Intestinal Obstruction 2

By
Prof. Dr.Prof. Dr. ISMAIL TANTAWYISMAIL TANTAWY

Definition:Definition:
Aetiology:Aetiology:
Invagination of a bowel segment into an adjoining one,Invagination of a bowel segment into an adjoining one, whichwhich
is usually the distal.is usually the distal.
Partial obstruction is the main predisposing factor as it initiatesPartial obstruction is the main predisposing factor as it initiates
hyperperistaltic movement that forces the wall of a segmenthyperperistaltic movement that forces the wall of a segment
((intussusceptumintussusceptum) to be telescoped into another () to be telescoped into another (intussuscepientintussuscepient).).
Infantile intussusceptionInfantile intussusception
(A) Idiopathic type (95%):(A) Idiopathic type (95%): No organic cause.No organic cause.
Predisposing factors:Predisposing factors:
Bulky ileocaecal valve.Bulky ileocaecal valve.
Wide ileocaecal angle.Wide ileocaecal angle.
Mobile caecum and ascending colon.Mobile caecum and ascending colon.
Bloodless fold of Traeves: a peritoneal fold between the mesentery ofBloodless fold of Traeves: a peritoneal fold between the mesentery of
ileum & caecum accused to guide the ileum toward the caecumileum & caecum accused to guide the ileum toward the caecum

Precipitating factors:Precipitating factors:
Swelling of Payer’s patches due to inflammation or hyperplasiaSwelling of Payer’s patches due to inflammation or hyperplasia
causes partial obstruction and initiates intussusception.causes partial obstruction and initiates intussusception.
Swelling in Payer’s patches may be due to:Swelling in Payer’s patches may be due to:
 Gastroenteritis at the time of teething & weaning due toGastroenteritis at the time of teething & weaning due to
change in intestinal flora.change in intestinal flora.
 Respiratory infection by adenovirusRespiratory infection by adenovirus →→ swelling of Payer’sswelling of Payer’s
patches.patches.
 Mesenteric adenitis.Mesenteric adenitis.
(B) Organic type (5%):(B) Organic type (5%):
Organic cause is detected as polyp or Meckel‘s diverticulum,Organic cause is detected as polyp or Meckel‘s diverticulum,
acting as a head of intussuscepton.acting as a head of intussuscepton.

Adult intussusceptionAdult intussusception
Usually there is an organic cause as tumours or parasite.Usually there is an organic cause as tumours or parasite.
Pathology:Pathology:
CompositionComposition
It is composed of three layers:It is composed of three layers:
Inner layerInner layer Middle layerMiddle layer Outer layerOuter layer
Entering layerEntering layer
((intussesceptumintussesceptum))
ReturningReturning
layerlayer
Ensheathing layerEnsheathing layer

intussuscepientintussuscepient

TypesTypes
IleocaecalIleocaecal IleocolicIleocolic Ileo-ilealIleo-ileal
Where the ileoWhere the ileo
caecal valve formscaecal valve forms
thethe apexapex ((headhead) of) of
intussusceptionintussusception
Where theWhere the
ileocaecal valveileocaecal valve
forms theforms the neckneck ofof
Ensheathing layerEnsheathing layer

intussuscepientintussuscepient
Ileo -ileo colicIleo -ileo colic Colo-colicColo-colic
RetrogradeRetrograde
(jejunogastric)(jejunogastric)

Multiple intussusceptionsMultiple intussusceptions
Occur in 1% of cases.Occur in 1% of cases.
IleocaecalIleocaecal IleocolicIleocolic Ileo-ilealIleo-ileal
Ileo-ileo colicIleo-ileo colic Colo-colicColo-colic JejunogastricJejunogastric
Composition of intussusceptionComposition of intussusception

PathophysiologyPathophysiology
In addition to luminal obstruction,In addition to luminal obstruction,
the blood supply of thethe blood supply of the
intussusceptum is also impairedintussusceptum is also impaired
due to compression of itsdue to compression of its
mesentery results in strangulatedmesentery results in strangulated
intestinal obstruction.intestinal obstruction.
The ileo colic variety isThe ileo colic variety is
the most vulnerable typethe most vulnerable type
to early gangrene as theto early gangrene as the
ileo caecal valve forms aileo caecal valve forms a
tight neck over thetight neck over the
intussusceptumintussusceptum
ComplicationsComplications
Intestinal obstruction withIntestinal obstruction with
all its complications.all its complications.
Gangrene (Gangrene (due to strangulationdue to strangulation),),
perforation, & peritonitis.perforation, & peritonitis.

