adynamic intestinal obstruction dr syed ubaid associate professor of surgery

1. ADYNAMIC
OBSTRUCTION

8. Intestinal obstruction
Dynamic, in which peristalsis is working against
a mechanical obstruction.
Adynamic, in which there is no mechanical
obstruction;
peristalsis is absent or inadequate
(e.g. paralytic ileus or pseudo-obstruction)

9. Paralytic ileus
• This may be defined as a state in which there is
failure of transmission of peristaltic waves
secondary to neuromuscular failure
• (i.e. in the myenteric (Auerbach’s) and
submucous (Meissner’s plexuses).
• The resultant stasis leads to accumulation of fluid
and gas within the bowel, with associated
distension, vomiting,absence of bowel sounds
and absolute constipation.

10. Paralytic ileus
• Following most abdominal operations or
injuries, the motility of the gastrointestinal
tract is transiently impaired.
• Among the proposed mechanisms responsible
for this dysmotility are surgical stress-induced
sympathetic reflexes, inflammatory response-
mediator release, and anesthetic/analgesic
effects; each of which can inhibit intestinal
motility.

11. Paralytic ileus Varieties
• Conventional recovery times have been reported at 4:
small intestine: 0-24 hours
stomach: 24-48 hours
colon: 48-72 hours
• Postoperative. A degree of ileus usually occurs after any
abdominal procedure and is self-limiting, with a variable duration of
24–72 hours. Postoperative ileus may be prolonged in the presence
of hypoproteinaemia or metabolic abnormality.
•

12. Paralytic ileus Varieties
• Infection. Intra-abdominal sepsis may give
rise to localised or generalised ileus.
 Appendicitis
 Diverticulitis
 Nephrolithiasis
 Cholecystitis
 Pancreatitis
 Perforated Duodenal Ulcer

13. Paralytic ileus Varieties
Infectious, Inflammatory or irritation (bile, blood)
1. Intrathoracic
 Pneumonia
 Lower lobe rib fractures
 Myocardial Infarction
2. Intrapelvic
e.g. Pelvic Inflammatory Disease
Intestinal Ischemia
Mesenteric embolism, ischemia or thrombosis

14. Paralytic ileus Varieties
• Metabolic. Uraemia and hypokalaemia are the most
common contributory factors.
Serum electrolyte abnormality
1. Hypokalemia
2. Hyponatremia
3. Hypomagnesemia
4. Hypermagensemia
• Reflex ileus. This may occur following fractures of the spine
or ribs, retroperitoneal haemorrhage or even the
application of a plaster jacket.

15. Paralytic ileus Clinical features
• Paralytic ileus takes on a clinical significance if, 72 hours after
laparotomy:
• there has been no return of bowel sounds on auscultation;
• there has been no passage of flatus.
Abdominal distension becomes more marked and tympanitic.
Colicky pain is not a feature. Distension increases pain from the
abdominal wound. In the absence of gastric aspiration, effortless
vomiting may occur.
Radiologically, the abdomen shows gasfilled loops of intestine with
multiple fluid levels

16. Paralytic ileus Management
• Paralytic ileus is managed with the use of
nasogastric suction and restriction of oral
intake until bowel sounds and the passage of
flatus return. Electrolyte balance must be
maintained.

17. Paralytic ileus Management
• Specific treatment is directed towards the cause, but the following
general principles apply:
• If a primary cause is identified, this must be treated.
• Gastrointestinal distension must be relieved by
decompression.
• Close attention to fluid and electrolyte balance is
essential.
• There is no place for the routine use of peristaltic stimulants.
Rarely, in resistant cases, medical therapy with a gastroprokinetic
agent, such as domperidone or erythromycin may be used,
provided that an intraperitoneal cause has been excluded.

18. Paralytic ileus Management
If paralytic ileus is prolonged, CT scanning is the
most effective investigation; it will demonstrate
any intraabdominal sepsis or mechanical
obstruction and therefore guide any requirement
for laparotomy.
 The need for a laparotomy becomes
increasingly likely the longer the bowel inactivity
persists, particularly if it lasts for more than 7
days or if bowel activity recommences following
surgery and then stops again.

19. Pseudo-obstruction
This condition describes an obstruction,
usually of the colon, that occurs in the
absence of a mechanical cause or acute
intraabdominal disease.
 It is associated with a variety of syndromes in
which there is an underlying neuropathy
and/or myopathy and a range of other factors

20. Factors associated with pseudo-
obstruction
Metabolic :
• Diabetes
• Hypokalaemia
• Uraemia
• Myxodoema
• Intermittent porphyria

21. Factors associated with pseudo-
obstruction
Shock
• Burns
• Myocardial infarction
• Stroke
• Idiopathic
• Septicaemia
• Postoperative
(for example, fractured neck of femur)

22. Factors associated with pseudo-
obstruction
Retroperitoneal irritation
• Blood
• Urine
• Enzymes (pancreatitis)
• Tumour

23. Factors associated with pseudo-
obstruction
Drugs
• Tricyclic antidepressants
• Phenothiazines
• Laxatives

24. Factors associated with pseudo-
obstruction
Drugs
• Tricyclic antidepressants
• Phenothiazines
• Laxatives
Secondary gastrointestinal involvement
• Scleroderma
• Chagas’ disease
Severe trauma
(especially to the lumbar spine and pelvis)

25. Colonic pseudo-obstruction
This may occur in an acute or a chronic form.
The former, also known as Ogilvie’s syndrome,
presents as acute large bowel obstruction.
Abdominal radiographs show evidence of
colonic obstruction, with marked caecal
distension being a common feature.
Indeed, caecal perforation is a well-recognised
complication.

