How to Diagnose a case of Intestinal Obstruction


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Intestinal obstruction, if diagnosed early, can be managed efficiently. If diagnosed at a later stage, it may change in to life threatening situation.

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How to Diagnose a case of Intestinal Obstruction

  1. 1. Welcome Intestinal Obstruction By Dr Praveen Choudhary
  2. 2. Intestinal Obstruction When there is pathological interference with the normal progression of the intestinal luminal contents distally, the condition is called intestinal obstruction.
  3. 3. Etiology Intestinal obstruction may be classified into two types: 1. Dynamic/Mechanical obstruction. 2. Adynamic obstruction. Dynamic/Mechanical Obstruction I.Intraluminal (obstruction in the human). II.Intramural (lesion of bowel wall). III.Extramural (lesion extrinsic to the bowel). Adynamic Obstruction Peristalsis may be absent e.g. paralytic ileus. Peristalsis may be present in a non propulsive form.
  4. 4. Dynamic Obstruction I. Intraluminal Obstruction a) Meconium. b) Bezoars:  Trichobezoar.  Phytobezoar. c) Gall stones. d) Polypoid Tumour of bowel. e) Intussception. f) Impaction of barium/worms/foreign body.
  5. 5. Phytobezoa r
  6. 6. Dynamic Obstruction I. Intramural Obstruction This can be classified into (a) Congenital (b) Traumatic. (c) Inflammatory (d) Neoplastic (e) Miscellaneous
  7. 7. Meckel’s diverticulum
  8. 8. Dynamic Obstruction I.Extramural Obstruction: (a) constriction Adhesive (b) External hernia (c) Volvulus (d) Extrinsic masses band
  9. 9. Classification Classification of Intestinal obstruction can be made as follow: 1. Simple mechanical obstruction. 2. Strangulated obstruction. 3. Closed loop obstruction.
  10. 10. Clinical Classification Clinically obstruction may be classified into two types: 1. Small Bowel obstruction – high or low 2. Large Bowel obstruction
  11. 11. Presentation Presentation may be :1. Acute. 2. Chronic. 3. Acute on Chronic. 4. Subacute.
  12. 12. Pathophysiology Obstruction Increased bowel motility Relieve obstruction Does not relieve obstruction Distension Bacterial proliferation
  13. 13. Clinical Feature v Pain. v Vomiting. v Distension. v Constipation. Clinical Features Of Strangulation v Shock v Pain is never completely absent. vThe presence tenderness. and character of any local
  14. 14. Distension
  15. 15. Late Manifestation v Dehydration v Oliguria v Hypovolaemic shock v Pyrexia v Septicaemia v Peritonism v Respiratory embarrassment.
  16. 16. Examination 1. PHYSICAL EXAMINATION (a) Inspection (b) Palpation (c) Percussion (d) Auscultation 2. Rectal Examination
  17. 17. Inspection Physical Examination In early stage „visible peristalsis is the only sign.  Abdominal distension is the late sign. Hernial orfices, surgical scars must be inspected. Palpation During colic there may be muscle guarding. Slight tenderness may be present between attacks of pain. Tenderness and rigidity at the sight of obstruction usually indicates strangulation. Percussion Only reveals resonant note of gaseous distension of bowel. Auscultation Presence of loud borborygmi, conciding with intestinal colic is very diagnostic. In case of intestinal obstruction “Silent abdomen” suggests paralytic ileus.
  18. 18. Rectal Examination Presence of mass on rectal examination within or outside the lumen will give a clue to diagnosis. Presence or absence of feaces in rectum should be noted. Absence means obstruction is higher up. If present it should be studied for presence of occult blood, which include mucosal lesion e.g. cancer, intussusception or infarction. Sigmoidoscopy should be done if colonic obstruction is suspected.
  19. 19. Special Investigation (1) Blood Examination (2) Radiological Examination
  20. 20. Management There are three main measures: 1. Gastrointestinal drainage. 2. Fluid and electrolyte replacement. 3. Relief of obstruction (surgical).
  21. 21. Supportive Management Nasogastric Decompression Fluid And Electrolytic Replacement Antibiotics
  22. 22. Adhesions And Cause for Adhesions Bands 1.Ischaemic areas 2. Foreign material 3. Infection & Inflammation 4. Radiation enteritis 5. Drugs Cause for Bands Congenital A string band following previous bacterial peritonitis. A portion of greater omentum usually adherent to parictes.
  23. 23. Treatment Initial management of Adhesions And Bands is based on I.V. rehydration and nasogastric decompression. When obstruction is caused by an area of multiple adhesions, they should be freed by sharp dissection. To prevent recurrence the bare area should be covered with omental grafts.Following release of band obstruction, the constriction sites that have suffered direct compression should be carefully assessed
