The document provides a comprehensive overview of intestinal obstruction, detailing surgical anatomy, classifications, causes, and management strategies. It outlines specific types of obstructions, such as small bowel and large bowel issues, as well as conditions like duodenal atresia and intussusception. Diagnostic approaches and treatment options, including surgery and nonoperative measures, are discussed alongside potential complications.

1.  ‫الرحيم‬ ‫الرحمن‬ ‫هللا‬ ‫بسم‬
 Department of surgery
 Unit:-
 Mr Dhirar
 Mr Alhassan
 Mr Haidar
 Tettorial tittle:
 Intestinal obstruction
 Presented by:
 Ola abdalsalam

2. CONTENT
 Surgical anatomy
 Classifications
 C/F
 Management
 Specific types of intestinal obstruction

3. SMALL BOWEL
 6ms length
 Duodenum 25 cm
 Jejunum :proximal 40%
 Ileum:distal 60%
 Blood supply: superior mesentric artery
 Venous drainage: superior mesenteric vein
 Nerve:sympT9-T11 parasymp:vagus

5. LARGE BOWEL
 1.5 meter
 Blood Supply
♦ Iliocolic, right colic, and middle colic
arteries branches of superior mesenteric
artery supply the colon from caecum to
splenic flexure.
♦ Left colic, sigmoid, superior rectal arteries
branches of inferior mesenteric artery supply
the descending and sigmoid colon

6. CLACCIFICATIONS
Class 1:
 Dynamic adynamic
 Class 2:
 Small bowel large bowel
 Class 3:
 Acute Chronic acute on chronic
Class 4:
 Aquired congenital

7. DYNAMIC
extramural mural intramural
adhesions T.B Gall stone
hernia Crohn disease Round worm
intusseception malignancy Inspissated feaces
volvulus Meconium ileus

8. ADYNAMIC
 Postoperative period
 Electrolyte imbalance
 Spinal injuries
 Uraemia paralytic ileus
 Diabetes mellitus
 Mesenteric ischaemia
 Pseudo-obstruction

9. Congenital causes:-
 Congenital megacolon
 Duodenal atresia
 Intestinal atresia
 Band and adhesions
 Malrotation
 Volvulus neonatorum

10. Dynamic intestinal obstruction

11. PATHOPHYIOLOGY
 Changes proximal to the bowel obstruction:
Intestinal obstruction
↓
Increased peristalsis
↓
Becomes vigorous
↓
Obstruction not relieved
↓
Peristalsis ceases.
↓
Flaccid, paralysed, dilated bowel

12.  Fluid collects just proximal to the obstruction
which is derived from saliva, stomach, pancreas
and intestine
 Defective absorption, decreased fluid intake,
loss of fluid by vomiting, sequestration of fluid
into the bowel lumen dehydration and
electrolyte disturbance

13.  Increased bacterial colony in the bowel due
to altered luminal content and environment
→ multiplication →toxins → further mucosa
damage → translocation of bacteria across
mucosa into submucosa and also absorption
of bacterial into the circulation→bacteraemia

14.  Changes at the site of the obstruction:
Initially venous return is impaired.
↓
Congestion, oedema of bowel wall occurs which turns
purple.
↓
Later this jeopardizes the arterial supply.
↓
Loss of shineness, blackish discolouration, loss of peristalsis.
↓
Gangrene.
↓
Perforation occurs.
↓
Bacteria and toxins migrate into the peritoneum.
↓
Peritonitis

15.  Bowel distal to the obstruction is inactive
and collapsed

16. CLOSED LOOP OBSTRUCTION

17. CARDINAL FEATURES
 Abdominal pain
 Vomiting
 Distension
 Absolute conistipation

18. Proximal s.bowel Distal s.bowel Large bowel
Severe vomiting,
dehydration, no or
less distension,
colicky pain
Central distension,
vomiting,
dehydration
central abdominal pain
Constipation,
distension—
early;
Late vomiting less
pain

19. Vitally:
 Tachycardia
 Tahypnea
 Febrile
 hypotensive

20. Abdominal examination:
 Tenderness
 Reboud tenderness,guardning,rigidity
 Bowel sound: exaggerated /abscent
 PR: empty dilated rectum

