HEGAZY SURGERY -ABDOMINAL SWELLING

1. Brigadier Dr.
Khaled Elkholy
MD, MRCS, MSc

2. A 65y old man presented to the
A&E with
 Attacks of colicky abdominal pain associated with
repeated vomiting and absolute constipation
 On examination, the abdomen is hugely distended
showing visible peristalsis with a long midline scar of
previous laparotomy
 The patient is tachycardic and dehydrated with
disturbed electrolytes
 AXR showed dilated small bowel loops

4. Definition
 The normal flow of
intestinal contents is
interrupted

5. Classifications of IO:
 Type of obstruction
 Mechanical (dynamic)
 Functional (adynamic)
 Time of presentation
 Acute
 Chronic
 Extent of obstruction
 Partial
 Complete
 Pathological nature of
obstruction
 Simple mechanical
 Strangulation
 Paralytic ileus

6. Mechanical (dynamic)
 Peristalsis is working
against a mechanical
obstruction
Extramural Intramural Intraluminal
• Adhesions
• Hernias
• Volvulus
• Tumours
• Congenital
anomalies 
atresia
• Intussuscepti
on
• Neoplasm
• Stricture
• Gallstone
ileus
• Fecal
impaction
• FB  bezor
• Traumatic
intraluminal
hematoma

7. Functional (adynamic)
 Atony of the intestine
with loss of normal
peristalsis in the absence
of mechanical
obstruction e.g. ileus
 Peristalsis present in a
non-propulsive form e.g.
MVO or pseudo-
obstruction

8. Commonest causes
 Strangulated hernias 
most common cause of
SBO in children
 Adhesions  most
common cause of SBO in
adults
 Cancer colon  most
common cause of LBO

9. Cardinal clinical features of acute
obstruction
 Abdominal pain
 Distension
 Vomiting
 Absolute constipation

10. Features according to level of obstruction
 High small bowel obstruction
 Vomiting  early & profuse 
rapid dehydration
 Distension  minimal
 Few fluid levels on AXR
 Low small bowel obstruction
 Pain  predominant
 Central distension.
 Vomiting  delayed.
 Multiple central fluid levels on
AXR
 Large bowel obstruction
 Distension  early + marked
 Pain  mild
 Vomiting & dehydration  late
 The proximal colon and
caecum are distended on AXR

11. General examination
Signs of dehydration
 Tachycardia
 Oliguria
 Dry tongue
 Hypotension

12. Abdominal examination
 Inspection
 Distension
 Scars
 Visible peristalsis
 Hernia
 Palpation
 Mass
 Tenderness
 Percussion
 Tenderness
 Hyper-resonance
 Auscultation
 ↑Bowel sounds
 Silent
 Rectal examination
 Empty
 Blood
 Fecal mass

13. Clinical features of strangulation
 Constant pain
 Tenderness + rebound
tenderness
 Rigidity
 Shock
 Toxicity

14. Investigations
 CBC
 Urea & creatinine
 S. electrolytes
 AXR
 Ultrasound
 CT scan

15. Radiological features of obstruction
 SBO
 Straight segments that are generally
central and lie transversely
 No gas is seen in the colon
 Jejunum  Valvulae conniventes
 Pass across the width of the bowel
 Regularly spaced, giving a
‘concertina’ or ladder effect
 Ileum  featureless
 Caecum – a distended caecum  a
rounded gas shadow in the RIF
 Large bowel, except for the caecum 
haustral folds (unlike VC)
 Spaced irregularly
 Do not cross the whole diameter of
the bowel
 Do not have indentations placed
opposite one another

16. MCQ
The following features are present in SBO except
 Distension
 Vomiting
 Dehydration
 Diarrhoea
 Hyperkalemia
 Dilated bowel loops on AXR

17. Preoperative management (drip & suck)
 NGT
 Free drainage + 4-hourly
aspiration /continuous
or intermittent suction.
 Decompression
proximal to the
obstruction
 Reduce risk of
aspiration
 IV fluids
 Antibiotics
 Urinary catheter

