1. Intestinal obstruction can be classified as dynamic or adynamic and can have various causes such as hernias, adhesions, tumors, or strangulation. 2. Clinical features include abdominal pain, distension, vomiting, and constipation. Imaging shows bowel dilation and fluid levels. 3. Treatment involves resuscitation, nasogastric decompression, and surgery if conservative measures fail or if there are signs of strangulation or ischemia. Surgical options depend on the cause and may include adhesiolysis, resection, or bypass procedures.

1. INTESTINAL
OBSTRUCTION
1

2. OVERVIEW:
CLASSIFICATION
CAUSES
CLINICAL FEATURES
INVESTIGATIONS
TREATMENT
2

3. CLASSIFIACTION
Mainly into two type
DYNAMIC-
Peristalsis is working against a mechanical obstruction. It may
be acute or a chronic form
ADYNAMIC-
There is no mechanical obstruction;
Peristalsis is absent or inadequate
3

4. CLINCICAL CLASSIFICATION
1. Small bowel obstruction (SBO) – may
be high or low
2. Large bowel obstruction (LBO)
4

5. CAUSES OF DYNAMIC OBSTRUCTION
1.Intraluminal
Impacted faeces
Foreign bodies
Gallstones
Bezoars.
2.Intramural:
Tumors
Inflammatory
Strictures,
Volvulus,
Intussusception,
3.Extramural:
Adhesion,
Hernias,
5

6. CAUSES OF ADYNAMIC
OBSTRUCTION
 Paralytic ileus
 Pseudo obstruction
6

7. PATHOPYSIOLOGY
 Irrespective of etiology or
acuteness of onset is divided as:
 Proximal to obstruction
 Distal to obstruction
Intestinal
obstruction
Increased
peristalsis
Bowel
continues to
dilate
Reduction in
peristaltic
strength
Flaccidity and
paralysis
7

8. PROXIMAL TO OBSTRUCTION
GAS
Due to overgrowth of
both aerobic and
anaerobic organisms
FLUIDS
Due to various
digestive juices
DISTENTION
8

9. DISTAL TO OBSTRUCTION:
 nothing is passed & bowel collapse constipation
 Dehydration and electrolyte loss is due to
 Reduced oral intake
 Defective intestinal absorption
 Losses as result of vomiting
 Sequestration in the bowel lumen
 Transudation of fluid into peritoneal cavity
9

10. OBSTRUCTION CAN BE..…..
1. SIMPLE:
 Blockage without interfering with vascular supply
2. STRANGULATION:
10

11. STRANGULATION
when strangulation occurs, blood
supply is compromise and bowel
becomes ischemic
Venous return first affected
Translocation and systemic exposure
to microbes/ toxins comprises the
viability of bowel.
11

12. CAUSES
 Direct pressure on the bowel wall
 Hernial orifices
 Adhesions/bands
 Interrupted mesenteric blood flow
 Volvulus
 Intussusception
Morbidity/mortality-
 Age – more in elderly with co morbidities
 Extent – any length can causes systemic effect
 Peripheral vascular failure can occur 12

13. CLOSED LOOP OBSTRUCTION:
 Bowel is obstructed at both the
proximal and distal end.
 Example-malignant stricture of
the colon with a competent
iliocaecal valve
13

14. SPECIAL TYPE OF
OBSTRUCTION
14

15. INTERNAL HERNIA
 When a portion of small intestine is entrapped in one of
retroperitoneal fossa or in a congenital mesenteric defect.
 Sites of internal herniation:
 Foramen of winslow.
 A hole in mesentery / transverse mesocolon.
 Defects in broad ligaments.
 Congenital/ acquired diaphragmatic hernia.
 Intersigmoid fossa. It is uncommon in the absence of
adhesions.
 Treatment : to release the constricting agent by division.
15

16. OBSTRUCTION FROM ENTERIC
STRICTURES
 Small bowel strictures usually occur secondary to
tuberculosis or Crohn’ disease
 Malignant strictures are associated with lymphoma
are uncommon
 Carcinoma and sarcoma are rare
 Presentation is subacute or chronic
 Standard surgical management is resection and
anastomosis
16

17. BOLUS OBSTRUCTION
 Gall stones-
 It tends to occur in elderly.
 Erosion of large gallstone into duodenum.
 Present with recurrent obstruction.
 X-ray: small bowel obstruction with air in billiary tree.-
May show a radio opaque gall stone.
 Treatment : laparotomy & removal /crushing of stone.
17

