This document discusses intestinal obstruction, including its causes, symptoms, diagnosis, and treatment. It covers both dynamic and adynamic obstructions. Dynamic obstructions are caused by mechanical blockages and present with pain, distension, vomiting, and constipation. Adynamic obstructions are paralytic and can be caused by ileus, vascular issues, or pseudo-obstruction. Diagnosis involves physical exam, abdominal x-rays, and CT scans. Treatment focuses on relieving the obstruction either conservatively or surgically, as well as managing fluid and electrolyte imbalances. Specific causes like hernias, strictures, volvulus, and intussusception are also described.

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Intestinal Obstruction

2. 2
Abdomen- Bowel sound
 Present- Mechanical obstruction
Not present-
 Adynamic obstruction
 (no gas under diaphragm)
 Perforation
 (gas under diaphragm)

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Objectives
 Pathophysiology – dynamic, adynamic
 Cardinal features – history,
examination
 Causes – small, large gut obstruction
 Indications – contraindications for
conservative Mx

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Obstruction
 Dynamic – peristalsis, mechanical
obstruction
 Adynamic- paralytic ileus, non
propulsive Mesenteric vascular
obstruction or, pseudo obstruction

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Dynamic Obstruction
 Pain, distention, vomiting, absolute
constipation
 Two- small gut – high , low
 Large gut
 Acute , chronic, acute on chronic or,
sub-acute
 Simple – intact vascularity
 Strangulated – compromised
vascularity

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Intestinal obstruction:
Causes
Adhesion
Inflammatory
Carcinoma
Obstructed
hernia
Fecal
obstruction
Pseudoobstruc
tion
Misc

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Causes –Dynamic obstruction
 Intra-luminal –impaction, FB, Bezoars,
gallstones
 Intramural- strictures, malignancy
 Extra-luminal- bands/adhesions, hernia,
volvulus, intussusception

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Adynamic obstruction-causes
 Paralytic ileus
 Mesenteric vascular occlusion
 Pseudo obstruction

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Pathophysiology
 Proximal gut dilates- altered motility
 Below the obstruction – normal motility,
immobile
 Proximal – increased peristalsis, dilates,
reduced peristalsis, flaccid
 Gas- bacteria. Aerobic/anaerobic, 90% N2
 Fluid- dig. Juices,

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Pathophysiology
 Dehydration and electrolyte imbalance
 Reduced intake
 Defective absorption
 Vomiting
 Sequestration in gut

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Strangulation
 Blood supply compromised
 Venous return first affected, arterial
 Hemorrhagic infarction
 Translocation and systemic exposure
to microbes/ toxins
 Morbidity/ mortality- age, extent,
Peripheral vascular failure

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Closed loop obstruction
 Strangulation
 Distention
 Necrosis
 perforation

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Acute Intestinal Obstruction-CP
 Location, age of obstruction,
pathology, ischemia
 Pain
 Vomiting
 Distension
 Constipation
 Dehydration, Hypokalemia, fever,
abdomen tenderness

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 Pain – severe, colicky, umbilical, lower
abdomen
 Increases with peristalsis, later reduces
 Severe pain - strangulation

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Vomiting
 High obstruction- violent
 Low obstruction- slow onset
nausea/vomit
 Gradually digestive food changes to
feculent material

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Distension
 Greater if distal obstruction
 Visible peristalsis
 Peristalsis delayed in colonic obstruction
 Absent in Mesenteric vascular obstruction

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Constipation
 Absolute
 Relative
 Absent in – Richter’s hernia, gallstone,
MVO, Pelvic abscess, partial
obstruction

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Dehydration
 Vomiting, fluid sequestration
 Dry skin, poor venous filling, sunken
eyes, oliguria
 Raised blood urea, Hb, - secondary
polycythemia

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Hypokalemia
 K, amylase, LDH – strangulation, raised
TLC or, leucopenia
 Fever – indicates – ischemia,
perforation, inflammation
 Hypothermia – septic shock

