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intestinal obstruction

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intestinal obstruction

  1. 1. Supervisor : Dr. Hilda Prepared by: Ahmad Iqbal Syafiq Zuhratun Nazihah
  2. 2. • DEFINITION • CLASSIFICATION • CAUSES • HISTORY • EXAMINATION • INVESTIGATION • PSEUDO-OBSTRUCTION • MANAGEMENT • SURGERY : INDICATIONs • TAKE HOME MESSAGES
  3. 3. • Intestinal obstruction is blockage of bowel that prevents the contents of the intestine from passing through.
  4. 4. • Paralytic ileus - Postoperative - Inflammatory - Metabolic - neurogenic Mechanical Functional • Extramural • Intramural • Intraluminal
  5. 5. Mechanical Extramural • Adhesions • Hernia • Volvulus • Neoplasms Intramural • Neoplasms • Stricture • Intussuception Intraluminal • Gallstones • Fecal impaction • Bezoar • Foreign body • Intramural haematoma
  6. 6. • ELDERLY – carcinoma, diverticulitis, sigmoid volvulus • ADULT – hernia, adhesion, carcinoma • PAEDIATRICS – intussusception, congenital hypertrophic pyloric stenosis, atresia (duodenum, ileum), meconium obstruction, volvulus neonatorum
  7. 7. Pathophysiology
  8. 8. Pathophysiology • Bowel distal to obstruction collapse • Bowel proximal to obstruction distends and becomes hyperactive (distension due to intestinal secretions and swallowed air) • Bowel wall becomes edematous. Fluid electrolytes accumulate in the wall and lumen (third space loss) • Bacteria proliferate in the obstructed bowel • As the bowel distends, intramural vessels become stretched/compromised • Ischemia and necrosis
  9. 9. • 4 Cardinal Signs : • Abdominal pain • Nausea & vomiting • Abdominal distension • Absolute constipation • Others : • Dehydration, hypotension, tachycardia, pyrexia, abdominal tenderness, empty rectum on DRE, high pitched bowel sound.
  10. 10. • Pain • Small bowel : - periumbilical and colicky - comes in spasm - builds up in crescendo - then tappers off - regular pain at intervals of 2-3 minutes • Large bowel : below the umbilicus & comes at intervals of 6-10 minutes. • Severe & continuous pain suggest strangulation obstruction.
  11. 11. • Vomiting • The higher the obstruction, the vomiting is more severe • In large bowel obstruction vomiting comes later and sometimes patient may not vomit at all. • As obstruction progresses the character of the vomitus alters (digested food  feculent material; as a result of the presence of enteric bacterial overgrowth)
  12. 12. • Abdominal distention • The more distal the obstruction, the more distention of abdomen. • Visible peristalsis may be present. • Constipation • May pass feces or flatus if early onset • Occurs early in lower large bowel obstruction • Occurs late in high small bowel obstruction • Absolute constipation is a feature of complete intestinal obstruction.
  13. 13. • In high small bowel obstruction, vomiting occurs early and is profuse with rapid dehydration. Distension is minimal • In low small bowel obstruction, Vomiting is delayed. pain is predominant with central distension. • In large bowel obstruction, distension is early and pronounced. Pain is mild and vomiting and dehydration are late.
  14. 14. Inspection • Visible scar -band -adhesion Palpation • hernial orifices • large, slightly tender, mobile • mass changes its position with colicky pain • tender indurated mass • hard impacted masses -incarcerated -strangulated hernia +torsion +intussusception -mass of Ascaris worms +intraperitoneal abscess -fecaloma
  15. 15. Percussion - tympanic sound Auscultation -runs of borborygmi -tinkling high pitched musical sounds Rectal examination • fresh blood and mucus • hard mass of faeces • hard mass in the rectovesical pouch -strangulating lesion -carcinoma of large gut -intussusception +constipation -extraintestinal tumour
  16. 16. • Blood • FBC: • Hb  anaemic • PCV  elevated due to dehydration • TWBC  normal or elevated (strangulation, ischemia, perforation) • RP: • dehydration • electrolyte imbalance (hypokalemia, hyponatremia) • ABG: • alkalosis  proximal obstruction (severe vomiting) • acidosis  strangulation
  17. 17. • Radiological • AXR • Gas pattern • Fluid level • Masses shadow • Fecal pattern • Chest X-Ray • Elevated diaphragm • Air under diaphragm • Aspiration
  18. 18. • USG: • to differentiate mechanical obstruction & paralytic ileus, • poor visualization of gas filled structure, • only useful in selected patient ie pregnant, when CT is contraindicated, in critically ill patients • Free fluid • Masses • Mucosal folds • Pattern of peristalsis • CT scan: • level of obstruction (transition point) • Causes (hernias, inflammatory changes, masses) • sign of strangulation, ischemia, perforation
  19. 19. Large Bowel: Small Bowel: •Peripheral •Presence of haustration, diameter >8 cm •distended caecum a rounded gas shadow in the right iliac fossa. >10cm diameter. •Central •jejunum  valvulae conniventes •Ileum  featureless •Diameter >5 cm •No gas is seen in the colon
  20. 20. Pseudo-obstruction DEFINITION • Describes an obstruction that occurs in the absence of mechanical cause or acute intra abdominal disease • Diagnosis of exclusion in the absence of mechanical cause CAUSES • Idiopathic • Metabolic • Severe trauma • Shock • Septicaemic • Retroperitoneal irritation • Drugs
  21. 21. Ogilvie’s Syndrome • Acute large bowel obstruction • Absence of mechanical cause • AXR – evidence of colonic obstruction, usually marked cecal distension • Single contrast water soluble barium enema, CT scan and colonoscopy can be done • Once diagnosis confirmed, treat with colonoscopic decompression • Recurrence occurs in 25% • Complication – cecal perforation • Repeat colonoscopy with simultaneous placement of flatus tube may be required • Surgical intervention – subtotal colectomy and ileorectal anastomosis
  22. 22. Principles of Treatment • Gastrointestinal drainage • Fluid and electrolytes replacement • Relief of obstruction • Surgical intervention • necessary for most cases • Need to be delayed until resuscitation is complete
  23. 23. Early Management • ABC • Resuscitation • Oxygen supply • fluid replacement with hartman or normal saline • Nasogastric decompression • KNBM • NG tube with free flow or 4hly aspirate • Close monitoring • BP, PR, Temp, Input/output, CVP • Antibiotic s cover • Analgesia
  24. 24. Indication For Surgery • Immediate intervention • Evidence of strangulation • Signs of peritonitis resulting from perforation or ischemia • In the next 24-48H • Clear indication of no resolution of obstruction (clinical or radiological) • Diagnosis is unclear in virgin abdomen
  25. 25. Take Home Message • 4 cardinal signs of intestinal obstruction are abdominal pain, abdominal distension, vomiting and constipation • Pseudo-obstruction is the diagnosis of exclusion in the absence of mechanical obstruction • Decompress the obstructed gut (NGT!!)
  26. 26. • Replace fluid and electrolytes loses • Strict IO (CBD is least, CVP - especially in elderly, immuno compromised patient) • CT if only patient is stable and cause of obstruction is unclear • Surgical intervention promptly if signs of peritonitis or strangulation, underlying cause needs surgical treatment ie colonic carcinoma or hernias or patient does not improve with conservative treatment
  27. 27. References • http://www.primary-surgery.org/ps/vol1/ch-10.pdf • Bailey & Love’s Short Practice Of Surgery 25th edition
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