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Intestinal Obstruction 1

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Property of Prof Dr. Ismail Tantawy, Department of General Surgery, Faculty of Medicine. University of Zagazig

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Intestinal Obstruction 1

  1. 1. By Prof. Dr.Prof. Dr. ISMAIL TANTAWYISMAIL TANTAWY
  2. 2. Learning objectives to understand The pathophysiology ofThe pathophysiology of dynamic and adynamicdynamic and adynamic intestinal obstructionintestinal obstruction The causes, clinicalThe causes, clinical Pictures and complicationsPictures and complications of intestinal obstructionof intestinal obstruction.. The indications and contraindications of either surgical orThe indications and contraindications of either surgical or conservative treatment of intestinal obstruction.conservative treatment of intestinal obstruction.
  3. 3. Definition:Definition: Failure of propulsion of intestinal contents.Failure of propulsion of intestinal contents. Due to either mechanical occlusion of the lumenDue to either mechanical occlusion of the lumen ((dynamic obstructiondynamic obstruction) or failure of the propulsive) or failure of the propulsive movement (movement (adynamic obstructionadynamic obstruction).). AetiologyAetiology Mechanical (Mechanical (DynamicDynamic)) ObstructionObstruction Functional (Functional (adynamicadynamic)) Due to occluded lumen Patent lumen
  4. 4. Mechanical (Dynamic) ObstructionMechanical (Dynamic) Obstruction In the lumenIn the lumen In the wallIn the wall Outside the wallOutside the wall  Meconium ileusMeconium ileus  Gall stone ileus andGall stone ileus and bolus obstructionbolus obstruction  Ascaris massAscaris mass  Faecal impaction, F.B.,Faecal impaction, F.B., or enterolithor enterolith Congenital atresia.Congenital atresia. Inflammatory stricture. e.g.Inflammatory stricture. e.g. T.B. Crohn’s, ulcerativeT.B. Crohn’s, ulcerative colitis, diverticulitis.colitis, diverticulitis. Malignancy: cancer colon,Malignancy: cancer colon, and rectum.and rectum. Bands and adhesions (theBands and adhesions (the commonest cause).commonest cause). Tight rings of hernia sacTight rings of hernia sac Tumours and enlarged LNs.Tumours and enlarged LNs. Functional (adynamic)Functional (adynamic) Paralytic ileusParalytic ileus Spastic ileusSpastic ileus: Hirschsprung's: Hirschsprung's disease is a good exampledisease is a good example Mesentric vascularMesentric vascular occlusion (occlusion (MVOMVO))
  5. 5. PathologyPathology Types of intestinal obstructionTypes of intestinal obstruction SimpleSimple obstructionobstruction StrangulatedStrangulated obstructionobstruction Occluded lumen withoutOccluded lumen without interference with blood supplyinterference with blood supply Obstruction with interference with blood supply of theObstruction with interference with blood supply of the affected loop:affected loop: Strangulated herniaStrangulated hernia VolvolusVolvolus IntussusceptionIntussusception Adhesive obstruction (someAdhesive obstruction (some cases e.g. internal herniation)cases e.g. internal herniation) Mesentric vascularMesentric vascular occlusion.occlusion.