21. INVESTIGATIONS
 General:
 CBC
 RFT + electrolytes
 ABG
 Coagulation profile

22. INVESTIGATIONS FOR DIAGNOSIS:
 Erect +supine abdominal x ray:
 Multiple air fluid level
 Dilated loop:-
 Small bowel > 3 cm diameter
 proximal large bowel> 9 cm
 transverse colon > 5.5 cm
 sigmoid colon> 5 cm
 Specific features
 pneumobilia
 CT scan

24. HAUSTRATION

25. VALVULAE CONNIVENT

26. TREATMENT
 NPO
 Fluid and electrolyte management
 NGT
 Catheter
 laprotomy

27.  Postsurgery Complications:-
♦ Pelvic abscess.
♦ Subphrenic abscess.
♦ Biliary or faecal fistulas.
♦ Burst abdomen.
♦ Bands and adhesions.
♦ Incisional hernias

28. SPECIAL TYPES

29. DUODENAL ATRESIA
- It is the commonest site of intestinal atresia
- It is usually a complete stenosis of the second
part
- Defective fusion of foregut and midgut with
failure of recanalization
-Duodenal atresia may be preampullary
(nonbilious vomiting) or postampullary (bilious
vomiting)

31.  Associated with:
 Down syndrome 30%
 CHD 30%
 ARM 10%
 Polyhydramnios and prematurity 50%

32. C/F
♦ Jaundice.
♦ Bilious/nonbilious vomiting immediately after
birth
♦ Dehydration. Electrolyte changes are
common.
♦ Growth retardation of newborn due to
deprived nutrition

33. INVESTIGATIONS
 Plain X-ray shows classic double-bubble sign
with absence of air in the distal part
 U/S will show distended stomach and
proximal duodenum( rail road track)

35. TREATMENT
 duodenodoudenostomy

36. INTESTINAL ATRESIA
 Jejunoileal atresia
 Intrauterine mesenteric vascular occlusion
 Commonly:proximal jejunum and distal ileum

38.  X-ray : triple bubble
 Barium enema: microcolon
 Treatment:
 Resection and anastomosis
 Jejunoplasty(extensive length involved)

39. MALROTATION
 Stages of normal rotation:
 Stage 1: coelomic cavity cannot
accommodate midgut during this period
protrude into umblical cord as physiological
hernia
 Stage 2: midgut migrate into coelomic
cavity;small bowel in left side;it rotate 270
anticlockwise into rt iliac
fossa;duodenojejunal segment rotate 270
anticlock to reach left of SMA and behind the
colon

40.  Stage 3: fusion of different parts of mesentry
and posterior peritoneum

41.  Errors:
 Stage 1: gastroschisis
 Stage 2: non-rotation
 Incomplete rotation
 Reverse rotation
 Hyper-rotation
 Stage 3: mobile caecum and ascending
colon

42.  Dark blood per rectum
 Erythrema of anterior abdominal wall
 Teatment: ladd operation

43. MECONIUM ILEUS
 Commonly associated with cystic disease of
pancreas but not necessarily always
 Respiratory dysfunction
 Exocrine pancreatic insufficiency
 High salt in the sweat > 90 mmol/L

44.  Complications of meconium ileus:
 Intestinal bolus obstruction
 Perforation and peritonitis
 Gangrene, volvulus formation

45. INVESTIGATIONS
♦ Plain X-ray shows calcified meconium pellets with
multiple air fluid levels which appear as ‘soap-
bubbles’
♦ Vomitus of the patient which does not contain trypsin,
when poured on the exposed X-ray film will not digest
the gelatin of the film
♦ Pilocarpine is injected into skin to stimulate the
sweating and collected sweat (100 µg sweat)is
analysed for sodium and chloride.
♦ Elevated albumin level in meconium

46. TREATMENT
Nonoperative measures:-
Dissolution through enema can be tried
using gastrografin
Operative measures:-
Bishop-Koop operation in critical pt
 If fit: resection and anastmosis

47. INTUSSUSCEPTION (ISS)
 It is invagination of one portion (segment) of
bowel into the adjacent segment.
Types
1. Antegrade: Most common.
2. Retrograde

48. ♦ It can be ileo-colic (most common type,
75%), colocolic, ileoiliocolic
♦ It is common in weaning period of a child
(common in male),between the period of 6-9
months

49. AETIOLOGY
 Change in diet during weaning
 Upper respiratory tract viral infection
 Intestinal polyps
 Submucous lipoma
 Leiomyoma of intestine
 Meckel’s diverticulum
 Carcinoma