IncidenceIncidence
It has seasonal incidenceIt has seasonal incidence
((moremore commoncommon inin summersummer),),
related to respiratory tractrelated to respiratory tract
or gastroenteritis.or gastroenteritis.
It is more common inIt is more common in
malesmales ((2: 12: 1),), betweenbetween 6-6-
1212 monthsmonths (age of(age of
weaning) .weaning) .
The baby is usuallyThe baby is usually
well nourished!!.well nourished!!.
Clinical pictureClinical picture
Symptoms:Symptoms: (told by the mother)(told by the mother)::
 Pain:Pain: sudden onset of attacks of abdominal colicky pain, the infantsudden onset of attacks of abdominal colicky pain, the infant
draws up his legs and screams. It lasts few minutes and recurs aboutdraws up his legs and screams. It lasts few minutes and recurs about
every 15 minutes.every 15 minutes.
 Vomiting:Vomiting: may occur early with the onset of pain or late due tomay occur early with the onset of pain or late due to
obstruction.obstruction.
 Bleeding:Bleeding: per rectum (red currant jelly).per rectum (red currant jelly).
 The patient often presents late with complications. Rarely, theThe patient often presents late with complications. Rarely, the
intussusception may be left to protrude through the anus , which may beintussusception may be left to protrude through the anus , which may be
confused with rectal prolapse.confused with rectal prolapse.

SignsSigns
MassMass
Dance’sDance’s
signsign PR examPR exam
AA sausage shaped,sausage shaped,
mildly tender mass ismildly tender mass is
often palpable belowoften palpable below
the costal margin withthe costal margin with
its concavity towardsits concavity towards
the umbilicus due tothe umbilicus due to
traction on the ends oftraction on the ends of
intussusception by theintussusception by the
mesentery.mesentery.
Sense ofSense of
emptiness of theemptiness of the
right iliac fossaright iliac fossa
(ascended(ascended
caecum).caecum).
May reveal redMay reveal red
currant jelly stoolcurrant jelly stool
or the apex ofor the apex of
may be felt.may be felt.

InvestigationsInvestigations
Abd. U/SAbd. U/S BariumBarium
enemaenema
ItIt shows theshows the
intussusception asintussusception as
concentric rings inconcentric rings in
end view (end view (targettarget
signsign), or pseudo-), or pseudo-
kidney sign inkidney sign in
lateral view.lateral view.
It shows bariumIt shows barium
arrest witharrest with
characteristiccharacteristic
claw signclaw sign..
Claw signClaw sign

Differential DiagnosisDifferential Diagnosis
Diarrhea mayDiarrhea may
be associatedbe associated
with bleeding.with bleeding.
A syndrome ofA syndrome of
purpuric rash,purpuric rash,
abdominal pain,abdominal pain,
bleeding perbleeding per
rectum, arthritis,rectum, arthritis,
and nephritis.and nephritis.
A probe can’t beA probe can’t be
insinuated betweeninsinuated between
the mass and thethe mass and the
anal verge while inanal verge while in
intussusception, itintussusception, it
can be admitted forcan be admitted for
a considerablea considerable
lengthlength
Gastroenteritis, enterocolitisGastroenteritis, enterocolitis
& bacillary dysentry& bacillary dysentry
Henoch Schonlien'sHenoch Schonlien's
purpurapurpura
RectalRectal
prolapsedprolapsed