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Abdomen tenderness
 Localized – ischemia
 Peritonitis – infarction or, perforation

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Strangulation
 Diagnosis is clinical
 Features of obstruction
 Persistent pain, Shock, local tenderness
 Non-responsive to conservative Mx
 Hernia strangulation – tender, irreducible,
absent cough impulse, recent increase in
size

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Radiology
 Supine/ erect plain abdomen films
 Small gut- central, transverse, no gas-
colon
 Jejunum- valvulae connivantes
 Ileum- featureless
 Cecum- round gas in RIF
 Large gut- haustral folds

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Supine

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Sigmoid volvulus
 Dilated, no haustral pattern
 Small gut- air and fluid levels
 More the fluid levels, more distal the
lesion

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Inv:
 Plain x ray- impacted foreign body
 Fluid levels – non obstructing
conditions – inflammatory bowel
disease, acute pancreatitis, abdominal
sepsis

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Treatment
 3 measures
 Intestinal drainage
 Fluid and electrolyte replacement
 Relief of obstruction

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Surgical Mx
 Mx of segment at the site of
obstruction
 The distended proximal bowel
 Underlying cause of obstruction

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Supportive
 NG tube drainage
 Na , water replacement
 Antibiotics

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Large gut
 Ca or diverticular disease
 Contrast study – pseudo-obstruction
 Caecal perforation- caecostomy,
ileostomy

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Adhesions/bands
 Commonest
 Fibrin – adhesions-fibrinous, fibrous
 Appendectomy , gynaecological op.
 Bands- congenital, bacterial peritonitis,
greater omentum causing band
 Mx- conservative – 72 hrs –lap
adhesiolysis

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Special obstructions
 Int. hernia – foramen of Winslow, hole in
the mesentery, hole in transverse
colon, defects in broad ligament, cong
diaphragmatic hernia, paraduodenal
fossae, intraperitoneal fossae
 Mx- release the ring, reduction of
hernia

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Enteric strictures
 TB, Crohn’s, Ca, lymphomas,
stricturoplasty
 Bolus obstruction – food, gall stone,
trichobezoars, phytobezoars,
stercoliths, worms

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Ac Intussusception
 Proximal gut enters distal gut
 Adults – lead point, polyp, submucosal
lipoma, tumor,
 Colo-colic – adults
 Pathology- inner tube, outer tube,
returning of middle tube
 Strangulating obstruction- ileoileal,
ileocaecal, ileocolic

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Clinical picture
 Severe attacks of pain – lasts few
minutes
 Later - red currant jelly stool
 Exam –between episodes-50-60%
sausage shaped lump – empty RIF –
Sign de Dance
 P/R – blood stained finger
 Later vomit, distension

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Radiology
 Plain film – absent caecal gas
 Ba enema- claw sign
 CT scan
 Mx- Hydrostatic reduction with enema
 Operative reduction
 Recurrent – 5%- anchorage of ileum to
ascending colon

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Differential diagnosis
 Acute enterocolitis
 Henoch Schoenlein perpura
 Rectal prolapse

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Volvulus
 Axial rotation of bowel at its
mesentery
 Congenital or secondary
 Small intestine, caecum, sigmoid-
common
 Small gut- spontaneous, vegetable
consumption – untwist
 Caecal – clockwise- females- lap .
Untwist, resection if gangrene

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Sigmoid
 Anticlockwise
 Bands, overloaded colon, large
mesocolon, narrow pelvic mesocolic
attachment

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Treatment
 Flexible sigmoidoscopy/ rigid
 Laparotomy- untwisting
 Viable – fixing to retroperitoneum
 Resection – Paul Mickulikz- gangrene
 Sigmoid colectomy/ Hartmann’s
procedure later re-anastomosis

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Compound volvulus
 Rare, ile-osigmoid knotting
 Gangrene
 Laparotomy - Decompression,
resection and anastomosis

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