The document discusses intestinal obstruction, providing a classification system, the common causes including adhesions, hernias and volvulus, the clinical features of obstruction, investigations such as blood tests and imaging, and treatments which include supportive measures, surgery, and managing complications such as paralytic ileus. Intestinal obstruction accounts for 5% of acute surgical admissions and requires prompt assessment and treatment to address the mechanical blockage preventing gut contents from progressing.

1. INTESTINALOBSTRUCTION
Dr.Sundarprakash Sivalingam
Associate Professor in surgery

2. OVERVIEW
•CLASSIFICATION
•COMMONCAUSES OF OBSTRUCTION
•CLINICALFEATURES
•INVESTIGATION
•TREATMENT

3. Accounts for 5% of all acute surgical admissions
Patients are often extremely ill requiring prompt
assessment, resuscitation and intensive
monitoring
Obstruction
A mechanical blockage arising from a structural abnormality that presents a
physical barrier to the progression of gut contents.
Ileus
is a paralytic or functional variety of obstruction
Obstruction is:
-Partial or complete
-Simple or strangulated
INTRODUCTION

4. CLASSIFICATION

5. DYNAMIC OBSTRUCTION
(MECHANICAL)

6. CAUSES OF I.O (DYNAMIC)

7. PATHOPHYSIOLOGY:

8. OBSTRUCTIONBYADHESIONS
•
•
Peritonealirritationlocalfibrinproductionproducesadhesionsbetweenapposedsurfaces
Asearlyas4weekspostlaparotomy.Themajorityof patientspresentbetween1-5 years
ColorectalSurgery 25%
Gynaecological 20%
Appendectomy 14%
• Prevention:goodsurgicaltechnique,washingof theperitonealcavitywithsalinetoremoveclots,
etc,minimizingcontactw/gauze,coveringanastomosis&rawperitoneal surfaces

9. TREATMENTOF ADHESIVE OBSTRUCTION
Initiallytreatconservativelyprovided there is no signs of
strangulation;should rarely continue conservative
treatmentfor longer than72 hours
atoperation, divide onlythecausativeadhesion andlimit
dissection
laparoscopic adhesiolysis in cases of chronic subacute
obstruction

10. HERNIA
•
•
•
•
•
•
Accounts for 20% of small bowel obstruction
Commonest 1. femoral hernia
2. id inguinal
3. umbilical
4. others: incisional
The site of obstruction is the neck of hernia the
Compromised viscus is with in the sac.
Ischaemia occurs initially by venous occlusion, followed by oedema and
arterial compromise.
Attempt to distinguish the difference between:
•
•
•
incarceration
sliding
obstruction
• Strangulation is noted by:
•
•
•
•
persistent pain
discolouration
tenderness
constitutional symptoms

11. VOLVULUS
•Atwistingoraxialrotationofaportionofbowelaboutitsmesentery.
whencompleteitformsaclosedloop obstruction
•Ischemiacanbeprimaryor secondary:
1°:congenitalmalformationofthegut(e.g:volvulusneonatorum,cecalorsigmoidvolvulus)
2°:morecommon,duetorotationofapieceofbowelaroundanacquired adhesion
orstoma
•Commonestspontaneoustype inadultissigmoid,canbe relieved
bydecompressionper anum
•Surgeryisrequiredtoprevent
Features: palpable tympanic lump
(sausage shape) inthe midline or left
side of abdomen.
Constipation, abdominaldistension
(early & progressive)

12. ACUTE INTUSSUSCEPTION
•Occurswhenoneportionof thegutbecomes
invaginatedwithinanimmediatelyadjacentsegment.
•Commonin1styearof life
•Commonafterviralillness enlargementof
peyer’s patches
•Ileocolicisthecommonest varietyinchild.
•Colocolicintussusception commonestinadult
Anintussusceptioniscomposedofthreeparts:
theenteringorinnertube;
Thereturningormiddletube;
thesheathoroutertube(intussuscipiens).

