Intestinal obstruction can be classified as dynamic or adynamic. Dynamic obstruction occurs when peristalsis works against a mechanical obstruction, while adynamic obstruction features no mechanical obstruction and lack of peristalsis. Causes include intraluminal, intramural, or extramural factors. Pathophysiology involves dilation of bowel proximal to obstruction and later fluid accumulation. Investigations include abdominal x-rays and CT scans. Treatment involves supportive care like NPO and IV fluids as well as surgical interventions like laparotomy, adhesiolysis, and resection depending on the specific cause and viability of the bowel.

1. INTESTINAL OBSTRUCTION

2. CLASSIFICATION
DYNAMIC
 Peristalsis working against a mechanical
obstruction
ADYNAMIC
 No mechanical obstruction
 No peristalsis

3. Causes
DYNAMIC
INTRALUMINAL
 Fecal impaction
 Foreignbody
 Bezoars
 Gall stone
INTRAMURAL
 Stricture
 Malignancy
 Intususception
 Volvulus
EXTRAMURAL
 Bands of adhesion
 hernia
ADYNAMIC
 Paralytic ileus
 Pseudo obstruction

4. Pathophysiology
 Bowel proximal to obstruction dilates
↓
Distal bowel - normal peristalsis & absorption→later empty &collapses
 Initially proximal peristalsis increased→later reduction in peristaltic strength
↓
flaccidity and paralysis
Proximal distention is caused by 1. gas
2.fluid

5. gas
 Significant overgrowth of both aerobic
and anaerobic bacteria
 Reabsorption – oxygen & corbondioxide
 Nitrogen and hydrogen sulphide
fluid
 24 hrs
 Saliva -500ml, bile- 500ml ,pancreatic secretion -
500ml ,gastric secretion-1L
 Accumulates & absorption –retarded
Dehydration & electrolyte loss
Reduced oral intake
Defective absorption
Vomiting
Sequestration in the bowel lumen
Transudation of fluid in to peritoneal cavity

6. Strangulation – Blood supply is
compromised and the bowel becomes
ischaemic
 CAUSES
DIRECT PRESSURE ON THE BOWEL WALL
 Hernial orifices
 Adhesions / Bands
INTERRUPTED MESENTERIC BLOOD FLOW
 Volvulus
 Intussuseption
INCREASED INTRALUMINAL PRESSURE
 Closed loop obstruction

7. Closed loop obstruction
 Bowel is obstructed at both the proximal and distal points
 Malignant stricture of the colon with a competent ileocaecal valve
↓
Inability of distended colon to decompress itself in to the small bowel
↓
Increase in luminal pressure
↓
necrosis and perforation

8. Internal hernia
 Portion of small intestine becomes entrapped in one of the retroperitoneal fossae
or in a congenital mesenteric defect
 SITES OF INTERNAL HERNIA
 the foramen of winslow
 a defect in the mesentery / transverse mesocolon/ broad ligament
 congenital or acquired diaphragmatic hernia
 Duodenal retro peritoneal fossae- left paraduodenal and right duodenojejunal
 Caecal /appendiceal retroperitonel fossae- sup, inf, and retrocaecal
 Intersigmoid fossa

9. Obstruction from enteric strictures
 Small bowel – secondary to TB / Crohns disease
 Subacute or chronic presentation
 Mx- resection and anastomosis

10. Bolus obstruction
 Gallstone
 Food
 Stercolith
 Worms
 Trychobezoars and phytobezoars

11. Gallstone ileus
 60 cm proximal to ileo-caecal valve
Rigler’s triad
 Small bowel obstruction
 Pneumobilia
 Atypical metallic shadow on abdominal x ray

12. Trichobezoar
 Usually seen in psychiatric patients
 Ingestion of hair

13. phytobezaors
 High fibre intake
 Inadequate chewing
 Previous gastric Sx
 Hypochlorhydria
 Loss of gastric pump mechanism

14. Stercoliths
 Jejunal diverticulum and ileal stricture

15. Worms
 Ascaris lumbricoids

16. Common causes of intra-abdominal
adhesins
Acute inflammation Sites of anastomoses,
of raw areas, trauma, ischaemia
Foreign material Talc ,starch ,gauze, silk
infection Peritonitis, TB
Chronic inflammatory condditions Crohn’s disease
Radiation enteritis

17. Prevention of adhesions
 Good surgical technigue
 Washing of the peritonela cavity with saline to remove clots
 Minimising contact with gauze
 Covering anastomosis and raw peritoneal surfaces

18. Laproscopic technique
 May reduce post op adhesins
 Others
 Hyaluronidase
 Hydrocortisone
 Silicone
 Dextran
 Polyvinylpropylene
 Chondroitin
 Streptomycin
 Anticoagulants
 Antihistamines
 NSAIDS
 Streptokinase

19. Bands
 Usually only one band is culpable
 Congenital, e.g. obliterated vitellointestinal duct;
 A string band following previous bacterial peritonitis
 A portion of greater omentum, usually adherent to the parietes