18. Surgery
Indications for early surgical
intervention
Principles of surgical
intervention for obstruction
 Obstructed or strangulated external
hernia
 Internal intestinal strangulation
 Acute obstruction
Management of:
 The segment at the site of
obstruction
 The distended proximal bowel
 The underlying cause of obstruction

19. Differentiation between viable and non-viable
intestine
Viable Non-
viable
Circulation • Dark color
becomes
lighter
• Mesentery
bleeds if
pricked
• Dark colour
remains
• No bleeding
if mesentery
is pricked
Peritoneum Shiny Dull & lustreless
Intestinal
musculature
• Firm
• Pressure
rings may or
may not
disappear
• Peristalsis
may be
observed
• Flabby, thin
& friable
• Pressure
rings persist
• No
peristalsis

20. Conservative treatment
 Adhesions  drip & suck
 Ileo-caecal
intussusception 
hydrostatic effect of
barium enema
 Sigmoid volvulus 
rectal tube
 Fecal impaction 
enema

21. MCQ
In the treatment of dynamic bowel obstruction
 Conservative management is the only option
 Non-viable bowel should be resected during the
operation
 Volvulus can be treated conservatively
 Drip and suck is tried in adhesive intestinal
obstruction
 Fecal impaction should be treated operatively
 Intussusception should be treated operatively

22. A 10 months old child presented to
the A&E with
 Episodes of screaming and drawing up of the legs lasting
for 1-2min and recurs every 15-20min
 The condition is associated with Pallor + sweating +
retching
 Vomiting which is bile-stained
 Initially, the passage of stool was normal, but now the
patient is passing blood and mucus PR
 Hx of recent respiratory tract infection
 On examination, the right iliac fossa felt empty with
Sausage-shaped mass palpated in the right hypochondrium

23. Most commonly in children

24. Definition
 Segment of the gut
(intussusceptun) becomes
invaginated within an
immediately adjacent
segment (intussuscepiens)
 Usually proximal into
distal
 An example of a
strangulating obstruction
as the blood supply of the
inner layer is usually
impaired

25. Aetiology
 Peak between 5-10 months
 ~90% idiopathic  ?
• Upper respiratory tract
infection
• gastroenteritis
 >2 years  a pathological
lead point in 1/3
 Adult  lead point usually
a polyp (e.g. Peutz–Jeghers
syndrome), a submucosal
lipoma or other tumour.

26. Types
 Ileo-ileal
 Ileo-colic (ileo-caecal)
In most children
 Ileo-ileo-colic
 Colo-colic  common in
adults

27. Symptoms
Early
 Intermittent colicky pain
 Screaming and drawing up
of the legs
 Pallor + sweating +
retching
 Vomiting
 Episodes 1-2min every 15-
20min
 Redcurrant jelly stool
Late
 Symptoms of peritonitis &
IO

28. Signs
 Examination between episodes of
colic
 Abdomen is not initially distended
 Emptiness in the right iliac fossa
(sign of Dance)
 Sausage-shaped mass
 PR
 Blood-stained mucus
 Apex palpable / protrude from the
anus  in extensive ileocolic or
colocolic
 Unrelieved 
 Progressive dehydration
 Abdominal distension
 Gangrene  peritonitis

29. Imaging in intussusception
 AXR 
 IO
 Absent caecal gas in
ileocolic
 Soft tissue opacity in
children
 Barium enema  the claw
sign in ileocolic I
 US  high sensitivity in
children  typical
doughnut appearance of
concentric rings in
transverse section
 CT  in equivocal cases

30. Pneumatic or hydrostatic reduction
 Successful 
 free reflux of air or barium into
the small bowel
 resolution of symptoms &
signs
 Contraindicated if
 Signs of peritonitis or
perforation
 Known pathological lead point
 Profound shock
 >70% can be reduced non-
operatively
 10% recurrence