50. ♦ Apex is the one which advances;
♦ Intussuscipiens is the one which receives
♦ Intussusceptum

52. FEATURES
 on/off
 screaming
 Red currant jelly stool
 Palpable mass (85%)
– Sausage shaped smooth, firm mass
– Mass does not move with respiration
– Mobile in all directions
– Resonant
– Mass contracts under the palpating fingers
– Mass appears and disappears
Empty right iliac fossa

53. INVESTIGATIONS
♦ Barium enema shows typical claw sign
♦ Ultrasound shows target sign or
pseudokidney sign

55. TREATMENT
 Nonoperative measures:
 Reduction by hydrostatic pressure but
contraindicated in:
 1- doubtful diagnosis
 2-Late cases
 3-abdominal distension/rigidity
 Operative:
 Manual reduction
 Resection and anastamosis

56. Recurrence rate:
♦ In hydrostatic reduction—10%.
♦ In open manual reduction—2%.
♦ In resection—very less < 1%

57. VOLVULUS
 Definition
It is the twist (rotation) in the axis of the loop
of the bowel either clockwise or anticlockwise

58. ♦ Sigmoid colon is the commonest site (anticlock wise)—
65%.
♦ Caecal volvulus
Caecum is the second common site(clockwise) 30%
 Caecum will be markedly distended and found in the
centre of the abdomen
 X-ray shows round gas shadow in right iliac region.
CT scan is very useful. Barium enema is also helpful.
Resection and anastomosis (surgery) is the only treatmen

59. SEGMOID VOLVULUS
 It is common in patients with chronic
constipation with laxative abuse
 Predisosing factors:
Adhesions
Peridiverticulitis
Overloaded redundant pelvic colon
Long pelvic mesocolon
Narrow attachment of sigmoid mesocolon

60.  More than 180 : luminal obsrtuction
 It requires one and half turn of rotation to
cause vascular obstruction

61. INVESTIGATIONS FOR DIAGNOSES
1. Plain X-ray:(diagnostic in 70-80%)
Ω sign (omega sign).
Coffee-bean sign.
2. Contrast enema:
Birds beak sign
3. CT scan

63. TREATMENT
 A flatus tube or Sigmoidoscope
 Laprotomy

64. PARALYTIC ILEUS
 It is a state in which intestines fail to transmit
peristalsis due to failure of neuromuscular
mechanism

65. C/F
♦ No passage of flatus.
♦ No bowel sounds.
♦ Marked abdominal distension.
♦ Vomiting of large volume of fluid.
♦ Tachycardia.
♦ Respiratory distress due to pressure over the
diaphragm.
♦ Dull abdominal pain (not colicky).
♦ Features of fluid/protein/electrolyte imbalance

66. TREATMENT
♦ Nasogastric aspiration.
♦ The primary cause is treated.
♦ IV fluids.
♦ Electrolyte management.
♦ Catheterisation and urine output
measurement

67.  Measurement of abdominal girth
Decompression of the large bowel can be
tried by inserting a flatus tube per anally

68. ADHESIONS AND BANDS
 Causes may be classified as:—
 Congenital adhesions
 Ischaemic
 Traumatic
 Irritants
 Inflammatory

69. TYPES
 Type I—Fibrinous adhesions occur during 5-
10th post-surgical period. It usually gets
resolved completely. It is avascular .
Type II—Fibrous adhesions. Due to lack/poor
blood supply It will persist and precipitate
intestinal obstruction

70.  1) Pain may get aggravated or relieved on
change ofposture.
 2) Pain in the region of old abdominal scar.
 3) Tenderness is elicited by pressure over the
scar

71.  Conservative(72 hrs)
 surgical

72. INTERNAL HERNIA
 Portion of bowel entrapped in one of the
retroperotineal fossae or congenital
mesenteric defect including:
 Foramen of winslow
 Defect in mesentry;transverse
mesocolon;broad ligament
 Diaphragmatic hernia
 Duodenal;ceacal or intersegmoid fossae

73.  Treatment:
 Division of constricting agent

74. PSEUDO-OBSTRUCTION
 Obstruction in absence of mechanical cause
or acute intra-abdominal disease
 Acute colonic: Ogilvie syndrome
 Marked ceacal distention/ceacal perforation

76.  Management:
 Exclude the mechanical causes
 Treat the underlying cause
 I.V neostigmine 1 mg
 decompression