20. Acute intussusception
 One portion of the gut invaginate in to an immediately adherent segment;
 Almost invariably-proximal in to the distal
 MC in children ( 5-10 months ; peak incidence)
 Hyperplasia of Peyer’s patches in the terminal ileum
 Weaning – loss of passively acquired maternal immunity
 Common viral pathogens

21. Associated pathological lead points in
children
 Meckels diverticulum
 Polyp
 Duplication
 HSP
 Appendix

22. Lead points in adults
 Polyp eg; Peutz jeghers syndrome
 Submucosal lipoma
 Other tumors

23. Pathology

24. 3 parts
 The Entering or inner tube- intussusceotum
 The returning or middle tube
 The sheath or outer tube – intussuscipiens
 The part that advances apex, the mass- intussusception and neck is the junction
of entering layer with the mass

25. Volvulus
 Twisting or axial rotation of a portion of bowel abouts its mesentery
 Causes obstruction ( > 180 degree tortion)
 If tight – vasocular occlusion in the mesentery( 360 degree)
 Primary or secondary
 May involve small intestine, caecum or sihmoid colon
 Neonatal midgut volvulus sec to midgut malrotation is life threatening
 Commonest spontaneous type in adult – SIGMOID
 Sigmoid volvulus – relieved by decompression per anum
 Surgery – to prevent or relieve ischaemia

27. Clinical features
 Abdominal pain
 Abdominal distention
 Vomiting
 Absolute constipation

28. classifications
High small bowel
Low small bowel
Large bowel
Simple
strangulated
Complete
Incomplete

29. Intestinal obstruction with out
constipation
 Richter’s hernia
 Gallstone ileus
 Mesenteric vascular occlusion
 Functional obstruction associated with pelvic abcess
 Partial obstruction

30. Other manifestations
 Dehydration
 Hypokalaemia
 Pyrexia
 Abdominal tenderness

31. Pyrexia
 Oncet of ischaemia
 Intestinal perforation
 Infalammation oe abcess associated with obstructive disease

32. Abdominal tenderness
 Localised tenderness- impending ischaemia
 Diffuse tenderness- perforation peritonitis

33. c/f; strangulation
 Constant severe pain
 Tenderness with rigidity and peritinism
 Shock

34. c/f; intussusception
 Redcurrant jelly stool
 Sousage shaped lump
 Empty right iliac fossa- sign of dance

35. c/f; sigmoid volvulus
 Abdominal distention
 constipation

36. investigations
 Abdominal x ray – erect- ; multiple air fluid level
 abdominal xray - supine ; jejunanum –conniventose
; ileum- featureless
colon-haustral fold
CECT ABDOMEN

40. IMAGING IN INTUSSUSCEPTION
 Barium enema – claw sign
 USG-DOUGHNUT APPEARANCE OF CONCENTRIC RINGS IN TRANSVRSE COLON
 CT – target sign

41. X ray finding – volvulus
 Coffee bean appearance

43. Treatment
 Supportive management
 Surgical management

44. Supportive management
 NPO
 RT- aspiration
 IV - Fluids

45. Surgical management
 INDICATION FOR EARLY SURGICAL INTERVENTION
 Obstructed external hernia
 Clinical features s/o strangulation
 Obstruction in a ‘virgin’ abdomen

46.  In complete obstruction with out evidence of intestinal ischaemia, surgery may be
deferred until the patient is fully resuscitated
 In adhesive obstruction conservative management may be adviced for up to 72
hrs

47. Surgical interventions
Laparotomy and assess
 Site of obstruction
 Nature of obstruction
 Viability of the gut

49. Operative decomression
 Retrograde milking of small bowel content to stomach
 Savage’s decompresser with in a seromuscular purse string suture

52.  Adhesiolysis
 Resection
 Bypass
 Proximal decompression

54. Treatment of adhesions
 adheiolysis

55. Rx of recurrent intestinal obstructiom
caused by adhesions
 Noble’s plication
 Child Philips transmesenteric plication
 Intestinal intubation

56. Rx of intussusception
 Non operative reduction- air or barium enema
 CONTRA-INDICATIONS
 Signs of perforation/ peritonitis
 Known pathological lead point
 Profound shock

57.  Surgery - when radiological reduction is failed or contra –indicated
 Reduction- gently compressing the most distal part of the intussusception
towards its origin
 Resection and anastomosis- irreducible or one complicated by infarction or
pathological lead point

58. Rx of acute large bowel obstruction
 Emergency right hemicolectomy
Removal of lesion in the caecum, ascending colon, hepatic flexure, proximal
transverse colon
If the lesion is irremovable – proximal stoma or ileo- transverse bypass

59.  For lesion in the left colon or recto sigmoid- resection should be done followed by
a) anastomosis
 b)paul mikulicz procedure
 c)hartmann’s peocedure

62. Rx of sigmoid colon
Sigmoidoscopy +insertion
of flatus tube
detortion of sigmoid and
fixation to anterior
abdominal wall
sigmoidectomy