TreatmentTreatment
Preoperative measuresPreoperative measures Reduction byReduction by
hydrostatic pressurehydrostatic pressure
Operative reductionOperative reduction
Preoperative measures:Preoperative measures:
 I.V. fluidsI.V. fluids  N/G suctionN/G suction  AntibioticsAntibiotics
Reduction by hydrostatic pressure:Reduction by hydrostatic pressure:
 Using saline underUsing saline under U/SU/S guide or barium enema underguide or barium enema under
radiological guide under anaesthesia in the operatingradiological guide under anaesthesia in the operating
theatre.theatre.
 This trial may succeed in many cases, but it should be doneThis trial may succeed in many cases, but it should be done
with caution as it may be risky due to perforation.with caution as it may be risky due to perforation.

Operative reduction:Operative reduction:
 Exploration through Rt. transverse supraumbilical incision.Exploration through Rt. transverse supraumbilical incision.
 Try to reduce the intussusception by milking the apexTry to reduce the intussusception by milking the apex
proximally.proximally.
 Do not pull on the proximal segment as it is ischaemic and mayDo not pull on the proximal segment as it is ischaemic and may
rupture on pulling.rupture on pulling.
 If this failed, try again after pressure with hot fomentation for aIf this failed, try again after pressure with hot fomentation for a
sometime to reduce oedema.sometime to reduce oedema.
 If failed, try withIf failed, try with Cope’s method.Cope’s method.
 Insert the little finger into the neck to dilate it, break adhesions,Insert the little finger into the neck to dilate it, break adhesions,
and try again.and try again.
 If failed, open the ensheathing layer and reduce theIf failed, open the ensheathing layer and reduce the
intussusception.intussusception.
 If viable, close the ensheathing layer.If viable, close the ensheathing layer.
 If gangrenous, do Rt. hemicolectomy and ileotransverseIf gangrenous, do Rt. hemicolectomy and ileotransverse
anastomosis.anastomosis.

It is an axial rotation of a portion of the alimentary tractIt is an axial rotation of a portion of the alimentary tract
around two fixed points.around two fixed points.
TypesTypes
Volvulus ofVolvulus of
the stomachthe stomach
Volvulus of theVolvulus of the
small intestinessmall intestines
Volvulus of the midgutVolvulus of the midgut
(Volvulus neonatorum)(Volvulus neonatorum)
Volvulus ofVolvulus of
the caecumthe caecum
Volvulus of theVolvulus of the
sigmoid colonsigmoid colon

Volvulus of the small intestineVolvulus of the small intestine
Commonly due to adhesions or bands between the antimesentricCommonly due to adhesions or bands between the antimesentric
border of the loop and the parieties or female pelvic organs.border of the loop and the parieties or female pelvic organs.
Site:Site: It occurs more commonly in the lower ileum.It occurs more commonly in the lower ileum.
Pathology, clinical picture & investigations:Pathology, clinical picture & investigations:
Are those of strangulated intestinal obstruction:Are those of strangulated intestinal obstruction:
TreatmentTreatment
PreoperativePreoperative ExplorationExploration
N/G suction.N/G suction.
IV. fluids.IV. fluids.
AntibioticsAntibiotics
Untwist & examine intestine.Untwist & examine intestine.
If not viable then do primary resectionIf not viable then do primary resection
anastomosis.anastomosis.

Volvulus of the caecumVolvulus of the caecum
Uncommon condition, due to abnormally hypermobile caecumUncommon condition, due to abnormally hypermobile caecum
and ascending colon.and ascending colon.
It is more common in young adult female.It is more common in young adult female.
The Volvulus occurs usually inThe Volvulus occurs usually in the clockwise directionthe clockwise direction
obstructing both the ascending colon and the terminal ileum.obstructing both the ascending colon and the terminal ileum.
The caecum usually moves out of the right iliac fossa.The caecum usually moves out of the right iliac fossa.
Clinical picture:Clinical picture:
It is that of strangulated intestinal obstruction.It is that of strangulated intestinal obstruction.
A tympanitic mass may be palpated in the mid abdomen.A tympanitic mass may be palpated in the mid abdomen.