  6. 6. Patho-pathologyPatho-pathology Local effectsLocal effects Proximal to the site of obstructionProximal to the site of obstruction At the site of obstructionAt the site of obstructionDistal to obstructionDistal to obstruction Proximal to the site of obstruction:Proximal to the site of obstruction: The proximal loop passes through the following phases:The proximal loop passes through the following phases: (A) Proximal to the site of obstruction:(A) Proximal to the site of obstruction: The proximal loop passes through the following phases:The proximal loop passes through the following phases: Hyperperistaltic with antiperistaltic waves: occurs early inHyperperistaltic with antiperistaltic waves: occurs early in trial to overcome the obstruction .trial to overcome the obstruction . Stage of dilatation (due to exhaustion and paralysis) & TheStage of dilatation (due to exhaustion and paralysis) & The loop becomes distended with:loop becomes distended with:
  7. 7. FluidsFluids LateLateGasesGases 1000-1500 ml saliva 1500 - 2500 ml gastric juice 1000 ml bile 1500 ml pancreatic secretion. 3000 ml intestinal secretion Swallowed, secretedSwallowed, secreted & diffused from& diffused from bloodblood ((The secretedThe secreted part alone is morepart alone is more than 8 liters per daythan 8 liters per day).). Either swallowedEither swallowed ((70%70%), diffused), diffused from blood (from blood (20%20%)) or produced fromor produced from putrefaction ofputrefaction of food (food (10%10%).). Bacterial proliferation withBacterial proliferation with breakdown of retainedbreakdown of retained intestinal contentsintestinal contents produces toxins thatproduces toxins that accumulate in the stagnantaccumulate in the stagnant fluid and do not pass to thefluid and do not pass to the circulation except aftercirculation except after release of obstruction,release of obstruction, which may lead towhich may lead to toxaemia which may betoxaemia which may be fatal.fatal.
  8. 8. Distal to obstructionDistal to obstruction Normal peristalsis to evacuateNormal peristalsis to evacuate the residual content.the residual content. The distal segment is empty, collapsed,The distal segment is empty, collapsed, contracted and immobile.contracted and immobile. EarlyEarly LateLate At the site of obstructionAt the site of obstruction SimpleSimple obstructionobstruction StrangulatedStrangulated obstructionobstruction The strangulated loopThe strangulated loop becomes distendedbecomes distended with gas & fluidwith gas & fluid At first, the venous flow is occluded (being of low pressure) leadingAt first, the venous flow is occluded (being of low pressure) leading to oedema and congestion.to oedema and congestion. Arterial flow is then occluded leading to ischaemia and gangrene.Arterial flow is then occluded leading to ischaemia and gangrene. The devitalized wall of the intestine permits passage of toxins &The devitalized wall of the intestine permits passage of toxins & bacteria to the peritoneal cavity & circulation causing toxaemia.bacteria to the peritoneal cavity & circulation causing toxaemia. Lastly, perforation leads to peritonitis.Lastly, perforation leads to peritonitis.
  9. 9. Complications (Complications (general effectsgeneral effects))  Hypovolaemic shock:Hypovolaemic shock: due to fluid loss by vomiting,due to fluid loss by vomiting, sequestration of fluids in the third space (dilatedsequestration of fluids in the third space (dilated loops).loops).  In strangulated obstruction:In strangulated obstruction: shock is more markedshock is more marked due to additional blood loss into the strangulateddue to additional blood loss into the strangulated loop.loop.  Dehydration & electrolytes imbalance:Dehydration & electrolytes imbalance: hyponatraemia & hypokalaemia.hyponatraemia & hypokalaemia.  Toxaemia:Toxaemia: in strangulated obstruction.in strangulated obstruction.  Perforation & peritonitis.Perforation & peritonitis.
  10. 10. Clinical pictureClinical picture SymptomsSymptoms PainPain VomitingVomiting ConstipationConstipation DistensionDistension  Simple obstSimple obstruction:ruction: colicky pain in attackscolicky pain in attacks with long free intervals.with long free intervals.  Strangulated obstructionStrangulated obstruction:: colicky pain with shortcolicky pain with short intervals with constantintervals with constant dull aching pain betweendull aching pain between the attacks of colics.the attacks of colics.  Paralytic ileus:Paralytic ileus: No colic.No colic. The higher theThe higher the obstruction,obstruction, the earlier thethe earlier the vomiting.vomiting.  Absolute constipation toAbsolute constipation to both faeces and flatus.both faeces and flatus.  The lower theThe lower the obstruction, the earlierobstruction, the earlier the constipation.the constipation. The lower theThe lower the obstructionobstruction the more isthe more is distension.distension.
