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Intestinal obstruction
This document provides guidance on the emergency management of intestinal obstruction. It outlines the initial steps of airway, breathing and circulation management. It describes signs of airway obstruction and interventions like endotracheal intubation. It emphasizes fluid resuscitation to treat dehydration from vomiting and recommends nasogastric decompression. The document also differentiates between simple and strangulated obstructions and indications for emergency surgery, like perforation or irreducible hernia.
Intestinal obstruction
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- 2. First Step • Airway •Breathing • Circulation
- 3. Airway • Signs ofobstructed 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 thepatient 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 islost 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.
- 6. HISTORY General Abdominal pain – firstsymptom usually severe colicky in nature Abdominal distension Vomiting Constipation absolute / relative
- 7. Specific Age •neonatal – imperforatedanus, 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
- 8. Examination General Examination Ill looking Uncomfortablylying on the bed Dyspnea Febrile Tachycardia Dehydration
- 9. Abdominal Examination Inspection Asymmetrical abdomen Abdominaldistention Surgical Scars Palpation Tenderness Tense Abdominal mass Reduce or absent bowel sounds
- 10. Examine hernial orificesto exclude strangulated hernia
- 11. Digital Rectal Examination(DRE) •Obstructing Mass of pouch of Douglas • Apex of an intersusseption
- 12. Investigations • Imaging • Haematological •Biochemical
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- 14. Supine abdominal x-ray- Itmay show abnormal bowel pattern (dilation of bowel loops in case of obstruction or sentinel loop). It may also show masses
- 15. Erect abdominal Xray- ThoughIt shows fluid levels in case of obstructed bowel it is no longer routinely obtained.
- 16. Ultrasound- It is lessuseful 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 ofobstruction ■ 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 jejunumis 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.
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- 21. Other investigation • Fullblood 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 thenext 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.
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- 26. Simple obstruction • causedby 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 • About6 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 Emergencysurgery • 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 • Mechanicalobstruction 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 smallintestine 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 biochemicalabnormality 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 calculatefluid 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 • Thisis 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.
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Editor's Notes
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