This document discusses intestinal obstruction, including its classification, etiology, causes, symptoms, diagnosis and management. It classifies obstruction by site (small vs large bowel), presentation (acute, chronic, acute on chronic), and blood flow (simple vs strangulated). Common causes are adhesions, hernias, tumors, strictures and volvulus. Diagnosis involves history, exam, labs, imaging like abdominal X-rays and CT scans. Treatment depends on the severity and includes resuscitation, NG decompression, IV fluids, antibiotics if needed, and surgery for severe cases to remove the obstruction. Surgical procedures vary based on the site and nature of the obstruction.

1. Intestinal Obstruction
Dr.Usman Haqqani
TMO
Surgical B
Hayatabad Medical complex peshawar

2. Classification
• According to obstructing site
• Small bowel obstruction
• Large bowel obstruction
• According to presentation
• Acute obstruction
• Chronic obstruction
• Acute on chronic obstruction
• Subacute obstruction
• According to blood flow
• Simple obstuction
• Strangulated obstuction
• Primary
• External
• Closed loop obstruction

3. AETIOLOGY

4. CAUSES OF INTESTINAL
OBSTRUCTION
Dynamic causes
 Intraluminal
impaction
foreignbodies
bezoars
gallstones
 Intramural
stricture
malignancy
 Extramural
bands/adhesions
hernia
Volvulus
Intussusception
Adynamic causes
Paralytic ileus
Mesenteric vascular
occlusion
Pseudo -obstruct

5. Common causes of obstruction
ADHESION
TUMOR

6. Common causes of obstuction

7. Incidence
Small Bowel
(85%)
 Cancer (75%)
 Diverticulos.(10%)
 Volvulus(10%)
 Miscellan.(10%)
In Eastern Countries& Middle
East volvulus accounts for >
50% of causes of colon
obstruction
COLON
(15%)
 Adhesions(80%)
 Hernia(10%)
 Tumors(5%)
 Miscellan.(5%)

8. etiology:
I. Adhesions(40%of causes)
A. Postoperative:
• Commonest after lower abdominal and gynaecological surgery
• Patients can present as early as 4 weeks postop.but often 1-5 years
postoperative.
B.Inflamatory:
• Cholecystitis
• Appendicitis
• PID
• T.B
• Peritonitis

9. ADHESIVE INTESTINAL OBSTRUCTION

10. ADHESIVE INTESTINAL
OBSTRUCTION

11. Etiology(small bowel)
II. Hernia(12% of causes)
A. External:
 Inguinal ; Femoral; Umbilical
B. Internal:
Sites
Foramen of Winslow
Defect in the mesentery or transverse mesocolon
Defect in the broad ligament
Diaphragmatic hernia
Duodenal/caecal/appendiceal retroperitoneal fossae

13. Strangulated small bowel loop(strangulated
inguinal hernia)

14.  Neoplasms(15% of causes)
Colorectal carcinoma:
• 75% occure in Rectosigmoid colon
• 15-20% of colorectal cancer present with obstruction
• LT.colon commonest site of obstruction due to constricting
lesion&solid faeces

15.  strictures
A.Congenital:
Intestinal Atresia
B.Inflammatory:
Crohns Disease
Tuberculosis
C. Neoplastic:
Lymphoma
Carcinoid

16. Volvulus
• Twisting or axial rotation of a portion of bowel about its
mesentery
• Primary or secondary

17. Malrotation & neonatal volvulus
• Treatment:
• The volvulus is reduced, the
transduodenal band(Ladd’s band)
divided, the duodenum mobilised & the
mesentry freed.
• Appendicectomy is routinely performed
to avoid diagnostic difficulty with
appendicitis in the future.
• Infarcted bowel necessitates resection.

19.  Intussusception:
• Invagination of segment of bowel(intussusceptum) into
another(intussuscepien).
• it is often antegrade
• Most common:
ileocolic(ileocaecal)
Ileo-ileal
A. Primary: infants & young children
Due to lymphoid hypertrophy of terminal ileum
B. Secondary: adult
Due pathological lead point :
Meckles diverticulum ;polyp ;submucous lipoma ; haemangiomas
;Lymphoproliferative disease

20. Intussusception

21. JEJUNO-JEJUNAL INTUSSESCEPTION(IN ADULT)

22. Bolus Obstruction
1. Gall stones
• In the elderly
• Classically there is impaction about 60 cm proximal to the
ileocaecal valve

23. 2. Food
Occur after partial or total gastrectomy when unchewed
articles can pass into the small bowel
3. Stercolith
• In association with jejunal diverticulum or ileal stricture