18. Food
 After partial /total gastrectomy.
 Unchewed food can cause obstruction.
 Treatment similar to gall stone.
Bezoars
 Trichobezoars
 Phytobezoars
Worms
 Ascaris lumbricoides
 Frequently follows initiation of antihelminthic therapy.
 Eosinophilia/worm with in gas filled bowel loops.
 Laparotomy.
18

19. OBSTRUCTION BY ADHESIONS AND
BANDS
 Most common cause of intestinal obstruction.
 Peritoneal irritation results in local fibrin production,
which produce adhesions.
Bands
 Congenital : obliterated vitellointestinal duct.
 A string band following previous bacterial peritonitis.
 A portion of greater omentum adherent to parietes.
19

20. CAUSES OF ADHESIONS :
 Abdominal operation : anastomosis, raw
peritoneal surfaces
 Foreign material: talc, starch, gauze, silk
 Infection: peritonitis, T.B.
 Inflammatory conditions: Crohn’s disease.
 Radiation entritis.
20

21. PREVENTION
 Good surgical technique.
 Washing the peritoneal cavity with saline to remove
the clots.
 Minimizing contact with gauze.
 Covering the anastomosis & raw peritoneal
surfaces.
21

22. ACUE INTUSSUSCEPTION
 One portion of gut becomes invaginates with in
adjacent segment.
 Most common in children(3-9 months.)
 Ideopathic-70%
 Associated gastroenteritis/UTI- 30%
 Hyperplasia of peyer’s patches in terminal ileum can
be initiating factor.
 In older children intussusceptions is usually
associated with a lead point – meckel’s
diverticulum, polyp, & appendix.
 Adults always with a lead point.- Polyp, submucosal
lipoma/ tumor.
22

23.  It is composed of three parts:
 Entering/ inner tube(intussusceptum)
 Returning/ middle tube
 Sheath/ outer tube(intussuscipiens)
 It is an example of strangulating obstruction with
impaired blood supply of inner layer.
 It may be
 ileoileal(5%);
 ileocolic(77%);
 ileo-ileo-colic(12%);
 colocolic (2%) &
 multiple.
23

24. VOUVLUS
 A volvulus is a twisting or axial rotation of a portion of
bowel about its mesentery
 Lumen obstruction- >180 torsion
 Vascular occlusion- >360 torsion
 Bacterial fermentation adds to distention and increased
intraluminal pressure impairs capillary perfusion
 Mesenteric veins become obstructed as result of
mechanical twisting and thrombosis results and
contributes to ischemia
24

25.  It may be primary or secondary.
 Primary- occurs secondary to congenital malrotation of
the gut, abnormal mesenteric attachments or congenital
bands.
 Example- volvulus neonatrum, ceacal volvulus and sidmoid
vovulus.
 Secondary- due to the rotation of segment of bowel
around an acquired adhesions.
25

26. SIGMOID VOLVULUS
 It is nearly always in anticlockwise direction.
 Presentation can be classified as;
 Fulminant- sudden onset, severe pain, early
vomiting, rapidly deteriorating clinical course.
 Indolent- insidious onset, slow progressive course,
less pain, late vomiting.
26

27. COMPOUND VOLVULUS
 It is also called ileosigmoid knotting.
 The long pelvic mesocolon allows the ileum to twist
around the sigmoid colon resulting in gangrene of
either or both the segments of the bowel.
 Presents with acute intestinal obstruction, but
distention is mild.
27

28. CLINICAL FEATURES
 Cardinal clinical features of acute obstruction
1. Abdominal pain
2. Distension
3. Vomiting
4. Absolute constipation
28

29. ABDOMINAL PAIN
 Colicky in nature, around the umbilicus in SBO
while in the lower abdomen in LBO
 If it becomes continuous, think about perforation or
strangulation.
 Does not usually occurs in paralytic ileus
29

30. DISTENSION
 Greater if distal obstruction
 Visible peristalsis may be present
 Peristalsis delayed in colonic obstruction
 Absent in Mesenteric vascular obstruction
30

31. VOMITING
 Starts early in SBO and late in LBO
 As obstruction progresses vomitus alters from
digested food to faeculent due to enteric bacterial
overgrowth
31

32. CONSTIPATION
 Absolute (no feces or flatus)
Cardinal feature of complete intestinal obstruction
 Relative (flatus passed)
 It does not apply in
-richter’s hernia
-Gallstone ileus.
-Mesenteric vascular occlusion.
-Obstruction associated with pelvic abscess.
-Diarrhea may be present with partial obstruction
32

