case presentation on intestional obstruction

1. Case presentation
Intestinal obstruction
intern
deepak paudel
GMCTH
DEPARTMENT OF SURGERY

2. 68yr/M from Armala ,Ex Army by profession was admitted
through GMC ER on 27th of Asad 2073( @ 10:20 PM) with chief
complaints of:
• pain abdomen for 3 days
• Dyspepsia for 3 days
• Abdominal distention for 3 days

3. HOPI
• Pain - in RIF
gradual on onset
burning sensation
continuous
started in the morning
non radiating
no known aggravating factor
relieved by shifting position

4. Pain is associated with
abdominal distention
water brash
nausea
burning micturation
H/O loss of appetite

5. • H/O passage of hard stool
• No H/O fever ,headache ,trauma
• No H/0 cough ,weight loss
• No H/0 vomiting.

6. PAST HISTORY
• H/0 appendectomy 40 yrs ago
• From than ,he started to develop abdominal
pain of similar nature .
• According to him, he experiences similar
problem once in every year.
• Last time on Bhadra 2072 he was admitted to
GMCTH for abdominal pain ,admitted ,treated
conservatively and relieved.

7. FAMILY HISTORY
• No such H/O in the family
• no H/O of HTN, DM, TB

8. PERSONAL HISTORY
• Consumes alcohol occasionally.
• Non vegeterian
• Doesn’t smoke
• But has a habit of chewing tobacco.

9. ALLERGIC HISTORY
• No known allergic history of any drug

10. • GENERAL EXAMINATION
Pt .was concious, well oriented to T,P,P lying comfortably in supine
position with cannula fitted in the left hand
- Vitals
R/R:-25/min
BP:- 110/70 mm of Hg in rt brachial Artery.
Pulse-84beats/min
Temp 98 F

11. • Pallor
• Icterus
• Lymphadenopathy nil
• Clubbing
• Cyanosis
• Oedema nil
• Dehydration

12. GI EXAMINATION
Inspection
-umbilicus centrally placed and abdomen is
distended.
-visible scar in rt iliac fossa
-all quadrants move equally with respiration
-no visible pulsation and peristalsis
-hernial sites intact
-ext. genitilia-normal

13. Palpation
-Abdominal girth :90 cm(01) -86 cm(02) -72 cm (04/04)
-local temprature normal
-tenderness on lower abdominal region
-no palpable mass
-no organomegaly
-hernial sites intact and normal ext. genital

14. Percussion – resonant note
- tender RIF
-shifting dullness –ve
auscultation – normal bowel sound heard
-no vascular bruits heard
P/R exm- no mass, no blood, faeces present.

15. • Respiratory exmn-normal
• CVS exmn- normal
• CNS exmn –normal

16. Provisional diagnosis
• Intestinal obstruction:
For abdominal pain
Constipation
Abdominal distention

17. Differential Diagnosis
D/d For Against
Meckels
Diverticulitis
Pain abdomen No antecedent
h/o of lower GI
bleeding
Rt. Ureteric colic Abdominal Pain
Aggravated on
movement
No history of
hematuria
no radiation to
loin

18. D/D For Against
Perforated peptic
ulcer
Severe pain in
RIF
history of
dyspepsia
pain is not
related to food
intake.
Crohns diseases Pain abdomen No diarrhoea and
wt loss

19. Investigation
• CBC:-WBC -10,000/mm3
• Na+ 141 ,k+ 4.0
• USG impression :
slightly prominent bowel loop.
• Plain abdominal X-ray

20. Treatment
• Under liquid diet.
• IV fluids
• Analgesics:inj tramadol ,buscopan,
• Antibiotics :levoflox,inj xone
• Soap water enema.

21. Intestinal obstruction

22. Definition:
• Intestinal Obstruction(IO) is a condition in
which there is a sudden stoppage of the
onward passage of intestinal contents-i.e. Gas,
digestive juices and food

23. Intestine

24. CLASSIFICATION
According to:
Aetiopathology
Onset
Level
Nature

25. Peristalsis is working against
a mechanical obstruction
DYNAMIC
(MECHANICAL)
Result from atony of the
intestine with loss of normal
peristalsis, in the absence of a
mechanical cause.
or it may be present in a non-
propulsive form (e.g. mesenteric
vascular occlusion or pseudo-
obstruction)
ADYNAMIC
(FUNCTIONAL)

26. Small or Large bowel
High (Proximal) or Low (Distal) small bowel
According to LEVEL

27. High IO- near the ampulla- jejunum and
proximal ileum.
Low IO- distal to the ampulla- distal ileum
and colon.

29. According to nature of Obstruction:
1. Simple Obstruction- the bowel lumen is occluded ,blood supply remains
intact. The source of obstruction is usually intra-abdominal. ( Eg. Intra-
abdominal adhesions, very rarely gallstones, ball of worms, bezoars).
2. Strangulation- the bowel lumen together with its blood supply is cut-off.
Eg. Strangulated inguinal hernias. Pure strangulation without bowel
luminal narrowing is usually due to mesenteric embolism/thrombosis.

30. 3. Closed loop obstruction- The bowel is
obstructed both proximally and distally. Here
the blood supply may be impaired.
A classic example is seen in an obstruction of
the colon with a competent ileo-caecal valve.
NB: All the 3 types spoken about can occur at
the same time for example in a strangulated
inguinal hernia.

31. Closed loop obstruction

32. According to onset:
-Chronic Obstruction-Usually seen in large
bowel obstruction. The symptoms may arise
from the cause and the subsequent obstruction.
-Acute on Chronic Obstruction- sudden
obstruction in a previously incomplete
obstruction.
Sub-acute Obstruction- There is a partial
obstruction.

33. Causes Dynamic obstructrion

34. BANDS

35. Ball of Ascaris worms

36. Adynamic cause of Obstruction
• Paralytic ileus
• Electrolyte imbalance
• Spinal injury
• Diabetis mellitus
• Renal surgeries
• Mesenteric ischemia

37. Pathophysiology

38. Clinical presentation
The clinical presentation varies according to;
- The location of the obstruction
- The age of the obstruction
- Underlying pathology
- Presence or absence of intestinal ischaemia.

39. Clinical features
• Abdominal pain
• Vomiting
• Distension
• Constipation
• Dehydration
• Feature of toxemia and septicemia
• Feature of strangulation
• Temperature
• Bowel sound
• Per rectal examination

40. Small vs large bowel obstruction

41. Investigation
• CBC
• Electrolyte Na/K
• Plan X-ray abdomen erect and supine
• CT scan

42. A. Investigations
(i) Supportive- FBC, BU+Cr. Other investigations may be
requested on the basis of clinical suspicion.
(ii)Diagnostic
-Plain abdominal x-rays
Erect and supine
-CXR
-Enema
-Endoscopic techniques

43. Managmenet
I.V fluids and electrolytes rescusitation
N.G tube if repeated vomiting
Antibiotics
Exploratory laparatomy
Hernia  operation
Adhesions  Adhesiolysis
Obstruction  remove
Volvulus  derotate and or operate
Mesenteric ischemia  operate
Abscess or peritonitis  drain and treat
Intussusception  pneumatic or barium reduction or operate

44. • SRB’s Manual of surgery, 4E
• Bailey & Love’s Short practice of surgery, 25th
Edition
• Principles of surgery
• Internet
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