Treatment:Treatment:
Exploration:Exploration:
The ballooned caecum should be decompressed first byThe ballooned caecum should be decompressed first by
insertion of a needle then try untwisting (insertion of a needle then try untwisting (usually in theusually in the
anticlockwise directionanticlockwise direction) then examine the caecum:) then examine the caecum:
 If viable, do caecostomy to decompress the bowel and fix theIf viable, do caecostomy to decompress the bowel and fix the
caecum.caecum.
 If non-viable, Rt. hemicolectomy and ileotransverseIf non-viable, Rt. hemicolectomy and ileotransverse
anastomosis is advisable.anastomosis is advisable.

Volvulus sigmoid colonVolvulus sigmoid colon
Axial rotation of the sigmoid colon around its mesenteric axisAxial rotation of the sigmoid colon around its mesenteric axis
producing strangulated intestinal obstruction.producing strangulated intestinal obstruction.
AetiologyAetiology
Predisposing factorsPredisposing factors Precipitating factorsPrecipitating factors
Dolichocolon: long pelvic colon with
tall mesocolon.
Narrow attachment of the pelvic
mesocolon.
Over-loaded pelvic colon with faeces
due to habitual constipation.
Presence of bands between the
antimesentric border & parieties.
Straining:Straining: the volvulus usually occursthe volvulus usually occurs
while the patient is straining at stool.while the patient is straining at stool.
Pregnancy:Pregnancy: may be due to elevation ofmay be due to elevation of
the colon by the pregnant uterus.the colon by the pregnant uterus.

 The volvulus usually occurs in anticlockwise direction resulting inThe volvulus usually occurs in anticlockwise direction resulting in
obstruction of the pelvic colon at its both ends “obstruction of the pelvic colon at its both ends “closed loopclosed loop
obstructionobstruction”.”.
 The loop becomes hugely distended with gases & fluids.The loop becomes hugely distended with gases & fluids.
 Rotation also compresses the blood vessels.Rotation also compresses the blood vessels.
 When it turnsWhen it turns 1½1½ turn, the veins are occluded and the loop becomesturn, the veins are occluded and the loop becomes
congested.congested.
 When the loop turns more, the arteries become also occluded causingWhen the loop turns more, the arteries become also occluded causing
ischaemia, gangrene then perforation and peritonitisischaemia, gangrene then perforation and peritonitis
Acute intestinalAcute intestinal
obstruction with all itsobstruction with all its
complications.complications.
of surgery inof surgery in
elderly patients.elderly patients.
Gangrene,Gangrene,
perforation, &perforation, &
peritonitis.peritonitis.

 The most common type of volvulus of intestine in adults.The most common type of volvulus of intestine in adults.
 Common is elderly males specially those with habitual constipationCommon is elderly males specially those with habitual constipation
e.g.e.g. bed-riddenbed-ridden..
Clinical pictureClinical picture
SymptomsSymptoms SignsSigns
 Pain:Pain: sudden severe abdominalsudden severe abdominal
pain usually during straining.pain usually during straining.
 Distension:Distension: is early & marked.is early & marked.
 Hiccough:Hiccough: due to irritation ofdue to irritation of
the under surface of thethe under surface of the
diaphragm.diaphragm.
 Constipation:Constipation: is very early.is very early.
Inspection:Inspection: marked abdominal distension.marked abdominal distension.
Palpation:Palpation: a large cystic tender mass witha large cystic tender mass with
rebound tenderness.rebound tenderness.
Percussion:Percussion: tympanitic hyper-resonance overtympanitic hyper-resonance over
the mass.the mass.
PR: exam:PR: exam: empty edematous rectum andempty edematous rectum and
blood on the gloves due to kink of theblood on the gloves due to kink of the
superior rectal vein causing congestion of thesuperior rectal vein causing congestion of the
rectum.rectum.
Signs of complications.Signs of complications.