33. OTHERS MANIFESTATION
Dehydration
 More common in small bowel obstruction due to repeated
vomiting .
 Secondary polycythemia due to raised Blood urea &
hematocrit.
Pyrexia
 Onset of ischemia.
 Intestinal perforation.
 Inflammation associated with int. obstruction
33

34. Hypokalaemia
 Is not common feature in simple mechanical obstruction
 Increased potassium , amylase, LDH – strangulation, raised
TLC or, leucopenia
Abdomen tenderness
 Localized – ischemia
 Peritonitis – infarction or, perforation
Bowel sound
 High pitch sounds are present in most cases
 Long standing case bowel sounds may be absent
34

35. CLINICAL FEATURESOF
STRANGULATION
 Severe constant abdominal pain
 Fever
 Tenderness with rigidity/rebound tenderness.
 Shock
35

36. CLINICAL FEATURES OF ACUTE
INTUSSUSCEPTION
 Severe colic pain.
 Vomiting as time progress
 Blood & mucus (the ‘redcurrent’ jelly stool).
 Abdominal lump(sausage shaped)
 Emptiness in RIF(the sign of dance).
 Death may occur from bowel obstruction or
peritonitis secondary to gangrene.
36

37. CLINICAL FEATURES OF VOLVULUS
 Volvulus of small intestine-
 it may be primary or secondary and usually occurs lower
ileum.
 Usually occurs after consumption of large volume of vegetable
matter.
 Ceacal volvulus-
 Usually clockwise twist
 Common in females in fourth and fifth decades
 Initially obstruction may be partial with passage of flatus and
feaces.
 The volvulus typically results in lying in the left upper quadrant.37

38.  Sigmoid volvulus-
 presents with varying in severity and acuteness.
 Symptoms are of large bowel obstruction.
 Abdominal distention is an early and progressive sign may be
associated with hiccups and retching.
 Constipation is absolute
38

39. IMAGING
When distended by gas:
 Jejunum is characterized by valvulae
conniventes(completely pass across the width & regularly
placed)
 Ileum is featureless.
 Caecum is shown by rounded gas shadow in RIF.
 Colon shows haustral folds.
 Fluid level appears later than gas shadow
 No. of fluid level is proportional to degree of obstruction
and distal site in small bowel. 39

40. 40

41. IMAGING IN INTUSSUSCEPTION
 Plain X-ray Abd.: Bowel obstruction with
absent caecal shadow gas in ileo-ileal &
ileo-colic cases.
 Ba-enema: the claw sign in ileocolic &
colocolic cases.
 CT scan in the most sensitive method of
diagnosis of intussusceptions
41

42. IMAGING IN VOLVULUS
 In caecal volvulus- often the findings are non
specific with ceacal dialation, single air fulid level,
small bowel dialation and abscense of gas in distal
colon
 Barium enema can be used for conformation if
there is no concern of ischeamia, shows bird beak
deformity
 In sigmoid volvulus- a plain radiograph shows
massive colon distention, there is classical
appearance of loop of bowel; two limbs are seen
running diagonally across the abdomen form right
to left, with two fluid levels, one within each loop
42

43. TREATMENT
 Three main measures-
- Gastrointestinal drainage via nasogastric tube
- Fluid & Electrolyte replacement
- Relief of obstruction, usually surgical
43

44. CONSERVATIVE:
 Nasogastric aspiration by Ryles tube
 IV fluids- volume varies depending on dehydration.
 Urinary catheter
 Abdominal examination 8 hourly
 Broad spectrum antibiotics initiated early- reduce
bacterial overgrowth.
44

45.  Some cases will settle by using this conservative
regimen, other need surgical intervention.
 Surgery should be delayed till resuscitation is complete
unless signs of strangulation and evidence of closed-
loop obstruction.
 Cases that show reasons for delay should be monitored
continuously for 72 hours in hope of spontaneous
resolution e.g. adhesions with radiological findings but no
pain or tenderness
45

46. INDICATION FOR SURGERY:
 Failure of conservative management
 Tender, irreducible hernia
 Strangulation
 If the site of obstruction is unknown; assessment is
directed to-
 The site of obstruction.
 The nature of obstruction.
 The viability of gut.
46

47. SURGICAL TREATMENT
 Operative decompression required-if
 Dilatation of bowel loops prevent exposure,
 Bowel wall viability is compromised,
 If subsequent closure will be compromised.
 Savage’s decompressor used within seromuscular purse-
string suture.
 Large-bore nasogastric tube may be used for milking
intestinal contents into stomach.
47