31. Surgery
 Radiological reduction failed
or contraindicated
 Transverse right-sided
abdominal incision
 Gently compress the most distal
part of the intussusception
toward its origin
 The last part of the reduction is
the most difficult
 Resection & 1ry anastomosis 
 Irreducible intussusception
 Infarction
 Lead point

32. MCQ
Intussusception
 Most common in children
 Always secondary to intestinal pathology, e.g. polyp,
Meckel’s diverticulum in infants
 Ileo-colic is the least common
 Can lead to an ischaemic segment
 Pneumatic reduction is usually successful in children
 Laparotomy is always required

33. A 70y old black male present to
the A&E with
 Recurrent attacks of abdominal pain associated with
absolute constipation
 The patient complained of nausea but no vomiting is
experienced
 On examination, the abdomen is distended hugely,
tympanitic on percussion with exaggerated bowel
sounds
 AXR showed the coffee-bean sign

35. Definition
 Twisting or axial rotation of a
portion of bowel around its
mesentery
 When complete it forms a closed
loop of obstruction with resultant
ischaemia secondary to vascular
occlusion
 May involve
 Sigmoid colon  commonest in
adults
 Small intestine
 Caecum
 Stomach
 Neonatal midgut volvulus
secondary to midgut malrotation is
life-threatening

36. Sigmoid volvulus
 Predisposing factors 
 Symptoms
 Large bowel obstruction
 initially intermittent
 Abdominal distension 
early & progressive sign
 Hiccough & retching
 Vomiting occurs late
 Constipation is absolute
 In elderly  chronic form

37. AXR  Coffee-bean sign or Omega sign Ὠ

38. Barium study

39. CT Scan

40. Treatment
 Flexible sigmoidoscopy or
rigid sigmoidoscopy +
flatus tube
 Laparotomy
 Untwisting of the loop +
per anum decompression
 Viable  fixation of the
sigmoid colon to the
posterior abdominal wall
 inexperienced hands
 Resection  preferable
Hartmann’s procedure +
subsequent re-
anastomosis

41. MCQ
Volvulus
 May involve the sigmoid colon only
 Neonatal midgut volvulus secondary to midgut
malrotation is life-threatening
 The commonest spontaneous type in adults is caecal
volvulus
 Sigmoid volvulus can be relieved by decompression per
anum
 Surgery is required to prevent or relieve ischaemia

42. A 50y old lady presented to the
A&E with
 Abdominal colicky pain
 Nausea and vomiting
 Absolute constipation
 Distension
 Tachycardia
 Dry tongue
 History of repeated laparotomies, the last one was rwo
years ago for perforated DU

43. Most common cause of intestinal obstruction in developed
countries

44. Common causes of intra-abdominal
adhesions
1. Ischaemic areas • Sites of
anastomoses
• Vascular occlusion
2. Foreign material Talc, gauze, silk
3. Infection Peritonitis, T.B.
4. Inflammatory
conditions
Crohn’s disease
5. Radiation
enteritis

45. Bands
 Congenital, e.g.
obliterated vitello-
intestinal duct
 String band following
previous bacterial
peritonitis
 Portion of greater
omentum, usually
adherent to the parietes

46. Prevention of adhesions
Factors that may limit
adhesion formation include:
 Good surgical technique
 Washing of the peritoneal
cavity with saline to
remove clots, etc.
 Minimising contact with
gauze
 Covering anastomosis and
raw peritoneal surfaces

47. Treatment of adhesive obstruction
 Initially treat conservatively
provided there are no signs of
strangulation; should rarely
continue conservative
treatment for longer than 72
hours
 At operation, divide only the
causative adhesion(s) and
limit dissection
 Cover serosal tears
 Invaginate (or resect) areas of
doubtful viability
 Laparoscopic adhesiolysis 
in chronic cases

48. MCQ
Prevention of intraoperative adhesions can be
done by
 Good surgical technique
 Copious irrigation with saline
 Curetting the bowel with gauze
 Excising omentum
 Avoid using powdered gloves