24. 4. Trichobezoar
• Firm masses of undigested hair balls

25. 5. Phytobezoar
• Firm masses of fruit or vegetable fibres

26. 6. Worms
• In children
• Ascaris Lumbricoides

27. Adynamic obstruction
I. Paralytic Ileus:
 There is Reflex Inhibition of Peristaltaic Activity of Small intestine due
to increase sympathetic Drive. smooth muscle become unresponsive to
neural and hormonal stimuli
 Causes:
1) Postlaparotomy: after Abd.Pelvic surgery

28. I. Paralytic ileus( CAUSES)
2) Intra-abdominal Sepsis
3) Abdomino-pelvic Trauma (Retroperitoneal Haematoma)
Other Contributing Factors:
 Electrolytes Imbalance
 Uraemia
 Drugs: Narcotics ; Antichlonergices; phenothiazines

29. II. Acute colonic pseudo-
obstruction
 It is massive colonic dilatation affecting caecum and Rt.colon with
presentation of colonic obstruction without mechanical blockage
 Occurs in
Elderly hospitalised patients with major TRAUMA;ILLENESS; MAJOR
NON-INTESTINAL SURGERY

30. ETIOLOGICAL FACTORES
 Major non-operative TRAUMA
 SEPSIS
 Myocardial infarction ; Heart Failure
 Major Abdomino-pelvic Surgery
 Orthopedic Surgery
 Gynecological ; Neurosurgical Procedures
 Cerebrovasular accident ; Spinal cord Injury
 Advanced Malignancy
 Respiratory ; Renal Failure
 Drugs: Opiates; phenothiazines ;Chanel blockers

31. III. Acute mesenteric ischemia
1. Embolic: (50%)
• Affects SMA
• Occur secondary to MI; Atrial Fibrilation
2. Trombotic(20%)
due to acute thrombosis on top of pre-existing atherosclerosis of
visceral artery
3. SHOCK:
• hypovolemic & septic

32. HISTORY
• Acute obstruction
• Sudden onset of central abdominal colicky pain
• Vomiting (party digested food>>mucoid>>greenish>>feculant)
• Abdominal distention
• Absolute constipation
• Chronic obstruction
• Constipation
• Abdominal distention
• Abdominal pain( bouts of colic pain in hyopogastrium)
• VOMITING DELAYED FOR 2-3 DAYS

33. PHYSICAL EXAMINATION
INSPECTION
Abdominal distention, scars, visible peristalsis.
PALPATION
Mass, tenderness, guarding
PERCUSSION
Tymphanic, dullness
AUSCULTATION
Bowel sound are high pitch and increase in
Frequency
DIGITAL RECTAL EXAMINATION

34. INVESTIGATIONS:
• Lab:
• FBC (leukocytosis, anaemia, hematocrit, platelets)
• Clotting profile
• Arterial blood gasses
• U& Crt, Na, K, Amylase, LFT and glucose, LDH
• Group and save (x-match if needed)
• Optional (ESR, CRP, Hepatitis profile)
• RadiOlogical:
• Plain ABDOMINAL xrays
• USS ( free fluid, masses, mucosal folds, pattern of
paristalsis, Doppler of mesenteric vasulature, solid organs)
• Other advanced studies (CT, Contrast studieS)

35. Errect abdomen x ray
with air fluid levels Supine radiograph
distended small bowel
loops in the central
abdomen with prominent
valvulae conniventes (
white arrow)
Figure 3. Lateral decubitus
view of the abdomen,
showing air-fluid levels
(arrows).

36. The Difference between small and large bowel
obstruction
Small BowelLarge bowel
•Central ( diameter 3 cm
max)
•Vulvulae coniventae
•Peripheral ( diameter 6
cm max)
•Presence of haustration

37. Abdominal X-Ray
What is Diagnosis?
(1) Dilated Colon >6cm
(2) Effacement of Haustrae
Peripherally located
(3) Multiple Air Fluid Levels
Large Bowel Obstruction
Rule of 3,6,9:
 suspect obstruction if small
bowel dilated >3cm; large
bowel >6cm, cecum >9cm.

38. Cecalvolvulus • Sigmoid volvulus

39. • Intussusception

40. Role of CT
• Used with iv contrast, oral and rectal contrast
(triple contrast).
• Able to demonstrate abnormality in the bowel
wall, mesentery, mesenteric vessels and
peritoneum.
• It can define:
• the level of obstruction
• The degree of obstruction
• The cause: volvulus, hernia, luminal and
mural causes
• The degree of ischaemia
• Free fluid and gas
• Ensure: patient vitally stable with no renal failure
and no previous alergy to iodine
• Figure: Axial computed tomography scan
showing dilated, contrast-filled loops of
bowel on the patient’s left (yellow arrows),
with decompressed distal small bowel on the
patient’s right (red arrows). The cause of
obstruction, an incarcerated umbilical hernia,
can also be seen (green arrow), with
proximally dilated bowel entering the hernia
and decompressed bowel exiting the hernia.
Source: Jackson, PG. & Raiji M., Evaluation and Management of Intestinal Obstruction, January 2011, American

