Gastrointestinal System

1. DR S C GAN FMHS/UTAR 12102012 1
GIT6: OBSTRUCTION
DR GAN SENG CHIEW
Associate Professor
FACULTY OF MEDICINE & HEALTH SCIENCES
UNIVERSITY TUNKU ABDUL RAHMAN

2. DR S C GAN FMHS/UTAR 12102012 2
Intestinal Obstruction
An obstruction may occur anywhere along the
small or large intestine and can be partial or
complete. The part of the intestine above the
obstruction continues to function. This part of the
intestine enlarges as it fills with food, fluid,
digestive secretions, and gas. The intestinal lining
becomes swollen and inflamed. If the condition is
not treated, the intestine can rupture, leaking its
contents and causing inflammation and infection of
the abdominal cavity (peritonitis).

3. DR S C GAN FMHS/UTAR 12102012 3
Causes
• Birth defect in newborns and babies.
• In adults, internal scar tissue from previous
abdominal surgery (adhesions), parts of the
intestine bulging through an abnormal opening
(hernias), and tumors.
• An obstruction of the duodenum may be caused by
cancer of the pancreas; scarring from an ulcer, a
previous operation, or Crohn's disease; or
adhesions. Rarely, a gallstone, a mass of
undigested food, or a collection of parasitic worms
may block the intestine.
• An obstruction of the large intestine is commonly
caused by cancer, diverticulitis, or a hard lump of
stool (fecal impaction). Adhesions and volvulus are
less common causes of large intestine obstruction.

4. DR S C GAN FMHS/UTAR 12102012 4
What Causes Intestinal
Strangulation?
Intestinal strangulation (cutting off of the blood supply to
the intestine) usually results from one of three causes.
Strangulation occurs in nearly 25% of people with small-
intestinal obstruction. Usually, strangulation results when part of
the intestine becomes trapped in an abnormal opening
(strangulated hernia); volvulus; or intussusception. Gangrene
can develop in as few as 6 hours. With gangrene, the intestinal
wall dies, usually causing rupture, which leads to peritonitis,
shock, and, if untreated, death.

5. DR S C GAN FMHS/UTAR 12102012 5
Symptoms and Diagnosis
• Intestinal obstruction usually causes cramping pain
in the abdomen, accompanied by bloating and
disinterest in eating (anorexia). Vomiting is common
with small-intestinal obstruction but is less common
and begins later with large-intestinal obstruction.
Complete obstruction causes severe constipation,
whereas partial obstruction may cause diarrhea.
With strangulation, pain may become severe and
steady. A fever is common and is particularly likely if
the intestinal wall ruptures.
• When an obstruction occurs, the abdomen is almost
always swollen.
• X-rays may show dilated loops of intestine that
indicate the location of the obstruction.

6. DR S C GAN FMHS/UTAR 12102012 6
Treatment
• Usually, a long, thin tube is passed through the
nose and placed in the stomach or intestine.
Suction is applied to the tube to remove the
material that has accumulated above the blockage.
Fluid and electrolytes (sodium, chloride, and
potassium) are given intravenously to replace
water and salts lost from vomiting or diarrhea.
• Occasionally, an endoscope, which is advanced
through the anus, or a barium enema, which
inflates the large intestine, may be used, such as in
a twisted intestinal segment in the lower part of
the large intestine. Most often surgery is
performed as soon as possible. In some cases, a
colostomy is required.

7. DR S C GAN FMHS/UTAR 12102012 7
Acute GastrointestinalAcute Gastrointestinal
EmergenciesEmergencies
DR GAN SENG CHIEW
Associate Professor
FACULTY OF MEDICINE & HEALTH SCIENCES
UNIVERSITY TUNKU ABDUL RAHMAN

8. DR S C GAN FMHS/UTAR 12102012 8
Classify By Site
Oesophagus
Acute dysphagia
• Perfusion
• Bleeding
Stomach/duodenum
• Perfusion
• Bleeding

9. DR S C GAN FMHS/UTAR 12102012 9
Gallbladder/Biliary Tract
• Cholecystitis
• Cholangitis
• Obstructive jaundice
Pancreas
• Acute pancreatitis
Small intestine
• Intestinal obstruction
• Mesenteric Infarct
• (Infectious diarrhoea)
• Crohn’s Disease
• Meckel’s Diverticulum
Large Bowel (+ App)
• Acute Appendicitis
• Acute Diverticulitis
• Lower GI bleeding
• Perforation
• Intestinal obstruction
• Uncontrolled
ulcerative colitis
Perintoneal cavity
• Peritonitis
• Intra-abdominal
abscess

10. DR S C GAN FMHS/UTAR 12102012 10
Oesophagus - BleedingOesophagus - Bleeding
Oesophagitis, Mallroy
Weiss, Varices
• Variceal bleeding –
can be catastrophic
• Treatment -
varices
– Sengstaken
tube
– Somatostatin
injection

