In these slides we will go through the surgical anatomy of the gut,pathophysiology of intestinal obstruction, clinical presentation and management. Also we will discuss specific types of intestinal obstruction.

1.  ‫الرحيم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬
 Department of surgery
 Unit:-
 Mr Dhirar
 Mr Alhassan
 Mr Haidar
 Tettorial tittle:
 Intestinal obstruction
 Presented by:
 Ola abdalsalam

2. CONTENT
 Surgical anatomy
 Classifications
 C/F
 Management
 Specific types of intestinal obstruction

3. SMALL BOWEL
 6ms length
 Duodenum 25 cm
 Jejunum :proximal 40%
 Ileum:distal 60%
 Blood supply: superior mesentric artery
 Venous drainage: superior mesenteric vein
 Nerve:sympT9-T11 parasymp:vagus

5. LARGE BOWEL
 1.5 meter
 Blood Supply
♦ Iliocolic, right colic, and middle colic
arteries branches of superior mesenteric
artery supply the colon from caecum to
splenic flexure.
♦ Left colic, sigmoid, superior rectal arteries
branches of inferior mesenteric artery supply
the descending and sigmoid colon

6. CLACCIFICATIONS
Class 1:
 Dynamic adynamic
 Class 2:
 Small bowel large bowel
 Class 3:
 Acute Chronic acute on chronic
Class 4:
 Aquired congenital

7. DYNAMIC
extramural mural intramural
adhesions T.B Gall stone
hernia Crohn disease Round worm
intusseception malignancy Inspissated feaces
volvulus Meconium ileus

8. ADYNAMIC
 Postoperative period
 Electrolyte imbalance
 Spinal injuries
 Uraemia paralytic ileus
 Diabetes mellitus
 Mesenteric ischaemia
 Pseudo-obstruction

9. Congenital causes:-
 Congenital megacolon
 Duodenal atresia
 Intestinal atresia
 Band and adhesions
 Malrotation
 Volvulus neonatorum

10. Dynamic intestinal obstruction

11. PATHOPHYIOLOGY
 Changes proximal to the bowel obstruction:
Intestinal obstruction
↓
Increased peristalsis
↓
Becomes vigorous
↓
Obstruction not relieved
↓
Peristalsis ceases.
↓
Flaccid, paralysed, dilated bowel

12.  Fluid collects just proximal to the obstruction
which is derived from saliva, stomach, pancreas
and intestine
 Defective absorption, decreased fluid intake,
loss of fluid by vomiting, sequestration of fluid
into the bowel lumen dehydration and
electrolyte disturbance

13.  Increased bacterial colony in the bowel due
to altered luminal content and environment
→ multiplication →toxins → further mucosa
damage → translocation of bacteria across
mucosa into submucosa and also absorption
of bacterial into the circulation→bacteraemia

14.  Changes at the site of the obstruction:
Initially venous return is impaired.
↓
Congestion, oedema of bowel wall occurs which turns
purple.
↓
Later this jeopardizes the arterial supply.
↓
Loss of shineness, blackish discolouration, loss of peristalsis.
↓
Gangrene.
↓
Perforation occurs.
↓
Bacteria and toxins migrate into the peritoneum.
↓
Peritonitis

15.  Bowel distal to the obstruction is inactive
and collapsed

16. CLOSED LOOP OBSTRUCTION

17. CARDINAL FEATURES
 Abdominal pain
 Vomiting
 Distension
 Absolute conistipation

18. Proximal s.bowel Distal s.bowel Large bowel
Severe vomiting,
dehydration, no or
less distension,
colicky pain
Central distension,
vomiting,
dehydration
central abdominal pain
Constipation,
distension—
early;
Late vomiting less
pain

19. Vitally:
 Tachycardia
 Tahypnea
 Febrile
 hypotensive

20. Abdominal examination:
 Tenderness
 Reboud tenderness,guardning,rigidity
 Bowel sound: exaggerated /abscent
 PR: empty dilated rectum

21. INVESTIGATIONS
 General:
 CBC
 RFT + electrolytes
 ABG
 Coagulation profile

22. INVESTIGATIONS FOR DIAGNOSIS:
 Erect +supine abdominal x ray:
 Multiple air fluid level
 Dilated loop:-
 Small bowel > 3 cm diameter
 proximal large bowel> 9 cm
 transverse colon > 5.5 cm
 sigmoid colon> 5 cm
 Specific features
 pneumobilia
 CT scan

