Abdominal issues

1. INTESTINAL OBSTRUCTION
Shangwe Kibona

2. Outline
 Introduction
 Definition
 Classification
 Risk factors
 Causes
 Pathophysiology
 Clinical Manifestation
 Investigation
 Medical Management
 Nursing Management

4. Overview
• Intestinal obstruction is a blockage that keeps food or
liquid from passing through the small intestine or large
intestine (colon).
• It can be caused by adhesions, in the abdomen that
form after surgery; hernias; colon cancer; certain
medications; or strictures from an inflamed intestine
caused by certain conditions, such as Crohn's disease or
diverticulitis.
• Without treatment, the blocked parts of the intestine
can die, leading to serious problems.
• However, with prompt medical care, intestinal
obstruction often can be successfully treated.

5. DEFINITION
• Intestinal obstruction is:
• Interruption of normal passage of intestinal
contents.
• Intestinal obstruction is a partial or complete
blockage of the bowel. The contents of the
intestine cannot pass through it.

6. CLASSIFICATION
1. Mechanical ( dynamic) :
• A mechanical cause, which means something is in
the way
• Bowel (peristalsis) movement present
2. Non-Mechanical (adynamic):
• Paralytic ileus, a condition in which the bowel does
not work correctly.
• Peristalsis movement absent

7. Risk factors
• Diseases and conditions that can increase risk of
intestinal obstruction include:
• Abdominal or pelvic surgery, which often causes
adhesions — a common intestinal obstruction
• Cohn's disease, which can cause the intestine's
walls to thicken, narrowing the passageway
• Cancer in abdomen

8. Mechanical causes of intestinal
obstruction
• Adhesions or scar tissue that forms after surgery
• Foreign bodies (objects that are swallowed and block
the intestines)
• Gallstones (rare)
• Hernias
• Impacted stool
• Intussusception (telescoping of one segment of bowel
into another)
• Tumors blocking the intestines
• Volvulus (twisted intestine)

10. Dynamic causes of intestinal
obstruction
• Paralytic ileus, (pseudo-obstruction) which caused by:
• Bacteria or viruses that cause intestinal infections (gastroenteritis)
• Chemical, electrolyte, or mineral imbalances (such as decreased
potassium level)
• Abdominal surgery
• Decreased blood supply to the intestines
• Infections inside the abdomen, such as appendicitis
• Kidney or lung disease
• Use of certain medicines, especially narcotics
• Retroperitoneal hematoma following lumber fracture or lumber
surgery
• Idiopathic

11. PATHOPHYSIOLOGY
• The fundamental concerns about intestinal obstruction
are its effect on whole body fluid/electrolyte balances
and the mechanical effect that increased pressure has
on intestinal perfusion.
• Proximal to the point of obstruction, the intestinal tract
dilates as it fills with intestinal secretions and
swallowed air.
• Failure of intestinal contents to pass through the
intestinal tract leads to a cessation of flatus and bowel
movements.
• Intestinal obstruction can be broadly differentiated
into small bowel and large bowel obstruction.

12. PATHOPHYSIOLOGY
• Fluid loss from emesis, bowel edema, and loss of
absorptive capacity leads to dehydration.
• In addition to derangements in fluid and electrolyte
balance, intestinal stasis leads to overgrowth of
intestinal flora, which may lead to the development
of feculent emesis.
• Additionally, overgrowth of intestinal flora in the
small bowel leads to bacterial translocation across
the bowel wall.

13. PATHOPHYSIOLOGY
• Ongoing dilation of the intestine increases luminal
pressures.
• A closed-loop obstruction, in which a section of
bowel is obstructed proximally and distally, may
undergo this process rapidly, with few presenting
symptoms.
• Intestinal volvulus, the prototypical closed-loop
obstruction, causes torsion of arterial inflow and
venous drainage, and is a surgical emergency.

14. MECHANICAL OBSTRUCTION
Three main types:
• 1 Simple
• 2 Closed-loop
• 3 Strangulation

15. MECHANICAL OBSTRUCTION
• SIMPLE OBSTRUCTION
 The bowel is usually occluded at one level.
• CLOSED LOOP OBSTRUCTION
 Bowel obstructed at both proximal & distal points
There is rapid increase in the intra luminal tension,
Gangrene or perforation can occur more
quickly(peritonitis).
• STRANGULATION
 This is the end result a closed loop obstruction when
major arterial supply to the affected bowel has been
occluded , causing gangrene over a considerable area

16. Symptoms
• The cardinal features of bowel obstruction are,
1. Pain
2. Vomiting
3. Constipation
4. Distension

17. Symptoms
Pain
• Sudden, severe
• Colicky in nature
• Central , around umbilicus in small bowel obstruction
• Lower abdomen in large bowel obstruction
• Continuous if perforation or strangulation is present
• Absent in paralytic ileus.
Vomiting
• Early in high small bowel obstruction,
• Late in low small bowel obstruction
• Delayed or absent in large bowel obstruction.
• Character : initially clear ,becomes discolored , and finally feculent (dark
and foul smiling).