41. Role of barium gastrografin studies
• As: follow through, enema
• Useful in recurrent and chronic
obstruction
• Can be used to distinguish
adynamic and mechanical
obstruction
Barium should not be used in
a patient with peritonitis

42. intussuseption• Bird beak sign in cecal
volvulus

43. Intussuseption

44. Source: Jackson, PG. & Raiji M., Evaluation and Management of Intestinal Obstruction, January 2011, American

45. TREATMENT
• URGENT RESUSCITATION
• NBM
• NG tube(bowel decompression)
• Cathetrization
• IV fluids (correct fluid and electrolyte disturbances)
• Start IV antibiotics (if indicated)
• Optimise Cardio respiratory status
• Consenting
• Bowel preparation
• Workup for surgery
• Close clinical and Radiological monitoring

46. II. SURGICAL INTERVENTION
1. URGENT:
• Strangulation / Suspected Strangulation
• Closed-Loop Obstruction
• Complete Obstruction
• Pnumoperitonium/ Peritonitis

47. 2. Elective Cases
• Adhesive Small intestine Obstruction NO Strangangulation
( Observe&Mointoring For 48-Hours )
• Incomplete Small intestine or Colonic Obstruction:
Investigate With Contrast Studies

48. 3. NOT TO OPERATE
• PARALYTIC ILEUS
• ACUTE COLONIC PSEUDO-OBSTRUCTION

49. INDICATIONS FOR SURGERY
• Absolute
• Generalised peritonitis
• Localised 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
Source: http: Surgical Tutor.co.uk

50. Generalsteps of Surgery
• At first most importantly the caecum is identified
collapsed distended
(small gut obstruction) (large gutobstruction)

51. Site of obstruction is identified
Nature of the obstruction is identified & removed
Viability of the gut is assesed

52. Gut is viable it is not viable
Gut is put inside the ResectionAnastomosis
Abdomen.
• Abdomen closed in layers using Non-absorbable sutures.

53. Comparison between Viable &
Non-viable Gut
Features of viable gut
• Pinkish
• Luster-present
• Peristaltic movement-
present
• When pricked by a
needle-bleeding from
the surface
• Pulsation-present in
mesenteric vessels
Features of non-viable gut
• Blackish
• Absent
• Absent
• There Is no bleeding
• No pulsation

54. If still we are doubtful-
• Warm saline soaked mop over the doubtful area & 100% O2 is
administered
• If colour becomes normal with peristalsis,then it is viable.

55. Other means of checking
Viability
1. Doppler study
2. Fluorescence study

58. Management of bowel
obstruction
• Intussusception
• Reduction by hydrostatic pressure
• Operative reduction
• Volvulus neonatorum
• Early laprotomy
• Whole Midgut is delivered
• Untwisting is done in opposite direction
• Transduodenal band of lad is devided

59. • Cecal volvulus
• Laprotomy
• Balooned cecum defalted by needle
• Untwisting in anticlockwise direction
• Cecostomy is performed
• Sigmoid volvulus
• Deflation sigmoidoscopy
• Operative
• Laprotomy
• Untwisted in clockwise direction
• Rectal tube passed simultaneously to deflate

60. • Paralytic ileus
• Remove primary cause
• Decompress GI distension
• Fluid and electrolyte balance
• If not relieved  laparotomy exclude hidden cause
• Acute Mesenteric Occlusion
• Anti-coagulant
• Embolectomy
• Revascularization
• Colectomy
• Adhesions
• Conservative treatment should not be prolonged beyond 72
hours.
• divide only the causative adhesion(s) and limit dissection

61. MANAGEMENT FOR LARGE
BOWEL OBSTRUCTION
 (IF Lesion/Mass is removable)
•Right sided lesions – right hemicolectomy
•Transverse colonic lesion – extended right hemicolectomy
 (if lesion/Mass is irremovable)
•Proximal stoma
•Colostomy
•Ileostomy if ileocecal valve is incompetent
•Ileotransverse enterostomy
•Left sided lesions – various options

62. Two-staged procedure
•Resection and anastomosis with defunctioning colostomy
•Closure of colostomy
Two-staged procedure
•Hartmann’s procedure
•Closure of colostomy
One-stage procedure
•Resection, on-table lavage and primary anastomosis

63. Complications associated with
intestinal obstruction repair
• include excessive bleeding
• infection
• formation of abscesses (pockets of pus)
• leakage of stool from an anastomosis
• adhesion formation
• paralytic ileus (temporary paralysis of the intestines)
• reoccurrence of the obstruction.