24. HAUSTRATION

25. VALVULAE CONNIVENT

26. TREATMENT
 NPO
 Fluid and electrolyte management
 NGT
 Catheter
 laprotomy

27.  Postsurgery Complications:-
♦ Pelvic abscess.
♦ Subphrenic abscess.
♦ Biliary or faecal fistulas.
♦ Burst abdomen.
♦ Bands and adhesions.
♦ Incisional hernias

28. SPECIAL TYPES

29. DUODENAL ATRESIA
- It is the commonest site of intestinal atresia
- It is usually a complete stenosis of the second
part
- Defective fusion of foregut and midgut with
failure of recanalization
-Duodenal atresia may be preampullary
(nonbilious vomiting) or postampullary (bilious
vomiting)

31.  Associated with:
 Down syndrome 30%
 CHD 30%
 ARM 10%
 Polyhydramnios and prematurity 50%

32. C/F
♦ Jaundice.
♦ Bilious/nonbilious vomiting immediately after
birth
♦ Dehydration. Electrolyte changes are
common.
♦ Growth retardation of newborn due to
deprived nutrition

33. INVESTIGATIONS
 Plain X-ray shows classic double-bubble sign
with absence of air in the distal part
 U/S will show distended stomach and
proximal duodenum( rail road track)

35. TREATMENT
 duodenodoudenostomy

36. INTESTINAL ATRESIA
 Jejunoileal atresia
 Intrauterine mesenteric vascular occlusion
 Commonly:proximal jejunum and distal ileum

38.  X-ray : triple bubble
 Barium enema: microcolon
 Treatment:
 Resection and anastomosis
 Jejunoplasty(extensive length involved)

39. MALROTATION
 Stages of normal rotation:
 Stage 1: coelomic cavity cannot
accommodate midgut during this period
protrude into umblical cord as physiological
hernia
 Stage 2: midgut migrate into coelomic
cavity;small bowel in left side;it rotate 270
anticlockwise into rt iliac
fossa;duodenojejunal segment rotate 270
anticlock to reach left of SMA and behind the
colon

40.  Stage 3: fusion of different parts of mesentry
and posterior peritoneum

41.  Errors:
 Stage 1: gastroschisis
 Stage 2: non-rotation
 Incomplete rotation
 Reverse rotation
 Hyper-rotation
 Stage 3: mobile caecum and ascending
colon

42.  Dark blood per rectum
 Erythrema of anterior abdominal wall
 Teatment: ladd operation

43. MECONIUM ILEUS
 Commonly associated with cystic disease of
pancreas but not necessarily always
 Respiratory dysfunction
 Exocrine pancreatic insufficiency
 High salt in the sweat > 90 mmol/L

44.  Complications of meconium ileus:
 Intestinal bolus obstruction
 Perforation and peritonitis
 Gangrene, volvulus formation

45. INVESTIGATIONS
♦ Plain X-ray shows calcified meconium pellets with
multiple air fluid levels which appear as ‘soap-
bubbles’
♦ Vomitus of the patient which does not contain trypsin,
when poured on the exposed X-ray film will not digest
the gelatin of the film
♦ Pilocarpine is injected into skin to stimulate the
sweating and collected sweat (100 µg sweat)is
analysed for sodium and chloride.
♦ Elevated albumin level in meconium

46. TREATMENT
Nonoperative measures:-
Dissolution through enema can be tried
using gastrografin
Operative measures:-
Bishop-Koop operation in critical pt
 If fit: resection and anastmosis

47. INTUSSUSCEPTION (ISS)
 It is invagination of one portion (segment) of
bowel into the adjacent segment.
Types
1. Antegrade: Most common.
2. Retrograde

48. ♦ It can be ileo-colic (most common type,
75%), colocolic, ileoiliocolic
♦ It is common in weaning period of a child
(common in male),between the period of 6-9
months

49. AETIOLOGY
 Change in diet during weaning
 Upper respiratory tract viral infection
 Intestinal polyps
 Submucous lipoma
 Leiomyoma of intestine
 Meckel’s diverticulum
 Carcinoma

50. ♦ Apex is the one which advances;
♦ Intussuscipiens is the one which receives
♦ Intussusceptum