13. classically, a previously
healthyinfant presents with
colickypain andvomiting(milk then
bile).
between episodes the child
initially appears well.
later, they may pass a
‘redcurrant jelly’stool.
Redcurrantjelly
stools

14. LARGEBOWELOBSTRUCTION
•
•
Distinguishingileus frommechanical obstructionis challenging
Accordingtolaplace’s law: maximumpressure is at the maximumdiameterarea
CAECUMIS AT THE GREATESTRISKOF PERFORATION
• perforation results in the releaseofformed feces with heavy bacterial contamination
aetiology:
1.Carcinoma:
the commonestcause, 18% ofcolonic ca. presentwith obstruction
2. Benign stricture:
duetodiverticulardisease, ischemia, inflammatoryboweldisease.
3. Volvulus:
-sigmoidvolvulus/caecal volvulus
4. Hernia.
5. Congenital: hirschprung, anal stenosis andagenesis

15. HIGHSMALL BOWEL OBSTRUCTION
•vomiting occurs early and is profuse with rapid
dehydration.
•distension is minimal withlittle evidence of fluid levels
on abdominal radiography
LOWSMALLBOWEL OBSTRUCTION
•pain is predominantwithcentraldistension.
•vomiting isdelayed.
•multiple centralfluid levels are seen on radiography
LARGE BOWELOBSTRUCTION
•distension is early andpronounced.
•pain is mildandvomiting anddehydration are late.
•the proximal colonandcaecumare distended on abdominal
radiography
CLINICAL FEATURES
CARDINAL
FEATURES:
Colicky pain
Vomiting
Abd distention
Constipation
OTHER FEATURES:
Dehydration
Hypokalaemia
Pyrexia
Abd tenderness

16. PHYSICAL EXAMINATION
INSPECTION
abdominaldistention,scars,visible peristalsis.
PALPATION
mass,tenderness,guarding
PERCUSSION
tymphanic,dullness
AUSCULTATION
bowelsoundarehighpitchandincreaseinfrequency

17. INVESTIGATIONS
• LAB:
•
•
•
•
•
•
FBC (LEUKOCYTOSIS, ANAEMIA, HEMATOCRIT, PLATELETS)
CLOTTING PROFILE
ARTERIAL BLOOD GASSES
U& CRT, NA, K, AMYLASE, LFT AND GLUCOSE, LDH
GROUP AND SAVE (X-MATCH IF NEEDED)
OPTIONAL (ESR, CRP, HEPATITIS PROFILE)
• RADIOLOGICAL:
•
• PLAIN ABDOMINAL XRAYS
• USG ( FREE FLUID, MASSES, MUCOSAL FOLDS, PATTERN OF PARISTALSIS,
DOPPLER OF MESENTERIC VASULATURE, SOLID ORGANS)
OTHER ADVANCED STUDIES (CT, MRI, CONTRAST STUDIES)

18. Fluid levels with gas above;
‘stepladder pattern’. Ileal
obstruction by adhesions; patient
erect.
Supine radiograph from a patient with
complete small bowel obstruction
shows distended small bowel loops in
the central abdomen with prominent
valvulae conniventes (small white
arrow)
Figure 3. Lateral decubitus view
of the abdomen, showing air-fluid
levelsconsistentwithintestinal
obstruction(a rrows ).

19. THE DIFFERENCE BETWEEN SMALL AND
LARGE BOWEL OBSTRUCTION
Large bowel
•Peripheral( diameter6cm
max)
•Presenceof haustration
Small Bowel
•Central( diameter3cmmax)
•Vulvulae coniventae
•Ileum:mayappeartubeless

20. ROLE OF CT
• USED WITH IV CONTRAST, ORAL AND RECTAL CONTRAST
(TRIPLE CONTRAST).
• ABLE TO DEMONSTRATE ABNORMALITY IN THE BOWEL
WALL, MESENTERY, MESENTERIC VESSELS AND
PERITONEUM.
•
•
•
•
•
•
IT CAN DEFINE:
THE LEVEL OF OBSTRUCTION
THE DEGREE OF OBSTRUCTION
THE CAUSE: VOLVULUS, HERNIA, LUMINAL AND MURAL
CAUSES
THE DEGREE OF ISCHAEMIA
FREE FLUID AND GAS
• FIGURE: AXIALCOMPUTED TOMOGRAPHY SCAN
SHOWING DILATED,CONTRAST-FILLEDLOOPS OF BOWEL
ON THE PATIENT’SLEFT(YELLO W ARRO WS), WITH
DECOMPRESSED DISTALSMALLBOWEL ON THE
PATIENT’S RIGHT(RED ARRO WS). THE CAUSE OF
OBSTRUCTION,ANINCARCERATED UMBILICALHERNIA,
CANALSO BE SEEN (GREENARRO W), WITHPROXIMALLY

