3. Airway
• Signs of obstructed airway are
• Cyanosis
• Apnea
• Stridor
• absence breath sounds
• Remove vomitus, blood
• Suck out the secretions
• Relieve the obstruction by intra oral soft tissues
• Jaw thrust and chin lift procedure
4. Breathing
• If the patient does not improve after air way is cleared start
cardiopulmonary resuscitation.
• Use bag valve mask ventilating system, oral airway,
• Two breaths accompanied by 30 chest compressions.
• After inserting the cuffed endotracheal tube
• Can provide ventilation and chest compressions simultaneously.
5. Circulation
• Patient is lost large amount of fluid due to vomiting and
sequestered fluid into the gut. Two large wide bow cannulas
inserted.
• After assessing the blood pressure adequate amount of Normal
Saline or Hartman's solution is given as bolus dosage or rapid
infusion. If fails to achieve optimum BP adrenalin is given. Then
inotropes are given.
7. Specific
Age
•neonatal – imperforated anus, volvulus
•infants – intersusseption , strangulated hernia
•young adults and middle age – strangulated hernia ,
adhesions , IBD
•elderly – strangulated hernia , colonic CA
Previous history of surgery – post op adhesions
Complicated hernia – acute pain
Past medical history – inflammatory bowel disease ,
carcinoma of bowel or other structure
14. Supine abdominal x-ray-
It may show abnormal bowel pattern (dilation of bowel
loops in case of obstruction or sentinel loop). It may also
show masses
15. Erect abdominal Xray-
Though It shows fluid levels in case of obstructed
bowel it is no longer routinely obtained.
16. Ultrasound-
It is less useful but may indicate presence of
intraperitoneal fluid or mass.
CT
It is performed with oral or Intravenous contrast. It
can localize the site of the obstruction. Lower
abdomen CT is useful in detection of acute
appendicitis, acute diverticulitis, intestinal
obstruction, aortic aneurysm & mesenteric
ischemia.
17. Radiological features of obstruction
■ The obstructed small bowel is
characterized by straight
segments that are generally central and
lie transversely. No
gas is seen in the colon
18. ■ The jejunum is characterized by its valvulae
conniventes,
which completely pass across the width of the
bowel and
are regularly spaced, giving a ‘concertina’ or ladder
effe
■ Ileum – the distal ileum has been piquantly
described by
Wangensteen as featureless
■ Caecum – a distended caecum is shown by a
rounded gas
shadow in the right iliac fossa
19. ■ Large bowel, except for the caecum, shows
haustral folds,
which, unlike valvulae conniventes, are spaced
irregularly,
do not cross the whole diameter of the bowel and
do not
have indentations placed opposite one another
A barium follow-through is contraindicated in
the presence of acute obstruction and may be life-
threatening.
21. Other investigation
• Full blood count
• Serum electrolytes
• Serum Creatinin
• Blood urea nitrogen
• Liver Function Test
• Serum Amylase
• Arterial blood gas
22. Full blood count
• Increased haemoglobin and haematocrit count.
• Due to heamoconcentration.
• Increased WBC
• Due to Infarction , Peritonitis
Serum electrolytes
• Hypokalaemia
• Due to severe emesis.
Blood urea nitrogen
• Due to vomiting and diarrhoea.
• Dehydration
23. Blood gas analysis.
• Metabolic acidosis
• Intestinal obstruction ischemia lactic acidosis.
Liver function tests.
• Increased serum bilirubin and alkaline phosphatase.
• Help to find the cause.
Serum amylase
• Increased levels due to irritation to pancreas by bowel loops. (Non
specific test.)
24. What is the next step ?
• NG tube placed to decompress the stomach.
• IV Fluids
• Catheterize the patient to monitor the urine out put.
• Maintain charts for pulse, BP, Temprature
• Repeated clinical assessment.
26. Simple obstruction
• caused by a mechanical block , without impairment of the blood supply
of the gut.
• The causes include,
- obstruction by adhesions.
- a ball of Ascaris worms .
• Simple obstruction may resolve spontaneously.
Operation is usually not urgent, and may be unnecessary.
• The treatment of simple mechanical obstruction may be non-operative
or operative.
• If it fails to improve after 48 hours of non-operative treatment, operate.
27. Strangulation obstruction
• About 6 hours after the interruption of its blood supply the
gut becomes gangrenous and may perforate into his
peritoneal cavity.
• It causes generalized peritonitis which may end in septic
shock.
• If it perforates into a hernial sac the infection may be more
localized.
• Patient is very ill and should be operate immediately.
• Strangulation obstruction should always be operated.
28. Indications of Emergency surgery
• incarcerated external hernia
• clinical and radiologic evidence of strangulation
• gangrene
• perforation
• carefully monitored non-operative treatment is indicated, at
least initially, while specific imaging methods are utilized to
identify specific etiology of intestinal obstruction or to monitor
progression of intestinal obstruction.
29. Indications for surgery
•Absolute
• Generalized peritonitis
• Localized peritonitis
• Visceral perforation
• Irreducible hernia
•Relative
• Palpable mass lesion
• 'Virgin' abdomen
• Failure to improve
•Trial of conservatism
• Incomplete obstruction
• Previous surgery
• Advanced malignancy
• Diagnostic doubt - possible ileus
30. Fluid Replacement
• Mechanical obstruction of small bowel causes accumulation of
fluid inside the distended bowel lumen. Therefore there is
depletion of intravascular volume & reduced perfusion of
other organs.
• Early recognition & restoration of intravascular volume to re-
establish the organ perfusion is important prior to operative
treatment, because induction of general anaesthesia in a
volume depleted patient may result in profound hypotension
& complications including renal failure.
31. Fluid entering small intestine per 24
hours
• Diet- 2-2.5 l
• Pancreatic juice- 0.75 – 1.5 l
• Saliva- 0.5 l
• Bile- 0.75 – 1.5 l
• Gastric juice- 1.5-3 l
• Total – 5.5-9 l
32. • Basic biochemical abnormality in intestinal obstruction is
sodium & water loss.
• Hartmann’s solution or normal saline can be used for fluid
replacement.
• The volume required is determined by clinical, hematological
& biochemical criteria.
• If renal functions are satisfactory & potassium is low,
potassium can be supplemented.
• If the patient is in shock, plasma expanders can be given.
33. • To calculate fluid losses & for accurate fluid replacement urine
output should be measured. Indwelling catheter is inserted.
• The patient should be kept nil by mouth.
34. Nasogastric Decompression
• This is achieved by the passage of a non-vented (Ryle) or
vented(Salem) tube.
• Tubes are normally placed on free drainage with 4 hourly
aspiration, but may be placed on continuous or intermitted
suction.
• As well as facilitating the decompression proximal to the
obstruction, they are essential to reduce the risk of
subsequent aspiration during induction of anaesthesia & post
extubation.