52. FEATURES
 on/off
 screaming
 Red currant jelly stool
 Palpable mass (85%)
– Sausage shaped smooth, firm mass
– Mass does not move with respiration
– Mobile in all directions
– Resonant
– Mass contracts under the palpating fingers
– Mass appears and disappears
Empty right iliac fossa

53. INVESTIGATIONS
♦ Barium enema shows typical claw sign
♦ Ultrasound shows target sign or
pseudokidney sign

55. TREATMENT
 Nonoperative measures:
 Reduction by hydrostatic pressure but
contraindicated in:
 1- doubtful diagnosis
 2-Late cases
 3-abdominal distension/rigidity
 Operative:
 Manual reduction
 Resection and anastamosis

56. Recurrence rate:
♦ In hydrostatic reduction—10%.
♦ In open manual reduction—2%.
♦ In resection—very less < 1%

57. VOLVULUS
 Definition
It is the twist (rotation) in the axis of the loop
of the bowel either clockwise or anticlockwise

58. ♦ Sigmoid colon is the commonest site (anticlock wise)—
65%.
♦ Caecal volvulus
Caecum is the second common site(clockwise) 30%
 Caecum will be markedly distended and found in the
centre of the abdomen
 X-ray shows round gas shadow in right iliac region.
CT scan is very useful. Barium enema is also helpful.
Resection and anastomosis (surgery) is the only treatmen

59. SEGMOID VOLVULUS
 It is common in patients with chronic
constipation with laxative abuse
 Predisosing factors:
Adhesions
Peridiverticulitis
Overloaded redundant pelvic colon
Long pelvic mesocolon
Narrow attachment of sigmoid mesocolon

60.  More than 180 : luminal obsrtuction
 It requires one and half turn of rotation to
cause vascular obstruction

61. INVESTIGATIONS FOR DIAGNOSES
1. Plain X-ray:(diagnostic in 70-80%)
Ω sign (omega sign).
Coffee-bean sign.
2. Contrast enema:
Birds beak sign
3. CT scan

63. TREATMENT
 A flatus tube or Sigmoidoscope
 Laprotomy

64. PARALYTIC ILEUS
 It is a state in which intestines fail to transmit
peristalsis due to failure of neuromuscular
mechanism

65. C/F
♦ No passage of flatus.
♦ No bowel sounds.
♦ Marked abdominal distension.
♦ Vomiting of large volume of fluid.
♦ Tachycardia.
♦ Respiratory distress due to pressure over the
diaphragm.
♦ Dull abdominal pain (not colicky).
♦ Features of fluid/protein/electrolyte imbalance

66. TREATMENT
♦ Nasogastric aspiration.
♦ The primary cause is treated.
♦ IV fluids.
♦ Electrolyte management.
♦ Catheterisation and urine output
measurement

67.  Measurement of abdominal girth
Decompression of the large bowel can be
tried by inserting a flatus tube per anally

68. ADHESIONS AND BANDS
 Causes may be classified as:—
 Congenital adhesions
 Ischaemic
 Traumatic
 Irritants
 Inflammatory

69. TYPES
 Type I—Fibrinous adhesions occur during 5-
10th post-surgical period. It usually gets
resolved completely. It is avascular .
Type II—Fibrous adhesions. Due to lack/poor
blood supply It will persist and precipitate
intestinal obstruction

70.  1) Pain may get aggravated or relieved on
change ofposture.
 2) Pain in the region of old abdominal scar.
 3) Tenderness is elicited by pressure over the
scar

71.  Conservative(72 hrs)
 surgical

72. INTERNAL HERNIA
 Portion of bowel entrapped in one of the
retroperotineal fossae or congenital
mesenteric defect including:
 Foramen of winslow
 Defect in mesentry;transverse
mesocolon;broad ligament
 Diaphragmatic hernia
 Duodenal;ceacal or intersegmoid fossae

73.  Treatment:
 Division of constricting agent

74. PSEUDO-OBSTRUCTION
 Obstruction in absence of mechanical cause
or acute intra-abdominal disease
 Acute colonic: Ogilvie syndrome
 Marked ceacal distention/ceacal perforation

76.  Management:
 Exclude the mechanical causes
 Treat the underlying cause
 I.V neostigmine 1 mg
 decompression