  11. 11. SignsSigns GeneralGeneral LocalLocal  Signs of dehydration,Signs of dehydration, shock or toxaemia.shock or toxaemia.  General signs of theGeneral signs of the cause e.g. distantcause e.g. distant metastasis of GITmetastasis of GIT cancer.cancer. InspectionInspection PalpationPalpation PercussionPercussion AuscultationAuscultation Per-rectal examinationPer-rectal examination (PR exam.)(PR exam.) AbdominalAbdominal distention.distention. VisibleVisible peristalsis on theperistalsis on the abdominal wall.abdominal wall. Simple obstruction: mildSimple obstruction: mild tenderness over the distendedtenderness over the distended loops maximum over the site ofloops maximum over the site of the obstruction.the obstruction. Strangulated obstruction:Strangulated obstruction: tenderness & rebound tendernesstenderness & rebound tenderness over the strangulated loop.over the strangulated loop. Hyper-resonanceHyper-resonance over the distendedover the distended loopsloops Loud exaggerated intestinal sounds inLoud exaggerated intestinal sounds in the hyperperistaltic stage (the hyperperistaltic stage (earlyearly).). Dead silent abdomen in paralytic ileusDead silent abdomen in paralytic ileus and during the stage of dilatation (and during the stage of dilatation (latelate).). Empty rectum supports the diagnosis.Empty rectum supports the diagnosis. It may reveal anorectal carcinoma orIt may reveal anorectal carcinoma or red currant jelly stool in intussusception.red currant jelly stool in intussusception.
  12. 12. How to suspect the level of obstruction clinically?How to suspect the level of obstruction clinically? ItemsItems High small bowelHigh small bowel Low small bowelLow small bowel Large bowelLarge bowel 1-Pain1-Pain above theabove the umbilicusumbilicus Around & belowAround & below itit LowerLower abdominalabdominal 2-Vomiting2-Vomiting -Very early (with-Very early (with pain)pain) -Copious-Copious -1-2h after pain-1-2h after pain -moderate-moderate 1-2 day after1-2 day after painpain mildmild 3-Constipation3-Constipation LateLate IntermediateIntermediate EarlyEarly 4-Abd. distension4-Abd. distension -Mild or absent-Mild or absent -central-central -Inter mediate-Inter mediate -central-central -Marked-Marked -peripheral-peripheral 5-Dehydration5-Dehydration Marked earlyMarked early IntermediateIntermediate Mild & lateMild & late
  13. 13. Differences between Simple, strangulated and functional obstruction (P. ileus)Differences between Simple, strangulated and functional obstruction (P. ileus) ItemItem Simple obst.Simple obst. Strangulated. Obst.Strangulated. Obst. Paralytic ileusParalytic ileus 1-Pain1-Pain IntermittentIntermittent colicky pain withcolicky pain with long free intervals.long free intervals. Attacks of colickyAttacks of colicky pain with shortpain with short intervals of constantintervals of constant dull aching pain.dull aching pain. Mild dull achingMild dull aching pain of distension orpain of distension or no painno pain 2-Shock2-Shock Mild.Mild. Severe.Severe. Moderate.Moderate. 3-Palpation3-Palpation TendernessTenderness especially over theespecially over the site of obstruction.site of obstruction. Tenderness andTenderness and rebound tenderness.rebound tenderness. Very mildVery mild tenderness.tenderness. 4-Auscultation4-Auscultation HyperperistalsisHyperperistalsis then silentthen silent abdomen.abdomen. HyperperistalsisHyperperistalsis then silent abdomen.then silent abdomen. Dead silentDead silent abdomen.abdomen. 5-N/G suction5-N/G suction It relieves pain inIt relieves pain in hours.hours. It does not relieveIt does not relieve pain.pain. It relieves distention.It relieves distention. 6- Leucocytic count6- Leucocytic count Not increasedNot increased IncreasedIncreased Not increased exceptNot increased except in cases secondary toin cases secondary to sepsissepsis
  14. 14. InvestigationsInvestigations Double enema test:Double enema test:  Two enemas are given one hour apart.Two enemas are given one hour apart.  If the second enema comes withoutIf the second enema comes without 3F3F ((Faeces FlatusFaeces Flatus oror ForceForce),), intestinal obstruction is proved.intestinal obstruction is proved. Radiological investigations:Radiological investigations: **Plain X. ray abdomen erect position:Plain X. ray abdomen erect position: It reveals distended loops with multiple fluidIt reveals distended loops with multiple fluid levels inlevels in stepladder patternstepladder pattern..  JejunumJejunum:: shows circular folds calledshows circular folds called ""valvulaevalvulae conniventsconnivents" giving" giving concertinaconcertina appearanceappearance  IleumIleum:: shows shapeless characterless tubes.shows shapeless characterless tubes.  Colon:Colon: typical haustrations of the colon.typical haustrations of the colon. Multiple fluid levelsMultiple fluid levels
  15. 15. **Barium enema:Barium enema: When colonic obstruction is suspected.When colonic obstruction is suspected. **Upper GIT series:Upper GIT series: Barium or Gastrograffin meal with follow-through to detectBarium or Gastrograffin meal with follow-through to detect upper small intestinal obstruction in neonates and infants.upper small intestinal obstruction in neonates and infants. Laboratory investigations:Laboratory investigations: Total leucocytic countTotal leucocytic count:: markedly rises in cases of strangulation.markedly rises in cases of strangulation. Serum electrolytes:Serum electrolytes: decreased sodium and potassium levels.decreased sodium and potassium levels. Differential Diagnosis:Differential Diagnosis: From other causes of acute abdomen.From other causes of acute abdomen.
