & beyond </li></ul><ul><li>Relief of constipation requires bowel washouts or manual evacuation. </li></ul><ul><li>Counselling </li></ul>
  18. 20. <ul><li>Investigations: </li></ul><ul><li>Double contrast Gastrograffin enema (‘claw sign’ of ileocolic intussusception) </li></ul><ul><li>In adults, a contrast CT scan of the abdomen or barium enema is confirmatory. </li></ul>
  19. 21. <ul><li>Rx: </li></ul><ul><li>The diagnostic enema may be used to reduce the intussusception by hydrostatic pressure (in children) </li></ul><ul><li>Surgical reduction by taxis; bowel resection if there is gross edema preventing reduction or vascular compromise. </li></ul>
  20. 22. <ul><li>Investigations: </li></ul><ul><li>Plain x-ray may be diagnostic </li></ul><ul><li>-Large gas-filled, ‘kidney bean-shaped’ swelling in the right upper zone: Sigmoid volvulus </li></ul><ul><li>-Large gas-filled, ‘kidney bean </li></ul><ul><li>-shaped’ swelling in the left </li></ul><ul><li>lower zone: Caecal volvulus. </li></ul>
  21. 23. <ul><li>Rx: </li></ul><ul><li>Sigmoid volvulus may be relieved at right sigmoidoscopy. </li></ul><ul><li>Emergency laprotomy & resection of the volvulus for strangulated or recurrent cases. </li></ul><ul><li>Gangrenous bowel is exteriorised & resected, with the formation of a ‘double barrel’ colostomy (Paul-Mikulicz procedure). </li></ul>
  22. 24. <ul><li>Investigations: </li></ul><ul><li>White cell count: >20×10 9 /L </li></ul><ul><li>Serum amylase: slightly raised (>200IU) </li></ul><ul><li>Mesentric angiography </li></ul><ul><li>Rx: </li></ul><ul><li>Laparotomy: superior mesentric embolectomy; </li></ul><ul><li>Resection of areas of non-viable bowel. </li></ul><ul><li>‘ second look’ laprotomy at 24 hours for further resection of non-viable bowel. </li></ul>
  23. 25. <ul><li>Treatment: </li></ul><ul><li>Surgical bypass of occlusion. </li></ul>
  24. 26. <ul><li>Investigations : </li></ul><ul><li>Plain x-ray abdomen: Characteristics of the distended bowel from which the level of obstruction is identified </li></ul><ul><li>Contrast enhanced CT : </li></ul><ul><li>Delineates the type & level of obstruction </li></ul>
  25. 27. <ul><li>Treatment: </li></ul><ul><li>Nasogastric decompression of stomach & bowel proximal to the obstruction. </li></ul><ul><li>I/v Fluids & electrolyte therapy </li></ul><ul><li>Analgesia </li></ul><ul><li>Antibiotics( inflammatory or infectious causes) </li></ul><ul><li>Emergency surgery * </li></ul><ul><li>Post operative adhesion obstruction usually resolves on conservative measures. </li></ul>
  26. 28. <ul><li>Operative procedures vary according to cause of obstruction. </li></ul><ul><li>Resection- The diseased part of the small intestine (ileum) is removed. The two healthy ends are then sewn back together and the incision is closed. </li></ul><ul><li>Indications </li></ul><ul><li>Gangrenous bowel </li></ul>
  27. 29. <ul><li>In cases of strangulated Inguinal/femoral hernias the standard groin incision is given & the weakness repaired using hernioplasty or herniorrhaphy, with bowel resection if required. </li></ul>
  28. 30. <ul><li>In adhesive obstructed cases, laproscopic adhesiolysis (adhesive band lysis) maybe performed in selected patients or using open procedure through an incision dictated by scar from previous surgery. </li></ul><ul><li>Bypass: Anastomosis of proximal small bowel or large intestine distal to the obstruction may be a good procedure in some cases of carcinoma or radiation injury. </li></ul>
  29. 31. <ul><li>Decompression-Done by use of gastrostomy or jejunostomy tube where adhesions can’t be freed & bypass can’t be done. Parentral nutrition is provided that </li></ul><ul><li>allows spontaneous resolution. </li></ul><ul><li>The tube can be passed orally or </li></ul><ul><li>By needle aspiration through the </li></ul><ul><li>bowel wall. </li></ul>
  30. 33. <ul><li>Short Practice of surgery- Bailey & love’s </li></ul><ul><li>Acute surgical management- Hwang Nian Chi </li></ul><ul><li>Current surgery </li></ul><ul><li>Medlineplus </li></ul>
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General & specific management of obstructed cases in acute abdomen.

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