Intestinal obstruction occurs when the contents of the intestine are impaired or blocked from passing through. It can affect the small or large intestine and be partial or complete. Causes include adhesions, hernias, tumors, and impacted stool. Symptoms are abdominal pain, vomiting, constipation, and distension. Diagnosis involves blood tests, imaging like x-rays and CT scans to locate the obstruction. Treatment depends on the severity but may include fluids, NG tubes, antibiotics, and sometimes surgery to remove the blockage.

1. INTESTINAL OBSTRUCTION
Prepared by :
Maziyana Musa
Wong Soo Ching
Supervised by :
Dr.Koh Cher Hui

2. OUTLINE
 Definition
 Causes & Classification
 Sign and Symptoms
 Investigation
 Management
 Take home messagers

3. Definition : impairment or arrest of the passage of
contents through the intestine.
Involve either small or large bowel.
It can be partial or complete obstruction.

4. CLASSIFICATION
 Nature
 Site of obstruction
 Blood supply
 Rate
 Small bowel or large bowel

5. Nature
 Dynamic
mechanical obstruction
 Adynamic
no structural obstruction
ie: paralytic ileus – absence of normal peristalsis
contraction.
Causes :1. post-abdominal surgery
2. electrolyte imbalance
ie hypokalaemia
3. intra or retroperitoneal inflammation
ie appendicitis, diverticulitis
4. reduce blood supply to abdomen
ie mesentric artery ischaemia

6. Location
 Intraluminal
- colorectal carcinoma
- constipation (faecal impaction)
- foreign body
 Intramural
- strictures
ie Crohns, Diverticular Disease, due to
radiation
- acute pseudo-obstruction
ie Olgivie Syndrome

7.  Extramural
- adhesion
- hernia
- volvulus
-bowel twisted on its mesentry which
cause rapid, severe strangulated
obstruction
-common site : sigmoid
- intussusception
bowel telescoped into its distal segment
Peritonitis
Previous abdominal
surgery
Congenital adhesion
band
obstructed
strangulated

8. Blood supply
 Simple obstruction
- without vascular compromise
- ingested fluids, foods, gas and digestive
secretion accumulate above obstruction.
- proximal bowel distended
- bowel wall become edematous as reduce
secretion and absorption function of mucosa
 Strangulated obstruction
- compromise blood flow
- usually associated with hernia, volvulus and
intussusception
- can progress to infarction and gangrenous bowel
in 6hours

9.  Closed loop obstruction
- 2 points along the course of bowel are obstructed
at a single location, thus forming closed loop
obstruction
- ie : recto sigmoid tumour which caused intestinal
obstruction.
- Proximal bowel distends and decompression
into small bowel depends on competency of ileo
caecal valve.
- Competent ileo caecal valve prevent
decompression and lead to distension of large
bowel particularly caecum.
- Increase intraluminal pressure of caecum impedes
blood flow which then can results in caecum
perforation.

10. Rate
 Acute
sudden onset, rapidly progressive abdominal
pain, vomiting, constipation and abdominal
distension.
 Chronic
sign and symptoms of intestinal obstruction
slowly develop over time.

11.  Small bowel obstruction
- sudden onset
- abdominal pain
- vomiting
- constipation
- AXR : central, valvulae conniventes
 Large bowel obstruction
- mild symptoms that develop gradually
- constipation
- abdominal distension
- crampy abdominal pain
- vomiting
- AXR : peripheral, haustra

12. 4 Cardinal features of IO
 Abdominal pain
 Vomiting
 Constipation
 Abdominal distension

13. How To Approach Intestinal
Obstruction?
Visible scar -band
-adhesion
Palpation
• hernial orifices
• large, slightly tender,
mobile
• mass changes its position
with colicky pain
• tender indurated mass
• hard impacted masses
-incarcerated
-strangulated hernia
+torsion
+intussusception
-mass of Ascaris worms
+intraperitoneal abscess
-fecaloma
GENERAL EXAMINATION:

14. Percussion - tympanic sound
Auscultation -runs of borborygmi
-tinkling high pitched
musical sounds
Rectal examination
• fresh blood and mucus
• hard mass of faeces
• hard mass in the
rectovesical pouch
-strangulating lesion
-carcinoma of large gut
-intussusception
+constipation
-extraintestinal tumour

15. How To Initiate Investigation?
Lab investigation:
• FBC
• BUSE
• Clotting profile
• Arterial blood gasses
• Optional (ESR, CRP,
Hepatitis profile, tumour
markers)
-high Hb and hematocrit
-leukocytosis
-anaemia
+electrolytes depletion
Radiological:
• X-RAYS -Gas pattern
-Fluid level
-Masses shadow
-Fecal pattern

16. • USE -free fluid
-masses
-mucosal folds
-pattern of paristalsis
• CT, MRI, Contrast studies -level of obstruction
-partial or complete
-cause of the obstruction
• Optional (colonoscopy,
endoscopy, laparoscopy)

17. Large Bowel: Small Bowel:
•Peripheral
•Diameter ~8 cm
•Presence of haustration
•Central
•Diameter ~5 cm
•Vulvulae coniventae
•Ileum: may appear tubeless

18. Multiple air fluid levels located centrally-
small bowel obstruction
Small bowel volvulus-coffee bean
appearance.

19. Air fluid level centrally-
small bowel obstruction
Small intestinal invagination

20. How to manage intestinal
obstruction?
 Conservative
 Operative
 Conservative treatment
 Nasogastric tube
 to help decompress the dilated bowel
 aspirate it with a 20 or 50 ml syringe half- hourly
 CBD
 To monitor urine output

21.  IV Fluids
 Normal saline or lactated ringer’s solution for intravascular
volume depletion
 Electrolytes correction
 Guided by test results
 Analgesic
 Opioid pain relievers may be used for patients with
severe pain
 Antibiotics
 If bowel ischemia or infarction is suspected

22.  Operative
 repair of hernias
 removal of foreign bodies
 lysis of the offending adhesions
 Resection
 colostomy.

23. Indication For Surgery:
 Immediate intervention:
 Evidence of strangulation (hernia….etc)
 Signs of peritonitis resulting from perforation or
ischemia
 In the next 24-48 hours
 Clear indication of no resolution of obstruction (
Clinical, radiological).
 Diagnosis is unclear in a virgin abdomen
 Intermediate stage
 The cause has been diagnosed and the patient is
stabalised

24. Take Home Messages:
 The 4 main Cardical signs of intestinal obstruction are
Abdominal pain, Abdominal distention, Vomiting and
Constipation.
 Always examine for hernia orifice.
 Follow-up lab results and correction of electrolyte
imbalance.
 Always request for Supine, Erect and CXR.
 Always provide adequate resusitation to the patient.
 Always be attentive of signs of peritonitis resulting
from perforation or ischemia of bowel.

25. References :
- Manipal manual of surgery by K Rajgopal Shenoy
- Life in the fast lane journal
- Surgery International Journal
- www.meb.uni-bonn.de
- www.merckmanuals.com
- www.radiologyassistant
- emedicine.medscape.com