  16. 16. Treatment:Treatment: Conservative treatment:Conservative treatment:  Correction of fluid & electrolytes imbalance i.e.Correction of fluid & electrolytes imbalance i.e. I.V.I.V. fluidsfluids according to the deficit.according to the deficit.  Fluid chart is mandatory.Fluid chart is mandatory.  Nasogastric suction through Ryle's tube for:Nasogastric suction through Ryle's tube for: **Preoperative benefits:Preoperative benefits:  It relieves distension, which may cause cardiac &It relieves distension, which may cause cardiac & respiratory embarrassment.respiratory embarrassment.  It relieves congestion & oedema of the intestines and helpsIt relieves congestion & oedema of the intestines and helps return of tone & peristalsis.return of tone & peristalsis. **Operative benefits:Operative benefits:  For anaesthesiaFor anaesthesia:: it prevents vomiting & aspirationit prevents vomiting & aspiration pneumonia.pneumonia.  For surgeon:For surgeon: it deflates the intestine providing easyit deflates the intestine providing easy manipulation & easy closure of the abdomen.manipulation & easy closure of the abdomen.
  17. 17. **Postoperative benefits:Postoperative benefits:  It prevents massive toxic absorption after release of obstruction.It prevents massive toxic absorption after release of obstruction.  It reduces the incidence of postoperative paralytic ileusIt reduces the incidence of postoperative paralytic ileus (distention and vomiting).(distention and vomiting).  Antibiotics:Antibiotics: to guard against respiratory infection, peritonitis &to guard against respiratory infection, peritonitis & septicemia.septicemia.  Repeated enemata are used to break faecal impaction and stimulateRepeated enemata are used to break faecal impaction and stimulate colonic motility.colonic motility. Surgical treatment:Surgical treatment: A part from few cases, in which the previousA part from few cases, in which the previous conservative measures may be curative, most cases needconservative measures may be curative, most cases need emergency exploration.emergency exploration.
  18. 18. Exploration:Exploration: In adults, midline incision is preferred.In adults, midline incision is preferred. Deliver the caecumDeliver the caecum and examineand examine Decompress the bowels ifDecompress the bowels if greatly distended bygreatly distended by Deal withDeal with the causethe cause If collapsed, it isIf collapsed, it is small intestinalsmall intestinal obstructionobstruction →→ followfollow the ileum to thethe ileum to the distended loops.distended loops. If distended, it isIf distended, it is large intestinallarge intestinal obstructionobstruction →→ followfollow the colon to thethe colon to the collapsed part.collapsed part. By this way you canBy this way you can reach the site of thereach the site of the obstruction .obstruction .  Threading a longThreading a long nasogastric tube throughnasogastric tube through the intestine down to thethe intestine down to the site of obstruction.site of obstruction.  Decompression throughDecompression through a small stab in the bowela small stab in the bowel and introduction of wideand introduction of wide bore catheter connectedbore catheter connected to a sucker then close theto a sucker then close the stab with sutures.stab with sutures. Simple obstruction:Simple obstruction: Remove the cause ifRemove the cause if possible or do bypass orpossible or do bypass or colostomy.colostomy. StrangulatedStrangulated obstruction:obstruction: Remove theRemove the cause of strangulationcause of strangulation and examine theand examine the viability of the loop.viability of the loop.