21. ROLE OF BARIUM GASTROGRAFIN
STUDIES
•
•
•
•
•
•
AS: FOLLOW THROUGH, ENEMA
LIMITED USE IN THE ACUTE SETTING
GASTROGRAFIN IS USED IN ACUTE
ABDOMEN BUT IS DILUTED
USEFUL IN RECURRENT AND CHRONIC
OBSTRUCTION
MAY ABLE TO DEFINE THE LEVELAND
MURAL CAUSES.
CAN BE USED TO DISTINGUISH ADYNAMIC
AND MECHANICAL OBSTRUCTION
Barium should not be used in
a patient with peritonitis

24. • SUPPORTIVE
1. Resuscitation
2. Ryletube freeflowwith4hourly aspiration
-decompressionofproximaltotheobstruction,reducesubsequent aspirationduringinductionofanesthesiaandpost
extubation.
3. IVnormalsaline/ Hartmann(sodium&waterlossduringio)
4. Broadspectrumantibiotic(notmandatorybutneedinallpatientundergoingsurgery.
TREATMENT OF INTESTINAL OBSTRUCTION

25. • SURGICAL
Indications: obstructed/strangulated externalhernia,internalintestinal strangulation and acute
obstruction
1. midlineincisionusuallylookon caecum
2. operativedecompression
3. Look atviabilityofintestine
4. largebowelobstruction:colostomy

26. INDICATIONSFORSURGERY
• ABSOLUTE
•
•
•
•
generalisedperitonitis
localisedperitonitis
visceralperforation
irreduciblehernia
• RELATIVE
• palpablemasslesion
• 'virgin'abdomen
• failuretoimprove
• TRIALOFCONSERVATISM
•
•
•
•
incompleteobstruction
previoussurgery
advancedmalignancy
diagnosticdoubt- possibleileus

27. MANAGEMENT FOR LARGEBOWELOBSTRUCTION
All patients require
•Adequate resuscitation
•Prophylactic antibiotics
•Consenting and marking for potential stoma formation
•At operation
•Full laparotomy should be performed
•Liver should be palpated for metastases
•Colon should be inspected for synchronous tumours
•Appropriate operations include:
•Right sided lesions – right hemicolectomy
•Transverse colonic lesion – extended right hemicolectomy
•Left sided lesions – various options

28. Three-staged procedure
•Defunctioning colostomy
•Resection and anastomosis
•Closure of colostomy
Two-staged procedure
•Hartmann’s procedure
•Closure of colostomy
One-stage procedure
•Resection, on-table lavage and primary anastomosis
•Three stage procedure will involve 3 operations!
•Associated with prolonged total hospital stay
•Transverse loop colostomy can be difficult to manage
•With two-staged procedure only 60% of stomas are ever reversed
•With one-stage procedure stoma is avoided
•Anastomotic leak rate of less than 4% have been reported
•Irrespective of option total perioperative mortality is about 10%

29. COMPLICATIONS ASSOCIATED WITH INTESTINALOBSTRUCTION REPAIR
• includeexcessivebleeding
• infection
• formationofabscesses(pocketsofpus)
• leakageofstoolfromananastomosis
•
•
•
adhesionformation
paralyticileus(temporaryparalysisoftheintestines)
reoccurrenceoftheobstruction.

30. PARALYTIC ILEUS
•Astateinwhichthereisafailure of transmissionof peristaltic waves due
toneuromuscularfailure(inAuerbach’sandMeissner’splexuses)
•Stasis
•Leadstoaccumulationoffluidandgaswithin bowel
distension,vomiting,absenceofbowelsound andabsoluteconstipation
•Varietiesfactors:postoperative,infection,reflexileus andmetabolic
•Radiological:gasfilledloopsofintestineswith multiplefluidlevels

31. MANAGEMENT
•Essence of treatment
prevention with use of nasogastric suction and restriction of oral intake until
bowel sound and passage of flatus return
•Maintain electrolyte balance
•Specific treatment:
• removed primary cause
• decompressed GI distension
• if prolong paralytic ileus , consider laparotomy, exclude hidden cause and facilitate bowel
decompression

32. ACUTE MESENTERIC OCCLUSION
• Acute ischemiaofmesentericvessel.commonlysuperiormesentericartery.
• Causes:atrialfibrillation,muralthrombosis,atheromatous plaquefromaortic
aneurysmandvalvevegetationfromendocarditis
• Features:-suddenonsetofsevereabd.paininptwithafand atherosclerosis
-persistentvomitinganddefecationthenpassageofaltered blood
-hypovolumicshock
• Investigations:- neutrophilleukocytosis
- abdxray:absenceofgasinthickenedsmallintestines
• Treatment:
- anti-coagulant
- embolectomy
- revascularization