48.  The type of surgical procedure depend upon the cause of
obstruction viz division of bands, adhesiolysis, excision
,or bypass
 Once obstruction relieved, the bowel is inspected for
viability, and if non-viable, resection is required.
Indication of non-viability
1. Absent peristalsis
2. Flabby this and friable intestinal musculature
3. Loss of pulsation in mesentery
4. Green or black color of bowel
5. Dull and lusterless
48

49.  If in doubt of viability, bowel is wrapped in hot packs for
10 minutes with increased oxygen and reassessed for
viability.
 Resection of non viable gut should be done followed by
stoma.
 Sometimes a second look laprotomy is required in 24-48
hours e.g. multiple ischemic areas.
49

50. TREATMENT OF ADHESIONS
 Usually conservative treatment is curative.
(i.v. rehydration & nasogastric decompression)
 It should not be prolonged beyond 72 hrs.
SURGERY
 Division of band.
 Minimal adhisiolysis.
 Laproscopic adhesiolysis is preferable.
50

51. TREATMENT OF RECURRENT
INTESTINAL OBSTRUCTION BY
ADHESIONS
 Repeat adhesiolysis alone.
 Noble’s plication : adjacent intestinal coils (15-20
cms) are sutured with serosal sutures.
 Charles-Phillips trans-mesenetric plication.
 Intestinal intubation : initraluminal tube insertion via
a WITZEL jejunostomy or gastrostomy.
 The later three procedure are rarely used.
51

52. TREATMENT OF ACUTE
INTUSSUSCEPTION
 In infant with ileocolic intussusceptions, after resuscitation with IV
fluids, broad spectrum antibiotics and nasogastric drainage, non
operative reduction can be achieved by using barium enema
 Contraindications- perforation and peritonitis, known pathological
lead point or in the presence of shock.
OPERATIVE
 After resuscitation, transverse right sided abdominal incision is taken
 Reduction is done by gently compressing the most distal part of the
intussusceptions towards the origin.
 Irreducible/ gangrenous intussusceptions: excision of mass &
anastomosis.
52

53. TREATMENT OF CAECAL VOLVULUS
 At operation the volvulus is found to be ischaemic
ad needs rescetion
 If viable, the volvulus should be reduced.
 Sometimes, this can only be achieved after
decomression of the caecum usuing a needle.
 Further management of the caecum is to fix the
caecum in the right ileac fossa
53

54. TREATMENT OF SIGMOID VOLVULUS
 Flexible sigmoidoscopy or rigid sigmoidoscopy and insertion of a
flatus tube should be carried out to allow deflation of the gut
 Repeat x-ray taken to ensure that decompression has occurred
 In young patients, an elective sigmoid colectomy is required
 In elderly patients with co-morbidities and recurrent episodes of
volvulus, the options are resection or two point fixation with
combined endoscopic tube insertion
 Failure results in an early laparotomy, with untwisting of the loop and
per anum decompression.
 Resection is preferable if it can be achieved safely.
 Paul-mikulicz procedure useful, perticularly if there is suspension of
impending gangrene. 54

55. ADYNAMIC
OBSTRUCTION
55

56. PARALYTIC ILEUS
 It is defined as a state in which there is failure of
transmission of peristaltic waves secondary to
neuromuscular failure.
 Results in accumulation of fluid and gas within the
bowel
 Associated with distention, vomiting, absence of
bowel sounds and absolute constipation
56

57. VARIETIES-
 Postoperative: occurs after any abdominal surgery and
is self limiting with a variable duration 24-72 hours
 Prolonged in presence of hypoproteinanemia or metabolic
abnormality
 Infection: intra-abdominal sepsis, gives rise to localized
or generalized ileus
 Reflex ileus: occurs after fracture or ribs or spine,
retroperitoneal hemorrhage
 Metabolic: uremia and hypokalaemia are the most
contributory factors
57

58. CLINICAL FEATURES
 Abdominal distention becomes more marked and
tympanitic
 Distention increases pain from the abdominal
wound
 In absence of gastric aspiration, effortless vomiting
occurs.
58

59. MANAGEMENT
 Use of nasogastric suction and restriction of oral intake till
bowel sounds and passage of flatus returns.
 Electrolyte balance must be maintained
 General principles-
 If a primary cause is identifies it must be treated
 GI distention must be relieved by decompression
 Close attention the fluid and electrolyte balance is essential
 If paralytic ileus is prolonged CT scan is the most effective
investigation; it will demonstrate any intrabdominal sepsis or
mechanical obstruction and therefore guide any requirement
for laprotomy. 59

60. THANK YOU
Reference : Bailey & Love's Short Practice of
Surgery, 27th Edition 60