Intestinal obstruction occurs when there is a partial or complete blockage of the small or large intestine, interrupting the normal flow of intestinal contents. Causes include adhesions, bands, hernias, volvulus, tumors, and gallstones. Symptoms depend on the cause and location of the obstruction. Imaging studies like plain x-rays can show signs of obstruction like dilated bowel loops and air-fluid levels. Management involves treating the underlying cause, decompressing the bowel, providing IV fluids and electrolytes, and surgery if conservative measures fail or if the bowel is nonviable. Surgical options include resection of nonviable bowel and anastomoses.

1. INTESTINAL OBSTRUCTION
PRESENTOR - DR NITU KUMARI
POST GRADUATE, SURGERY

3. INTESTINAL OBSTRUCTION
 Partial or complete blockage of the lumen of small or large intestine causing an
interruption in the normal flow of intestinal contents along the intestinal tract

5.  First 12 hours – decreased absorption; after 12 hours – increased secretion
 Distal to intestinal obstruction – normal peristalsis and absorption until it becomes
empty and collapse

6. STRANGULATION
Blood supply to bowel is compromised and the bowel becomes ischemic
The morbidity and mortality depend on duration of ischemia and its extent
CAUSES
 Direct pressure on bowel wall – Hernial orifices, adhesions/bands
 Interrupted mesenteric blood flow – volvulus, intussusception
 Increased intra-luminal pressure – closed loop obstruction

8. CLOSED LOOP OBSTRUCTION
 Bowel is obstructed at both proximal and distal points
 Distension is primarily confined to the closed loop

9. CLOSED LOOP OBSTRUCTION

10. FEATURES OF BOWELOBSTRUCTION

11. IMAGING
IN PLAIN XRAY
Dilated bowel loops
 small bowel > 3 cm
 Proximal large bowel > 9 cm
 Transverse colon > 5.5 cm
 Sigmoid colon > 5 cm
Multiple air fluid level
step ladder pattern
Jejunum : Valvulae conniventes - concertina or ladder effect
Ileum : featureless
Colon : Haustral folds

14. ADHESIONS
 Most common cause of intestinal obstruction
 Lifetime risk of requiring hospital admission following abdominal surgery is 4% and
the risk of requiring a laparotomy is around 2%
 Early fibrinous adhesions - disappear when the cause is removed
 Late fibrous adhesions - mature fibrous tissue; dense

15. BANDS
 Congenital : eg. obliterated vitellointestinal duct
 A string band following previous bacterial peritonitis
 A portion of greater omentum usually adherent to the parietes

16. VOLVULUS
 Twisting or axial rotation of a portion of bowel about its mesentery
 >180 degree torsion - obstruction to the lumen
 >360 degree torsion - vascular occlusion in the mesentery
 Bacterial fermentation adds to distension --> increased intraluminal pressure -->
impairs capillary perfusion
 Primary - d/t congenital malrotation of gut, abnormal mesenteric attachments,
congenital bands
 Secondary - d/t rotation of a segment of bowel around an acquired adhesion or
stoma

17. SIGMOID VOLVULUS
 Rotation nearly always occurs in anti-clockwise direction
 seen most often in elderly patients with chronic constipation
 a/w chronic psychotropic drug use
 Younger patients present earlier and the prognosis is inversely related to duration of
symptoms
 Fulminant presentation - sudden onset, severe pain, early vomitting, rapidly
deteriorating clinical course
 Indolent presentation - insidious onset. slow progressive course, less pain, less
vomiting

20. INTERNAL HERNIA
A portion of small intestine becomes entrapped in one of the retroperitoneal fossae or in a
congenital mesenteric defect
Potential sites of internal herniation
 The foramen of Winslow
 A defect in the mesentery
 A defect in the transverse mesocolon
 Defects in the broad ligament
 Congenital or acquired diaphragmatic hernia
 Duodenal retroperitoneal fossae
 Cecal/appendiceal retroperitonreal fossa
 Intersigmoid fossa

22. OBSTRUCTION FROM ENTERIC
STRICTURES
 Tuberculosis or Crohn’s disease
 Subacute or chronic presentation
 Management : Resection and anastomosis. In Crohn’s disease Strictureplasty may
be considered in presence of short multiple strictures without active sepsis