Investigations:Investigations:
Plain X-ray abdomen:Plain X-ray abdomen: single greatly distended loop of the bowel risessingle greatly distended loop of the bowel rises
up out of the pelvis.up out of the pelvis.
Barium enema:Barium enema: shows barium arrest at the recto sigmoid junction withshows barium arrest at the recto sigmoid junction with
characteristiccharacteristic ""ace of spadesace of spades““ or "or "bird's peak deformitybird's peak deformity".".
Leucocytic count: markedly elevated.Leucocytic count: markedly elevated.
Differential diagnosis:Differential diagnosis:
From other causes of large bowel obstruction e.g.From other causes of large bowel obstruction e.g. cancer rectum.cancer rectum.
Preliminary resuscitation:Preliminary resuscitation:
I.V. Fluids.I.V. Fluids.
N/G suction.N/G suction.
Antibiotics.Antibiotics.

Endoscopic decompression:Endoscopic decompression:
 In early cases and with endoscopic aid & the patient is put in theIn early cases and with endoscopic aid & the patient is put in the
knee elbow position and a soft rectal tube is introduced into theknee elbow position and a soft rectal tube is introduced into the
twisted colon to decompress it.twisted colon to decompress it.
 If this trial was successful, elective resection can be done later.If this trial was successful, elective resection can be done later.
Surgery:Surgery:
Indications:Indications:
Failure of proctoscopic decompression.Failure of proctoscopic decompression.
Complications e.g. gangrene perforation.Complications e.g. gangrene perforation.
Elective resection after successful decompression.Elective resection after successful decompression.
Exploration:Exploration:
Try to untwist the bowel (usually in the clockwise direction).Try to untwist the bowel (usually in the clockwise direction).
Meanwhile, an assistant advances a rectal tube through the anal route,Meanwhile, an assistant advances a rectal tube through the anal route,
guided by the surgeon to deflate the colonguided by the surgeon to deflate the colon
If it is non-viable, resection of the pelvic colon is done.If it is non-viable, resection of the pelvic colon is done.

Resection is done by either:Resection is done by either:
Paul Mickulicz operation:Paul Mickulicz operation:
Exteriorization resection ended by double barrel colostomy.Exteriorization resection ended by double barrel colostomy.
If the distal limb is too short to be exteriorized, it is closed as inIf the distal limb is too short to be exteriorized, it is closed as in
Hartmann’s operation for later anastomosis.Hartmann’s operation for later anastomosis.
Resection with primary anastomosis after:Resection with primary anastomosis after:
 On table colonic lavage.On table colonic lavage.
 Intraluminal colon bypass tube (Intraluminal colon bypass tube (coloncolon shieldshield).).
 Many surgeons advise resection of the colon even if it is viable asMany surgeons advise resection of the colon even if it is viable as
the recurrence rate is high (the recurrence rate is high (> 50%> 50%) and different maneuvers as) and different maneuvers as
colopexy or plication of the mesocolon are usually useless.colopexy or plication of the mesocolon are usually useless.

Mesenteric Vascular occlusionMesenteric Vascular occlusion
AetiologyAetiology
Mesenteric artery occlusionMesenteric artery occlusion Mesenteric vein thrombosisMesenteric vein thrombosis
Strangulated a dynamic obstruction due to occlusion of theStrangulated a dynamic obstruction due to occlusion of the
superior mesenteric artery or vein with patent intestinal lumen.superior mesenteric artery or vein with patent intestinal lumen.
 Embolism (commonest):Embolism (commonest): The sourceThe source
of the embolus (see the diagram).of the embolus (see the diagram).
 Thrombosis:Thrombosis: Usually on top ofUsually on top of
atherosclerosis.atherosclerosis.
Due to portal hypertension,Due to portal hypertension,
portal pyaemia, sickle cellportal pyaemia, sickle cell
anemia and hypercoagulableanemia and hypercoagulable
states.states.

