Intestinal obstruction

1. Level
• High small bowel
• Low small bowel
• Large bowel

2. 1. Dynamic
- mechanical
obstruction
1. Adynamic-
– Peristalsis –absent
– Peristalsis -non-
propulsive form

3. Dynamic
• Acute
• Chronic
• Acute on Chronic
• Subacute

4. Type of presentation
• Simple – Intact blood supply
• Strangulated – Compromised blood
supply

6. Pathology
Proximal to obstruction :
Altered mobility
Distension

7. Distension
Gaseous :
Swallowed air
Diffusion from blood
Products of digestion and bacterial
activity
O2 & CO2 reabsorbed
Nitrogen 90% and H2S

8. Strangulation
• External compression –
Hernia/Adhesions/Bands
• Interruption of mesenteric flow – Volvulus/
Intussuception
• Rising intraluminal pressure – Closed loop
obstruction

9. • Veins compressed first - Edema and
hemorrhages
• Arterial compression – Haemorrhagic
infarction
• Translocation of bacteria, toxins and
systemic absorption

10. Strangulation
External Internal
• Smaller
absorptive
surface
• Short segment –
Less blood and
fluid loss
• Larger absorptive
surface
• Large segment –
More blood and
fluid loss - shock

11. Closed loop obstruction
• Obstruction both at proximal and distal
point
– Strangulated loops
– Colonic obstruction with a competent
ileocecal valve

12. Clinical features
• Pain
• Vomiting
• Distension
• Constipation

13. Other features
• Dehydration
• Hypokalemia
• Pyrexia –
Ischemia/perforation/Inflammatory obs.
• Abdominal tenderness

14. Signs of strangulation
• Continous pain
• Localised tenderness, rigidity, rebound
tenderness
• Shock
• Does not respond to conservative
management

15. Radiology
• X – ray abdomen Erect
Air fluid levels
• X – ray abdomen Supine
Distended bowel

17. Small bowel
• Central and transverse lie
• Jejunum – Valvulae conniventes
(concertina / Stack of coins)
• Ileum – Characterless
• Colon – Haustral folds

18. • Sigmoid volvulus
• Impacted foreign bodies
• Gallstone ileus

20. Treatment
• Gastrointestinal drainage
• Fluid and electrolyte replacement
• Relief of obstruction

21. Timing of surgery
• Emergent
Obstructed/strangulated Ext hernia
Internal intestinal strangulation
Acute obstruction
• Other cases
Atleast within 24 hrs
• Adhesions
upto 72hrs

22. Principles of Surgical intervention
• Mt. of the segment at the site of
obstruction
• The distended proximal bowel
• Underlying cause of obstruction

23. Approach
Caecum
Dilated Not dilated
Large bowel Small bowel
Trace distally Trace proximally

24. Surgical procedure
• Adhesiolysis
• Excision / Resection
• Bypass / Proximal decompression

25. Viability of bowel
Viable
Dark color – Light Dark persists
Mesentery bleeds
on pricking
No bleeding
Peritoneum – Shiny Dull & Lustreless
Int Musc – Firm,
Peristalsis seen
Flabby, thin, friable
Non viable
Mesenteric pulsation + Absent

26. Doubtful – Resected ends as stomas
No resection / Multiple ischaemic areas
(Mesenteric Vasc Occlusion)
2nd
look laparotomy after 24-48hrs

27. Operative decompression
• Compromise of Exposure / Viability /
Closure
• Septic complications of spillage
• Savage’s decompressor / NG tube
• Replace fluid

28. Large bowel obstruction
Caecum to Prox trans colon
– Rt. Hemicolectomy, if resectable
– Ileotransverse bypass if not
resectable
Splenic flexure
– Extended Rt.Hemicolectomy

29. Left colon / Rectosigmoid
• Decompression proximal colostomy
• Resection with
– Anastamosis with covering colostomy
– Paul Mikulicz procedure
– Hartmann’s procedure

30. Adhesions
• Most common cause
• Difficult to differentiate from paralytic
ileus

31. Causes
• Ischaemic areas
• Foreign material
• Infection & Inflammatory conditions
• Radiation enteritis
• Drugs – Practolol

32. Peritoneal irritation
Local fibrin production
Adhesion between apposed surfaces
Early fibrinous adhesions Late fibrous adhesions

33. Prevention
• Good Surgical technique
• Peritoneal wash
• Minimizing contact with gauze
• Covering anastamosis & raw peritoneal
surfaces

34. Classification
• Early / Flimsy
• Late/ Dense

35. Bands
• Congenital
• Acquired
– Peritonitis
– Greater omentum adherent to parietes

36. Treatment
• Conservative
– NPO
– RT aspiration
– IV fluids
– Vital signs & Abd. girth monitoring
– Signs of strangulation
– Maximum 72hrs

37. Surgery
• Adhesiolysis
– Only those causing obstruction
– Covering with omental grafts
– Constriction sites

38. Recurrent adhesive obstruction
• Repeat Adhesiolysis
• Noble’s plication procedure
• Charles phillip Transmesenteric plication
• Intestinal intubation