  19. 19. ItemItem Viable loopViable loop Gangrenous loopGangrenous loop -Inspection-Inspection -luster-luster -colour-colour -peristalsis-peristalsis Present (shining)Present (shining) Red (light)Red (light) SeenSeen Absent (dull)Absent (dull) Dark or blackDark or black AbsentAbsent -Palpation-Palpation -tone-tone -Pulsation-Pulsation Present (firm)Present (firm) Felt in the mesenteryFelt in the mesentery Absent (flabby)Absent (flabby) AbsentAbsent -Operative Doppler U/S-Operative Doppler U/S + ve+ ve -ve-ve
  20. 20. If the viability of a loop is questionable,If the viability of a loop is questionable, try to improve it bytry to improve it by Wrapping the loops withWrapping the loops with hot fomentations.hot fomentations. Increase oxygenationIncrease oxygenation forfor 1010 minutes.minutes. If not improved or proved gangrenous,If not improved or proved gangrenous, resection of gangrenous loop is indicated.resection of gangrenous loop is indicated. If it isIf it is :: Small intestine or rightSmall intestine or right colon then do primarycolon then do primary resection anastomosis.resection anastomosis. Left colon then either resectionLeft colon then either resection ended by colostomy or recentlyended by colostomy or recently primary resection anastomosisprimary resection anastomosis after on table colonic lavageafter on table colonic lavage ((Dudely lavageDudely lavage) is done.) is done.
  21. 21. Common causes of obstruction inCommon causes of obstruction in different age groupsdifferent age groups Newborn (first month): (Newborn (first month): (see the chapter of pediatric surgery )see the chapter of pediatric surgery ) Jejuno ileal atresia or stenosis (Jejuno ileal atresia or stenosis (the commonest causethe commonest cause).). Malrotation or volvolus neonatorum.Malrotation or volvolus neonatorum. Congenital duodenal obstruction (Congenital duodenal obstruction (atresiaatresia).). Duplication of the intestineDuplication of the intestine Hirchsprung's diseaseHirchsprung's disease Imperforate anus.Imperforate anus. Meconium ileusMeconium ileus InfancyInfancy ((1 month – 2 years1 month – 2 years) &) & ChildhoodChildhood ((2y-12y2y-12y):): IntussusceptionIntussusception ((the commonest cause in infantsthe commonest cause in infants).). Strangulated external herniaStrangulated external hernia ((the commonest cause in childrenthe commonest cause in children) .) . Ascaris mass obstruction.Ascaris mass obstruction.
  22. 22. Young adult and middle age:Young adult and middle age: Adhesive intestinal obstruction (Adhesive intestinal obstruction (the commonest causethe commonest cause).). Strangulated hernia. (Strangulated hernia. (see the chapter of herniassee the chapter of hernias)) Paralytic ileus.Paralytic ileus. Stricture obstruction e.g.Stricture obstruction e.g. T.BT.B.. Gall stone obstruction.Gall stone obstruction. Old age:Old age: Malignant obstruction (Malignant obstruction (the commonestthe commonest).). Volvolus sigmoid.Volvolus sigmoid. Faecal impaction.Faecal impaction.
  23. 23. The commonest causes of intestinalThe commonest causes of intestinal obstruction as a whole areobstruction as a whole are Strangulated externalStrangulated external herniahernia Adhesive intestinalAdhesive intestinal obstructionobstruction Paralytic ileusParalytic ileusMalignant obstructionMalignant obstruction
  24. 24. AetiologyAetiology Peritoneal irritation leading to fibrinous exudate thatPeritoneal irritation leading to fibrinous exudate that causes fibrinous adhesions between adjacent intestinalcauses fibrinous adhesions between adjacent intestinal loops.loops. They may resolve or change into mature permanentThey may resolve or change into mature permanent fibrous tissue causing fibrous adhesions.fibrous tissue causing fibrous adhesions. The irritating causes may be (theories)The irritating causes may be (theories) Mechanical orMechanical or thermal e.g.thermal e.g. diathermy or hotdiathermy or hot fomentationsfomentations InfectionInfection ForeignForeign bodiesbodies TraumaTrauma VascularVascular PeritonitisPeritonitis & TB.& TB. Talk powderTalk powder (over surgical(over surgical gloves) & silkgloves) & silk suturessutures Ischaemia orIschaemia or congestion.congestion.
