This document discusses intestinal obstruction, including its causes, clinical presentation, diagnosis and treatment. It describes different types of intestinal obstruction including mechanical obstruction, paralytic ileus and strangulation obstruction. The clinical exam, abdominal x-rays, CT scans and laboratory tests used in diagnosis are outlined. Treatment involves fluid resuscitation, decompression of the intestine, monitoring of electrolytes and timely surgery depending on the severity and duration of the obstruction.

1. INTESTINAL OBSTRUCTION DR MAHIPAL REDDY.INDIA

2. Intestinal obstruction Mechanical obstruction Paralytic Ileus

3. Paralytic Ileus After abdominal surgery (laparotomy) Electrolyte imbalances (hypokalemia) Abdominal thrauma Spine fracture Retroperitoneal hemorrhage Ureter distension – Acute pancreatitis Ischemia of the intestine Drugs (Narcotics, Psychotropics) Peritonitis (ex. Gangrenous cholecystitis) Diabetic coma Extra abdominal infections (Lung) – Sepsis IBD (ulcerative colitis)

4. Intestinal mechanical obstruction Pathogenesis Stenosis Obstruction Compression Invagination Torsion Angulation Strangulation

5. Intestinal obstruction Pattern in Africa 70 % of the patients were below the age of 15 years 80% with gangrenous bowel segments

6. Large gallstones -- cholecystoenteric fistula – gallstone ileus Bezoars (children, mentally retarded, toothless, after gastrectomy) Congenital lesions (atresia, stenosis, duplication) Neoplasms of small bowel – peritoneal carcinosis Inflammation (Chron’s disease- diverticulitis- BK- endometriois) Fecal impaction (bedridden old patient) Meconium Foreign bodies Iatrogenic strictures (intest. Anastomosis o RT) Intestinal mechanical obstruction E tiology

9. Accumulation of fluids and gas proximal to the obstruction Simple mechanical obstruction PATHOGENESIS Distention of the intestine (self perpetuating) Increase intestinal secretion Losses of water, Na, Cl, K, H Dehydratation, ipokalemia, hypochloremia Metabolic alkalosis

10. Circultory changes Low central venous pressure Reduced cardiac output Hypotention Hypovolemic shock Rapid proliferation of intestinal bacteria Toxiemia Simple mechanical obstruction PATHOGENESIS

11. Paralytic Ileus Mechanical obstruction

12. Ischemia of the bowel Strangulation obstruction PATHOGENESIS Loss of blood and plasma into the strangulated segment Gangrene Perforation Peritonitis Sistemic absorption of toxic materia

13. Strangulation Obstruction Simple Mechanical obstruction Surgical timing

14. Intestinal obstruction Site Proximal s.b. obstruction Greather vomitimg and less intestinal distention than distal obstruction Colon obstruction Less fluid and electrolyte disturbance Large distension and perforation risk

15. Intestinal obstruction Clinical aspects Abdominal pain Vomiting Obstipation Abdominal distention Failure to pass flatus Fever Dehydratation Hypotention – hypovolemic shock

16. Intestinal obstruction Pain Typical crampy pain in paroxysm at 4 to 5 minute intervals in proximal obstruction Less frequently in distal occlusion After a long period of mechanical obstruction the crampy pain may subside A strangulation should be suspected when continuus severe pain replace crampy pain

17. Intestinal obstruction Vomiting Proximal obstruction produce profuse vomiting and little abdominal distension Distal obstruction is less frequent but feculent Initial phase byliary aspect Late phase feculent BUT

18. Intestinal obstruction - Level HIGH LOW PAIN Crampy pain in paroxism Less intensity VOMITING Early, profuse, biliary Late, feculent may be absent METEORISM + +++ BEGINNING Acute Slow, insidious ABDOMINAL DISTENTION Moderate, upper quadrant Early, intense GENERAL CONDIT Early compromission preserved ELECTOLYTES Cl, K, Na rapid loss Late hydro electrolytic imbalance

19. Intestinal obstruction Clinical examination Palpation abdominal masses can suggest neoplasms, intussusception, abscess Incarcerated hernias may be obscure (obese) Surgical scars can suggest adhesions Abdominal auscultation period of increasing separated by periods of quite bowel sounds (high pitched, tinkling or musical) in mechanical obstruction Rectal examination to seek luminal masses. Blood in the feces suggest mucosal lesion (cancer, intussusception, infarction) Key points

20. Intestinal obstruction Clinical examination Young children and babies Atresia Volvolus Anal imperforation Meconial ileus Intestinal Duplication Malrotation Intussusception Ascaris infestation Hernia Patient age and sex Adults Hernia Adhesions Neoplasm Inflammation RT Endometriosis Gynecological pathology

21. Intestinal obstruction Abdominal direct X ray exhamination Barium enema CT Endoscopy Ecography (very difficult because of the massive presence of gas) Radiological examination

22. Intestinal obstruction Gas abnormally large quantities of gas in the bowel Multiple gas-fluid levels in the upright or lateral decubitus position Abdominal direct X ray exhamination

23. Intestinal obstruction Multiple gas-fluid levels does not always mean intestinal obstruction Abdominal pain and diarrhea can be found in gastroenteritis (cytomegalovirus infection as well as salmonellosis) expecially if profuse watery for 12 or more hours. Abdominal direct X ray exhamination Remember

24. Intestinal obstruction Identify the distended tract Small bowel Colon Both plus stomach Radiological examination What can we see

25. Intestinal obstruction Gas in the small bowel outlines the valvulae conniventes, which usually occupy the entire trasverse diameter of the bowel image Radiological examination Small bowel

26. Intestinal obstruction Colonic haustral marking occupy only a portion of the transverse diameter of the bowel Radiological examination large bowel

27. Intestinal obstruction Radiological examination Typical the small bowel pattern occupies the more central portion of the abdomen, the colon shadow is on the periphery of the abdominal film or in the pelvis

28. Intestinal obstruction Radiological examination During paralytic ileus gaseous distention occurs somewhat uniformly in the stomach, small intestine and colon

29. Intestinal obstruction Helpful in distal occlusion may be operative in intussusception Barium Enema

30. Intestinal obstruction Is sensitive for diagnosing complete obstruction of the small bowel and determining the localization and cause of obstruction CT scan

31. Proximal obstruction Distal obstruction

32. Intestinal obstruction Hematocrit WBC Electrolytes PCR (C reactive protein) AST -ALT – GGT- LDH Laboratory test

33. Intestinal obstruction Fluid and electrolytes therapy Intestinal decompression (NG tube) Diuresys monitoring Correct surgical timing for relief of obstruction Treatment

34. Intestinal obstruction Duration of obstruction Severity of fluid, electrolyte and acid base abnormalities Opportunity to improve vital organ function Consideration of the risk of strangulation Timing of operation depends