 Whether the occlusion is arterial or venous, red infarction alwaysWhether the occlusion is arterial or venous, red infarction always
results.results.
 The bowel:The bowel: It is cyanosed and swollen with no peristalsis. TheIt is cyanosed and swollen with no peristalsis. The
serosa is lusterless and the mucosa sloughs and bleeds. Finally,serosa is lusterless and the mucosa sloughs and bleeds. Finally,
gangrene occurs.gangrene occurs.
 The peritoneum:The peritoneum: Blood stained fluid pours in the peritoneum andBlood stained fluid pours in the peritoneum and
the gangrenous bowel wall permits the passage of luminalthe gangrenous bowel wall permits the passage of luminal
organisms to the peritoneal cavity resulting to septic peritonitisorganisms to the peritoneal cavity resulting to septic peritonitis
Complications:Complications:
(1)(1) Shock:Shock: Early hypovolaemic shock rapidly develops due to loss ofEarly hypovolaemic shock rapidly develops due to loss of
blood into both lumen and peritoneal cavity. Later, septic shockblood into both lumen and peritoneal cavity. Later, septic shock
ensues due to gangrene & peritonitis.ensues due to gangrene & peritonitis.
(2)(2) Bleeding per rectum.Bleeding per rectum.
(3)(3) Gangrene, perforation & peritonitis.Gangrene, perforation & peritonitis.

Incidence:Incidence:
Common in middle age or elderly patients usually withCommon in middle age or elderly patients usually with
cardiovascular problem.cardiovascular problem.
History:History: Most patients give history of a cardiovascular problem.Most patients give history of a cardiovascular problem.
Symptoms:Symptoms:
Pain:Pain: sudden severe abdominal pain.sudden severe abdominal pain.
VomitingVomiting: repeated and may be with haematemesis.: repeated and may be with haematemesis.
Bleeding per rectum:Bleeding per rectum: may be only after enema.may be only after enema.
Shock:Shock: rapidly develops.rapidly develops.

Signs:Signs:
Generally:Generally: signs of shock and pallor.signs of shock and pallor.
Abdominally:Abdominally:
Tenderness, early mild, late marked with rigidity & reboundTenderness, early mild, late marked with rigidity & rebound
tenderness.tenderness.
Silent abdomen on auscultation.Silent abdomen on auscultation.
PR. Exam.:PR. Exam.: There may be blood on gloves.There may be blood on gloves.
Signs of complications may appearSigns of complications may appear
Plain X-ray abdomen:Plain X-ray abdomen: nonspecific finding.nonspecific finding.
Leucocytic count:Leucocytic count: markedly elevatedmarkedly elevated > 15.000> 15.000..

From other causes of acute abdomen especially internal hemorrhageFrom other causes of acute abdomen especially internal hemorrhage.
Differential Diagnosis:Differential Diagnosis:
Preoperative measures:Preoperative measures:
I.V. fluids & blood transfusion.I.V. fluids & blood transfusion.
N/G suctionN/G suction
Antibiotics.Antibiotics.
Preoperative:Preoperative: explorationexploration
Small branch occlusionSmall branch occlusion (short segment affection):(short segment affection):
Primary resection anastomosis.Primary resection anastomosis.

Main stem of SMA occlusion (Main stem of SMA occlusion (long segment affectionlong segment affection):):
Viable intestines:Viable intestines: Attempt for reperfusion by directAttempt for reperfusion by direct
arterial surgery e.g. mesenteric embolectomy,arterial surgery e.g. mesenteric embolectomy,
thrombendarterectomy. Second look operation is donethrombendarterectomy. Second look operation is done 12-12-
2424 hours later to ensure arterial patency & intestinalhours later to ensure arterial patency & intestinal
viability.viability.
Non viable gut:Non viable gut: Resection may extend up to transverseResection may extend up to transverse
colon with high mortality.colon with high mortality.