49. The ward nurse asked you to review a
postoperative patient complaining of
 Abdominal distension and absolute constipation
 The patient vomited twice
 No abdominal pain is felt
 On examination, abdominal tenderness is mild and no
bowel sounds are heard on auscultation
 AXR  showed dilated small bowel loops with
multiple fluid levels

51. Definition
 Failure of transmission of
peristaltic waves secondary
to neuromuscular failure
i.e. in the myenteric
(Auerbach’s) and
submucous (Meissner’s)
plexuses
  accumulation of fluid
and gas  distension,
vomiting, absence of bowel
sounds & absolute
constipation

52. Causes
 Postoperative: a variable duration
of 24–72
 Intra-abdominal sepsis: localised
or generalised ileus
 Reflex ileus: following
 # Spine or ribs
 Retroperitoneal hge
 Plaster jacket
 Metabolic:
 Uraemia
 Hypokalaemia
 Diabetic ketoacidosis
 Drugs in high doses:
 Anticholinergics e.g. probanthine
 Tricyclic antidepressants

53. Clinical features
 72 hours after laparotomy:
 no bowel sounds
 flatus.
 Abdominal distension 
more marked &
tympanitic.
 Pain is not a feature
 Vomiting  if no NGT
 AXR  gas-filled loops of
intestine + multiple fluid
levels

54. Prevention
 Correction of biochemical
disturbances
 Gentle handling of bowel
 Nasogastric suction
 Restriction of oral intake
 Electrolyte balance
 Enhanced recovery
programme with early
introduction of fluids and
solids

55. Treatment
 1ry cause must be
removed
 Drip & Suck
 Rarely, in resistant
cases:
 Adrenergic blocking
agent + cholinergic
stimulation, e.g.
neostigmine (the
Catchpole regimen)
 Laparotomy  to
exclude a hidden cause
& facilitate bowel
decompression

56. MCQ
Paralytic ileus
 Is functional and not mechanical
 Usually postoperative
 Pain is predominant
 Distension is present
 Bowel sounds are present
 Is due to neuromuscular failure
 Usually treated surgically

57. You was asked to review a patient with
known retroperitoneal sarcoma
showing
 Massive abdominal distension and respiratory distress
 Abdominal pain, nausea and vomiting
 Tympanitic abdomen and sluggish intestinal sounds
 AXR showed dilated colon from the caecum to the
splenic flexure
 Single-contrast water-soluble barium enema showed no
mechanical cause of LBO

59. Definition
 Obstruction, usually of
the colon, that occurs in
the absence of a
mechanical cause or
acute intra-abdominal
disease

60. Factors associated with pseudo-
obstruction
Idiopathic
 Metabolic
 Diabetes: intermittent porphyria
 Acute hypokalaemia
 Uraemia
 Myxodoema
 Severe trauma (especially to the lumbar spine and
pelvis)
 Shock
 Burns
 Myocardial infarction
 Stroke
Septicaemia
 Retroperitoneal irritation
 Blood
 Urine
 Enzymes (pancreatitis)
 Tumour
 Drugs
 Tricyclic antidepressants
 Phenothiazines
 Laxatives
 Secondary gastrointestinal involvement
 Scleroderma
 Chagas’ disease

61. Colonic pseudo-obstruction
 Acute (Ogilvie’s syndrome) or
chronic
 AXR  colonic obstruction +
marked caecal distension 
??Caecal perforation
 Absence of a mechanical cause
requires urgent confirmation by
 Colonoscopy
 single-contrast water-soluble
barium enema
 CT
 Colonoscopic decompression 
recur in 25%  further colonoscopy
+ flatus tube
 Colonoscopy fails or unavailable 
 Tube caecostomy
 Subtotal colectomy and ileorectal
anastomosis.

62. MCQ
Colonic pseudo-obstruction
 Is called Ogilvie’s syndrome in chronic cases
 AXR shows dilated large bowel
 Single-contrast water-soluble barium enema is used to
exclude mechanical cause
 Colonoscopy is used for colonic decompression
 Surgery is not an option for treatment