26. Colonic pseudo-obstruction
• The absence of a mechanical cause requires urgent
confirmation by colonoscopy or a single-contrast water-
soluble barium enema or CT.
• Once confirmed, pseudo-obstruction requires treatment of
any identifiable cause.
• If this is ineffective, intravenous neostigmine should be
given (1 mg intravenously), with a further 1 mg given
intravenously within a few minutes
• if the first dose is ineffective. During this procedure, it is
best to sit the patient on a commode. ECG monitoring is
required and atropine should be available.
• If neostigmine is not effective, colonoscopic
decompression should be performed.

27. Colonic pseudo-obstruction
• Caecal perforation can occur in pseudo-
obstruction.
• Abdominal examination should pay attention to
tenderness and peritonism over the caecum and
as with mechanical obstruction, caecal
perforation is more likely if the caecal diameter is
14 cm or greater.
• Surgery is associated with high morbidity and
mortality and should be reserved for those with
impending perforation when other treatments
have failed or perforation has occurred.

28. Small intestinal pseudo-obstruction
• This condition may be primary (i.e. idiopathic or
associated with familial visceral myopathy) or
secondary.
• The clinical picture consists of recurrent subacute
obstruction.
• The diagnosis is made by the exclusion of a mechanical
cause.
• Treatment consists of initial correction of any
underlying disorder.
• Metoclopramide and erythromycin may be of use.

29. Q.Post-operative ileus is most pronounced in:
a. Colon b. Stomach
• c. Ileum d. Duodenum

30. Q.First to recover from post-operative ileus:
(DNB 2008)
a. Small intestine b. Stomach
c. Colon d. None

31. Q. Paralytic ileus is characterized by all except:
(SGPGI 2005)
a. No bowel sound on ausculatation
b. No passage of flatus
c. Gas filled loops of intestine with multiple fluid
levels
d. Loops of intestine are not seen due to loss of
peristalsis

32. Q. Most common electrolyte imbalance that
causes Paralytic ileus is: (DNB 2014)
a. Hyponatremia
b. Hypernatremia
c. Hypokalemia
d. Hyperkalemia

33. Q. Commonest cause of acute intestinal
obstruction is: (NEET Pattern, PGI 88)
a. Adhesions
b. Volvulus
c. Inguinal hernias
d. Internal hernias

34. Q.A women of 35-years, comes to emergency
department with symptoms of pain in
abdomen and bilious vomiting but no
distension of bowel. Abdominal X-ray
showed no air fluid level. Diagnosis is: (AIIMS
June 99)
a. CA rectum b. Duodenal obstruction
c. Adynamic ileus d. Pseudo-obstruction

35. Q.Distended abdomen in intestinal obstruction
is mainly due to: (All India 95, PGI Dec 98)
a. Diffusion of gas from blood
b. Fermentation of residual food
c. Bacterial action
d. Swallowed air

36. Q.A neonate presents with colicky pain and
vomiting with sausage-shaped lump in the
abdomen, diagnosis is: (UPPG 2009)
a. Enterocolitis b. Perforation of the abdomen
c. Intussusception d. Acute appendicitis

37. Q.The most common type of intussusception:
(DNB 2009, 2005, 2001, 2000, All India 99, PGI
Dec 95, MHPGMCET 2009)
a. Ileocolic b. Colocolic
c. Ileoileal Sd. Retrograde

38. Q. A 6 months old child woke up in night, crying
with abdominal pain, which got relieved on
passing red stool. What is the most likely
diagnosis? (AIIMS November 2014)
a. Meckel’s diverticulum
b. Intussusception
c. Malrotation
d. Intestinal obstruction

39. Q.Most common cause of colonic obstruction is:
(AMI 86, PGI 86, UPSC 88)
a. Volvulus b. Hernia
c. Adhesions d. Neoplasm

40. Q. Acute pseudo-obstruction of the colon known
as: (DNB 2012, UPPG 2007)
a. Sjogren’s syndrome
b. Gardener’s syndrome
c. Ogilvie’s syndrome
d. Peutz-Jegher’s syndrome

41. Q.Most common site of volvulus: (DNB 2012, GB
PANT 2011)
a. Sigmoid colon
b. Caecum
c. Transverse colon
d. Stomach

42. Q.Bowel can get strangulated in all of the
following space except: (AIIMS Nov 2000)
a. Recto uterine pouch
b. Ileocolic recess
c. Paraduodenal recess
d. Omental recess

43. Q.A young healthy male patient presented with
abdominal pain and history of altered bowel
habits from the last 6 months. On CT
examination, there was dilated distal part of
ileum, thickened ileocecal junction with
thickened cecum with presence of sacculations
on the antimesenteric border. The vascularity of
adjoining mesentery is also increased and there
is surrounding mesentery fat. Which of the
following is not a differential diagnosis? (AIIMS
Nov 2013)
• a. Ulcerative colitis b. Crohn’s disease
• c. Tuberculosis d. Ischemic bowel disease

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