  25. 25. Pathology:Pathology: Types:Types: Occurs early, which is easilyOccurs early, which is easily broken by blunt dissectionbroken by blunt dissection FibrinousFibrinous adhesionsadhesions Which is firm and needs sharpWhich is firm and needs sharp dissection (dissection (adhesolysisadhesolysis).). FibrousFibrous adhesionsadhesions Clinical pictureClinical picture There is a history of previous operationThere is a history of previous operation e.g. appendicectomy or gynecologicale.g. appendicectomy or gynecological operations or past history of peritonitisoperations or past history of peritonitis FibrinousFibrinous adhesionsadhesions Picture of simple obstruction but the adhesionsPicture of simple obstruction but the adhesions may compress the blood supply and causemay compress the blood supply and cause strangulated intestinal obstructionstrangulated intestinal obstruction FibrousFibrous adhesionsadhesions
  26. 26. TreatmentTreatment ConservativeConservative SurgicalSurgical ConservativeConservative  Should be tried first even for few days so long as there is noShould be tried first even for few days so long as there is no Suspicion of strangulation.Suspicion of strangulation.  I.V. fluidsI.V. fluids,, N/GN/G suction may be beneficial and the intestinalsuction may be beneficial and the intestinal movement may break down fibrinous adhesions.movement may break down fibrinous adhesions. SurgicalSurgical Exploration and division ofExploration and division of the offending adhesions.the offending adhesions. Prevention of recurrencePrevention of recurrence
  27. 27. Exploration and division of the offending adhesions:Exploration and division of the offending adhesions: If adhesions are extensiveIf adhesions are extensive →→ bypass by lateral anastomosis.bypass by lateral anastomosis. Prevention of recurrence:Prevention of recurrence:  Instillation of different substances:Instillation of different substances: to reduce the fibrous tissueto reduce the fibrous tissue formation e.g. hyaluronidase, heparin, steroids, fibrinolysin,formation e.g. hyaluronidase, heparin, steroids, fibrinolysin, dextran…etc. is usually useless.dextran…etc. is usually useless.  Noble's plicationNoble's plication:: The adjacent loops are sutured along their anti-The adjacent loops are sutured along their anti- mesenteric border in ordered fashion.mesenteric border in ordered fashion.  Charle-Phillip's transmesenteric plicationCharle-Phillip's transmesenteric plication:: In which placation isIn which placation is done in the mesentery few centimeters from the bowel that looksdone in the mesentery few centimeters from the bowel that looks like a pouch of sausagelike a pouch of sausage  Baker's tube:Baker's tube: intraluminal tube splinting the loops gentle curves.intraluminal tube splinting the loops gentle curves. This tube is removed 12 days later.This tube is removed 12 days later.
  28. 28. Aetiology:Aetiology: Obstruction of the terminal ileum by aggregation ofObstruction of the terminal ileum by aggregation of AscarisAscaris lumbricoideslumbricoides worms forming a mass, usually followingworms forming a mass, usually following antihelminthic treatment.antihelminthic treatment. Incidence:Incidence: Rarely seen nowadays.Rarely seen nowadays. Common in children belowCommon in children below 10 years10 years in tropics.in tropics. Clinical picture:Clinical picture: History of Ascaris infestation or intake of antihelminthics mayHistory of Ascaris infestation or intake of antihelminthics may be positive.be positive. The vomitus may contain worms.The vomitus may contain worms. Picture of simple intestinal obstruction.Picture of simple intestinal obstruction.