11. DR S C GAN FMHS/UTAR 12102012 11
Oesophagus – AcuteOesophagus – Acute
DysphagiaDysphagia
• Presentation – cannot
swallow
– May have benign
stricture or cancer
– Triggered by food
bolus or tablet
– Treatment -
– remove bolus
– deal with
underlying
• oesophageal disease

12. DR S C GAN FMHS/UTAR 12102012 12
Oesophagus – PerforationOesophagus – Perforation
High mortality
May follow endoscopy
Presentation – acute
chest/abdominal pain
Air in mediastinum and
soft tissues
Treatment -
surgery - benign
intubation - malignant

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Stomach/duodenum –
Perforation
Presentation –
• abdominal pain
• rigidity
• peritonism, shock
• Air under diaphragm
on X-ray
Treatment -
• antibiotics,
resuscitate
• repair

14. DR S C GAN FMHS/UTAR 12102012 14
Stomach/duodenum –Stomach/duodenum –
BleedingBleeding
Presentation –
• Haematemesis +/-
• Melaena
• Severity
• Increased PR>90
• Fall BP<100
Causes
• DU, erosions, GU
Treatment –
• ransfusion
• inject DU

15. DR S C GAN FMHS/UTAR 12102012 15
Gall bladder/Biliary TractGall bladder/Biliary Tract
Obstructive Jaundice
• Yellow skin, sclerae
• Pale stools, dark urine
• +/- Pain
• +/- Courvoisier’s sign
• CT – dilated bile ducts
• Establish diagnosis
• Gallstones
• Ca Head of Pancreas
• Appropriate
treatment

16. DR S C GAN FMHS/UTAR 12102012 16
Gall bladder/Biliary TractGall bladder/Biliary Tract
Acute Cholecystitis
• Presentation
• Acute RUQ pain
• +/- Pyrexia
• +/- Rigors
• Diagnosis – FBC,
WBCC, USS
• Treatment –
Antibiotics,
• analgesics
• Early surgery

17. DR S C GAN FMHS/UTAR 12102012 17
PancreasPancreas
Acute pancreatitis
• Constant pain,
vomiting,
• Shock
Causes
• Gallstones, or
• Alcohol
Diagnosis
• Serum amylase
• elevation, USS
• complications
• pseudocyst,
phlegmon
• abcess

18. DR S C GAN FMHS/UTAR 12102012 18
Small IntestineSmall Intestine
Meckel’s
Diverticulum
• rare
• diverticulum of
terminal ileum
• can be lined by
gastric epithelium
• can perforate
• can present like
appendicitis

19. DR S C GAN FMHS/UTAR 12102012 19
Small IntestineSmall Intestine
Intestinal obstruction
• May arise due to
• adhesions, hernia,
tumour
Presentation
• colicky abdominal
pain,
• vomiting,
constipation
• Treatment
• resuscitate/operate

20. DR S C GAN FMHS/UTAR 12102012 20
Small IntestineSmall Intestine
Mesenteric infarct
• Sudden occlusion of
small
• bowel arterial supply
• Sudden onset of
abdominal pain,
shock
• Peritonitis
Treatment
• resuscitate/operate

21. DR S C GAN FMHS/UTAR 12102012 21
Large bowelLarge bowel
Acute diverticulitis
• Maximal in (L) colon
• Presentation LIF
pain,
• fever, tenderness,
• leukocytosis
• Middle aged or
elderly
Treatment –
• conservative
• antibiotics, fluids,
bed rest

22. DR S C GAN FMHS/UTAR 12102012 22
Large bowelLarge bowel
Lower GI bleeding
• Diverticulum, colitis,
• Crohn’s tumour
• Present with Fresh
Red Blood P/R
• Tendency to be more
conservative than
with upper GI
• Resuscitate,
transfusion

23. DR S C GAN FMHS/UTAR 12102012 23
Large bowelLarge bowel
Perforation
• Diverticulum,
colitis,
• sudden severe
abdominal pain,
• rigidity
• Faecal peritonitis
• Pyrexia, shock
• Free gas on X-ray
Treatment
• resuscitate, operate

24. DR S C GAN FMHS/UTAR 12102012 24
Inflammatory Bowel DiseaseInflammatory Bowel Disease
• Recurrent
regeneration
• Increased risk of
tumour
formation
• 14.8 X

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Large BowelLarge Bowel
Ulcerative colitis
• Presents – bloody
• diarrhoea, pyrexia
• leukocytosis
• may develop toxic
megacolon
Treatment –
• steroids
• Surgery on failure

26. DR S C GAN FMHS/UTAR 12102012 26
Peritoneal cavityPeritoneal cavity
Acute peritonitis
• any perforation,
• pancreatitis
• abdominal pain,
tenderness
• guarding, silent
abdomen
• shock
Treatment –
underlying condition