  24. 24. Recurrent Obstruction Due To Adhesion Procedures are:    plication.  Repeat adhesiolysis (enterolysis) alone. Noble‟s plication operation. Charles – Phillips transmesentric Intestinal intubation.
  25. 25. Special Types Of Obstruction 1. Internal Hernia 2. Obstruction From Enteric Strictures 3. Bolus Obstruction 4. Acute Intussusception 5. Volvulus
  26. 26. Internal Hernia Internal herniation occurs where a portion of the small intestine becomes entrapped in one of the retroperitoneal fossae or into a congenital mesenteric defect. Treatment : The standard treatment for a hernia is to release the constricting agent by division.
  27. 27. Enteric Strictures Small bowel strictures usually occur secondary to tuberculosis or Crohn‟s disease presentation is usually subacute or chronic. Treatment : Standard surgical management consist of resection and anastomosis.
  28. 28. Bolus Obstruction Bolus obstruction in small bowel may be caused by food, gallstone, Bezoars, stercolith and worms. Treatment : In case of stone or food, after milking the stone proximally, crush the stone if possible. If not, the intestine is opened and the gallstone disimpacted, milked back and removed. In case of Bezoars or stercolith, Lesion may be kneaded, if possible otherwise open removal is required.
  29. 29. Acute Intussusception When one portion of the gut invaginates into immediately adjacent loop, the condition is called intussusception Types: (i)Primary (ii)Secondary
  30. 30. Intussusception
  31. 31. Treatment Preopertive Management Nasogastric decompression. Intravenous rehydration. Hydrostatic Reduction : Barium enema can be used for hydrostatic reduction of intussusception. Operative Treatment After preoperative rescescitation a midline incision is used for proper exposure.Reduction is achieved by squeezing the most distal part. Cope,s method is used in difficult cases
  32. 32. V olvulus A volvulus is a twisting or axial rotation of a portion of bowel about its mesentry. When complete it forms a closed loop of obstruction with resultant ischemia secondary to vascular occlusion TwoTypes: 1. Primary Volvulus Causes 1. Congential malrotationof gut. 2. Abnormal mesentric attachments. 3. Congential bands. Example : Volvulus neonatorum, caecal & sigmoid volvulus. 2.Secondary Volvulus Cause:Actual rotation of a piece of bowel around an acquired adhesion or stoma.
  33. 33. V olvulus
  34. 34. V olvulus Volvulus Neonatorum It is predisposed to by arrested gut rotation with a resultant narrow mesentry of small bowel and caecum. Surgical Treatment Operation consist of reduction by untwisting and division of any secondary obstructive lesions such as transduodenal band of ladd. Volvulus of small intestine This may be primary or secondary & usually occurs in lower ileum. Treatment: Treatment consist of reduction of the twist and is than directed to underlying cause.
  35. 35. V olvulus Caecal Volvulus May occur as a part of volvulus neonatorum or denavo. Surgical Treatment At operation the volvulus should be reduced. Further management consist of either fixation of caecum to right iliac fossa(caecopaxy) or a caecostomy. Sigmoid Volvulus It occurs mainly due to band of adhesions. Treatment Flexible sigmoidoscopy or rigid sigmoidoscopy and insertion of a flatus tube should be carried out to allow deflation of gut.
  36. 36. V olvulus Compound volvulus Also known as ileosigmoid knotting. The long pelvic mesocolon allow the ileum to twist around the sigmoid colon resulting in gangrene of either or both segments of bowel. Surgery At operation decompression, resection and anastomosis are required.
  37. 37. Adynamic Paralytic Ileus Obstruction It may be defined as a state in which there is failure of transmission of peristaltic waves secondary to neuromuscular failure. Varietes Following varieties are recognised : 1. Postoperative 2. Infection: Intra-abdominal sepsis  Localised ileus.  Generalised ileus. 3. Reflex ileus 4.Matabolic: Uraemia & Hypokalaemia are commonest contributory factor.
  38. 38. Management The essence of treatment is prevention with the use of nasogastric suction and restriction of the oral intake untill bowel sounds and passage of flatus return.Treatment is according to cause but following general principle apply:1. Primary cause must be removed. 2. Gastrointestinal distension must be relieved. 3. Close attention to fluid and electrolyte balance is essential. 4. Use of peristalsis stimulant is recommended only in ressistant cases. 5. If paralytic ileus is prolonged, a laparotomy should be considered to exclude a hidden cause and facilitate bowel decompression.