  29. 29. Investigations:Investigations: Leucocytic count may show marked esinophilia.Leucocytic count may show marked esinophilia. TreatmentTreatment ConservativeConservative ExplorationExploration (N/G suction +(N/G suction + IV. Fluids) mayIV. Fluids) may succeed.succeed.  The mass is identified and trial is done to knead itThe mass is identified and trial is done to knead it along the ileum to the colon without opening thealong the ileum to the colon without opening the bowel.bowel.  If kneading fails, remove the mass throughIf kneading fails, remove the mass through transverse incision in the bowel.transverse incision in the bowel.  The bowel incision should be sutured withThe bowel incision should be sutured with silk suturessilk sutures because the worms tend to eat the catgut sutures andbecause the worms tend to eat the catgut sutures and re-open the sutured wound of the intestine, throughre-open the sutured wound of the intestine, through their way to the peritoneum.their way to the peritoneum.
  30. 30. Aetiology:Aetiology: Incidence:Incidence: Clinical picture:Clinical picture: Obstruction of the distal colon and rectum by inspissated faecesObstruction of the distal colon and rectum by inspissated faeces ((forming a massforming a mass).). It is common in elderly bed ridden patients with chronic constipation.It is common in elderly bed ridden patients with chronic constipation. Clinical picture of simple distal intestinal obstruction.Clinical picture of simple distal intestinal obstruction. Indentible mass may be felt in the Lt. iliac fossa and the faecal mass isIndentible mass may be felt in the Lt. iliac fossa and the faecal mass is felt per-rectumfelt per-rectum Treatment:Treatment:  Conservative measures + repeated enemata may succeed to loosen theConservative measures + repeated enemata may succeed to loosen the mass and relieve obstruction.mass and relieve obstruction.  If failed, anal dilatation under anaesthesia and manual removal of theIf failed, anal dilatation under anaesthesia and manual removal of the mass is done.mass is done.
  31. 31. Aetiology:Aetiology: Incidence:Incidence: Clinical picture:Clinical picture:  Obstruction of the terminal ileum by large gall stone (Obstruction of the terminal ileum by large gall stone (2.5 cm or more2.5 cm or more in diameterin diameter) which had ulcerated through the gall bladder wall into) which had ulcerated through the gall bladder wall into the duodenum.the duodenum.  It passes down to be impacted usuallyIt passes down to be impacted usually 2 feet2 feet from the ileocaecal valvefrom the ileocaecal valve causing simple intestinal obstruction.causing simple intestinal obstruction. It is a rare condition, common in old obese multiparous females withIt is a rare condition, common in old obese multiparous females with long history of dyspepsia.long history of dyspepsia. Clinical picture of simple intestinal obstruction:Clinical picture of simple intestinal obstruction:  Usually there is a long history of chronic cholecystitis with recentUsually there is a long history of chronic cholecystitis with recent exacerbation.exacerbation.  The diagnosis is usually delayed because it's clinical picturesThe diagnosis is usually delayed because it's clinical pictures resemble exacerbation attacks of gall bladder disease.resemble exacerbation attacks of gall bladder disease.
  32. 32. Investigations:Investigations: Plain X ray of abdomen in erect position: It may show:Plain X ray of abdomen in erect position: It may show: The classic multiple fluid level but the stone is rarely seen.The classic multiple fluid level but the stone is rarely seen. Gas in the gall bladder or biliary tree (Gas in the gall bladder or biliary tree (pneumobiliapneumobilia) is diagnostic.) is diagnostic. Treatment “Treatment “SurgicalSurgical”:”: Exploration after good preoperative preparation:Exploration after good preoperative preparation:  Try to crush the stone between fingers without opening theTry to crush the stone between fingers without opening the bowel.bowel.  If failed, open the ileum above the stone, and remove it thenIf failed, open the ileum above the stone, and remove it then close the incision transverselyclose the incision transversely  Avoid any manipulation in the region of the gall bladder, whichAvoid any manipulation in the region of the gall bladder, which may break down the cholecyto-enteric fistula and results inmay break down the cholecyto-enteric fistula and results in external duodenal or biliary fistula.external duodenal or biliary fistula.

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