Paralytic ileus occlusionParalytic ileus occlusion
Loss of intestinal peristalsis leading to functional (Loss of intestinal peristalsis leading to functional (adynamicadynamic) obstructio) obstruction
Aetiology:Aetiology: Inhibition of the Auerbach's (Inhibition of the Auerbach's (MyentericMyenteric) plexus caused by:) plexus caused by:
Reflex inhibition:Reflex inhibition: due to sympathetic stimulation afterdue to sympathetic stimulation after
operations, trauma, or labour.operations, trauma, or labour.
Toxic inhibition:Toxic inhibition: as in peritonitis, typhoid fever & uraemia.as in peritonitis, typhoid fever & uraemia.
Hypoxic inhibitionHypoxic inhibition:: hypoxia under anaesthesia.hypoxia under anaesthesia.
Biochemical inhibitionBiochemical inhibition:: electrolytes disturbance e.g.electrolytes disturbance e.g.
hypokalaemia & hyponatraemia.hypokalaemia & hyponatraemia.
Mechanical inhibitionMechanical inhibition:: by early fibrinous adhesions.by early fibrinous adhesions.

Pathology :Pathology :
 Inhibition of the nerve plexuses leading to loss of intestinalInhibition of the nerve plexuses leading to loss of intestinal
peristalsis & muscle tone causing distension with fluid & gas.peristalsis & muscle tone causing distension with fluid & gas.
 Which exerts more inhibition on intestinal motility (Which exerts more inhibition on intestinal motility (viciousvicious circlecircle).).
Complications (Complications (causes of deathcauses of death):):
Dehydration and shock.Dehydration and shock.
Electrolytes disturbance e.g. hyponatraemia & hypokalaemia.Electrolytes disturbance e.g. hyponatraemia & hypokalaemia.
Symptoms:Symptoms:
 Most cases occur after operations especially those done for diffuse orMost cases occur after operations especially those done for diffuse or
pelvic peritonitis.pelvic peritonitis.
 Paralytic ileus is diagnosed when the following occursParalytic ileus is diagnosed when the following occurs 2424 hourshours
postoperatively:postoperatively:
A-A- No abdominal colic.No abdominal colic. B-B- Absolute constipation.Absolute constipation.
C-Abdominal distension.C-Abdominal distension. D-D- Copious vomiting.Copious vomiting.

Signs:Signs:
Generally:Generally: Dehydration with or without shock and signs ofDehydration with or without shock and signs of
other complication.other complication.
Abdominal:Abdominal:
There is marked distension with no visible peristalsis.There is marked distension with no visible peristalsis.
Tympanitic hyper resonance.Tympanitic hyper resonance.
Dead silent abdomen.Dead silent abdomen.
 Double enema test:Double enema test: the first enema may be retained or passesthe first enema may be retained or passes
without faeces or force.without faeces or force.
 Plain X ray abdomen erect:Plain X ray abdomen erect: multiple fluid levels. Generalizedmultiple fluid levels. Generalized
distention of both small and large intestine.distention of both small and large intestine.

Consevative treatment:Consevative treatment:
 Resuscitation:Resuscitation: by I.V. fluids & correction of electrolytesby I.V. fluids & correction of electrolytes
disturbancedisturbance
 Removal or treatment of the aetiological factor.Removal or treatment of the aetiological factor.
 Wide nasogastric suction:Wide nasogastric suction: to break the viscous circle.to break the viscous circle.
 Drugs:Drugs:
Peristalsis stimulants (e.g.Peristalsis stimulants (e.g. prostigminprostigmin) are contraindicated (Do) are contraindicated (Do
not flog the tired horse).not flog the tired horse).
Prokinetic drugs e.g. Cisaprid have a promising effect.Prokinetic drugs e.g. Cisaprid have a promising effect.
Surgery:Surgery:
 It is only considered if paralytic ileus persists for more thanIt is only considered if paralytic ileus persists for more than 55
days, and when mechanical obstruction or missed foreign body ordays, and when mechanical obstruction or missed foreign body or
peritonitis is suspected.peritonitis is suspected.
 If exploration is negative, a long nasogastric tube is manipulatedIf exploration is negative, a long nasogastric tube is manipulated
as down as possible to ensure good decompression.as down as possible to ensure good decompression.

Intestinal Obstruction 2

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