18. Symptoms
Constipation
• Early in large bowel obstruction
• Absolute in complete obstruction
Distension
• Epigastric or hypogastric in small bowel obstruction
• Generalized in large bowel obstruction

19. Signs
Local signs in the abdomen are:
Inspection:
• Distension, central in small bowel obstruction and
peripheral in large bowel obstruction
• Visible peristalsis
Palpation:
• Abdominal mass may suggest carcinoma or
strangulated bowel.
• Rigidity and rebound tenderness.

20. Signs
 Percussion:
• Tenderness on percussion indicates the presence of
peritonitis.
Auscultation:
• Bowel sounds
• Tympani
• Silence if generalized peritonitis or paralytic ileus is
present.

21. Signs
On rectal examination:
• Impacted feces
• Rectal cancer
• Blood on finger which maybe present with
mesenteric artery occlusions, intussusception or
Volvulus

23. A) Small Bowel Obstruction secondary to adhesions
(B) Large Bowel Obstruction secondary to malignancy

24. Investigations
• Laboratory tests
FBP,LFT.X-Matching & HB
• Imaging
A CT scan
Abdominal radiograph (AXR)

25. MEDICAL MANAGEMENT
• These patients are often intravascular fluid deplete,
therefore need urgent fluid resuscitation and fluid
balance
• Make the patient nil-by-mouth (NBM) and insert
a nasogastric tube to decompress the bowel
• Start IV fluids and correct any electrolyte disturbances
• Urinary catheter and fluid balance
• Administration of Analgesia to relieve pain.
• Treat the underlying cause (such as a strangulated
hernia or obstructing tumour)

26. Surgical management
• Bowel obstruction surgery is performed when there is a
partial or complete blockage of the bowels, which
include the small intestine and the large intestine.
• Procedures to treat bowel obstruction range from
minimally invasive laparoscopic surgery to more
complicated open surgical procedures.
• This may include the removal of damaged intestines,
surgical resection, colostomy , removal of adhesions
and any material that's blocking the intestines (such as
feces, cancer, a polyp, an infectious abscess, or a twist
in the bowel)

27. NURSING MANAGEMENT
NURSING DIAGNOSIS
• Acute pain related to abdominal distension and
increased peristalsis.
GOAL To relief pain
INTERVENTION
• Assess the level of pain, location, intensity, duration.
• Provide comfortable position and promote restful
environment.
• Administer analgesics as advised by the physician.
EXPECTED OUTCOME
• Pain will be reduced

28. NURSING MANAGEMENT
NURSING DIAGNOSIS
• Deficient fluid volume related to decrease in intestinal fluid
absorption and loss of fluids secondary to vomiting.
GOAL
• To maintain the fluid volume.
INTERVENTION
• Monitor patient for signs of dehydration and electrolyte
imbalance
• A strict intake and output record should be maintain Fluids
should be administered as ordered.
EXPECTED OUTCOME
• Fluid volume will be maintained.

29. NURSING MANAGEMENT
NURSING DIAGNOSIS
• Imbalanced nutrition less than body requirements related to
intestinal obstruction and vomiting.
GOAL
• To maintain the nutritional status.
INTERVENTION
• Nasogastric tube is inserted for feeding
• Provide liquid diet rich in protein and high caloric diet.
• Encourage patient and assist in doing oral care
• Monitor intake and output chart
EXPECTED OUTCOME
• Nutritional status will be maintained.

30. NURSING MANAGEMENT
NURSING DIAGNOSIS
• Anxiety related to lack of knowledge about the disease process as
evidence by asking questions.
GOAL
• To reduce the anxiety level
INTERVENTION
• Assess the anxiety level of the patient.
• Explain about the disease condition at the level of their understanding.
• Encourage to ventilate feelings and clear doubts if any.
• Provide psychological support.
EXPECTED OUTCOME
• Anxiety level will be reduced.

31. Complications
• The complications of bowel obstruction include:
Renal impairment
 Electrolyte imbalance
Infection
Jaundice
Perforation(hole) in the intestine
Peritonitis
Sepsis