23. Bolus Obstruction
 Gall stones
 Trichobezoar, phytobezoar
 Stercoliths - a/w jejunal diverticulum or ileal stricture
 Worms – Ascaris lumbricoides

24. Gall stone ileus
 Elderly
 Fistula formation d/t direct erosion of GB wall by a large gallstone
 MC – Cholecystoduodenal fistula
 2nd MC – Cholecystocolic fistula
 Impaction 60cm proximal to IC valve
 Riggler’s triad : small bowel obstruction, pneumobilia, ectopic gall stones

25. Management
 Milk the stone proximally
 Intraluminal crushing
 Enterotomy by Longitudinal incision
 Elderly patient with comorbidity : Enterotomy
 Young patient with no comorbidity : Enterotomy, cholecystectomy, CBD
exploration
Bouveret syndrome – gall stones causing duodenal obstruction

26.  One portion of the gut invaginated into an immediately adjacent sement;
almost invariably the proximal into the distal.
 Peak incidence : between 5 and 10 months of age
CAUSES
 INFANTS : Peyer’s patch enlargement - weaning, common viral pathogens
 OLDER CHILDREN : Meckel’s diverticulum, Polyp, appendix, Henoch-
Schonlein purpura
 ADULTS : Polyp, Tumour, Submucosal lipoma
TYPES : Ileo-ileal, Ileo-colic, Colo-colic

28. CLINICAL FEATURES
 Intermittent pain
 Red currant jelly stool
 O/E :-
 right iliac fossa empty (Dance sign)
 Sausage or banana shaped lump with concavity towards umbilicus

29. CLAW SIGN

30. TARGET SIGN

31. TREATMENT OF INTUSSUSCEPTION
 Enema/ Air reduction
 Exploratory laparotomy and manual reduction
 Gangrene - Resection and anastamosis

32. Monitor
 Hematocrit
 Urine output
 RFT
 ABG analysis
 Total count
 Sr electrolytes
 serum D Lactate, CPK-BB, Intestinal fatty acid binding protein

33.  Nasogastric aspiration/ Tube decompression
 Replacement of IV fluids and electrolytes
 Abdominal girth charting
 Antibiotics
 Inotrope support if the patient develops shock
 Contrast challenge

34. Surgical Management
 Emergency laparotomy
 Assess
1.The site of obstruction
2.The Nature of Obstruction
3.The viability of the bowel
 Large bore orogastric tube insertion and retrograde milking
 Savage’s decompressor

36.  Nonviable - Resection and anastamosis
Sigmoid volvulus
 Flexible or Rigid sigmoidoscope - decompression
 Young patients - elective sigmoid colectomy
 Elderly - Resection or sigmoidopexy

37.  INTUSSUSCEPTION
 ENema/ Air reduction
 Exploratory laparotomy and manual reduction
 Gangrene - Resection and anastamosis

38. ADHESIONS
 conservative management upto 72 hrs
 At operation, divide only the causative adhesions; limit dissection
 Repair serosal tears; invaginate or resect areas of doubtful viability
 Laparoscopic adhesiolysis
CROHN’S DISEASE - conservative management, strictureplasty if chronic fibrotic
stricture is present

39. Intra-abdominal abscess
 Percutaneous drainage and abdominal wash
 Laparoscopic wash
Advanced malignant tumours
 Intestinal bypass - Ileostomy/ Colostomy
 Resection and anastamosis
Radiation enteropathy
 corticosteroid and tube decompression

42. PRINCIPLE OF ILEOSTOMY STOMA
FORMATION

43. PRINCIPLE OF COLOSTOMY STOMA
FORMATION

44. PARALYTIC ILEUS
 Failure of transmission of peristatic waves secondary to neuromuscular failure
TYPES
 Post-operative - 24 to 72 hrs
 Infection - intra-abdominal sepsis
 Metabolic - uremia or hypokalemia
 Reflex ileus

45.  Abdominal Distension - marked
 Colicky pain is not a feature
 Effortless vomiting

46. TREATMENT OF PARALYTIC ILEUS
 Treat the cause
 Decompression
 Nasogastric suction and delaying oral intake until bowel sounds and passage of
flatus return
 No evidence favouring the use of prokinetic agents