The patient presented with symptoms of intestinal obstruction including abdominal pain, nausea, vomiting and abdominal distension. Physical exam revealed abdominal tenderness and laboratory tests showed signs of dehydration and inflammation. Radiographic imaging confirmed multiple dilated loops of small bowel consistent with mechanical intestinal obstruction. The obstruction was determined to be complete based on symptoms. The patient's history of previous appendectomy suggested the underlying cause was likely adhesive obstruction. Treatment involved fluid resuscitation, gastrointestinal decompression and antibiotics, with potential for surgical lysis of adhesions if symptoms did not improve.

1. Intestinal Obstruction 肠梗阻

2. Defination A blockade of the flow of intestinal content.

3. Etiology and classification 1. According to its basic causes: mechanical obstruction dynamic obstruction obstruction of vascular supply origin

4. 2. According to whether the vascular supply to intestinal wall is compromised, Simple and strangulation obstruction .

5. 3. According to obstruction level or site . high and low obstruction 4. According to the extent of obstruction Incomplete and complete obstruction, 5. According to mode of onset and progression of obstruction. Acute and chronic obstruction

6. 6. Open-loop Obstruction: Closed-loop Obstruction:

7. Pathophysiology A.Local Effects Intestinal gas increases Intestinal fluid accumulates Intestinal flora is abnormal Intestinal motility (peristalsis) is abnormal

8. B. Systemic Effects Water and electrolyte losing Gut original endotoxemia Cardiopumonary dysfunction Shock and other organs insufficiency

9. Clinical manifestations Abdominal pain Nausea and vomiting Obstipation Abdominal distention.

10. Physical Examination the signs of dehydration: Vital Signs:

11. a.Inspection: visible peristalsis distending gut incisions of previous surgery

12. b.Palpation: Localized tenderness Signs of localized or generalized peritonitis: referred tenderness muscle spasm the mass in abdominal cavity

13. c.Percussion: Tympanic resonance Shifting dullness demonstrates ascites.

14. d.Auscultation: Bowel sounds increased Intestinal sound is absent

15. Laboratory Study Hemoconcentration Leukocyte counts Water and electrolyte imbalance Acid-base imbalance

16. Radiological Examination A plain abdominal film dilated loops of small intestine multiple air-fluid level Computed tomography

18. Endoscopy Early ileal carcinoma demonstrating submucosal invasion

19. disposable capsule: 30 x 11 mm Capsule endoscopy

20. Capsule endoscopy provide more than five hours of real-color images The data is later downloaded to a computer workstation and processed to produce a 20-minute video clip of the images transmitted by the capsule

21. Capsule endoscocpy : normal findings

22. Capsule endoscopy angiodysplasia, jejunum bleeding angiodysplasia, ileum

23. Diagnosis must make clear the following questions: 1. Whether intestinal obstruction exists: Through symptoms and signs, the diagnosis can be made without difficulty. Abdominal Radiology is much helpful in diagnosis.

24. 2. Whether the obstruction is mechanical or dynamic : mechanical obstruction, typical symptoms and signs. paralytic obstruction, cramping abdominal pain is absent, distention is prominent

25. 3. Whether the obstruction is simple or strangulation obstruction: Indications for strangulation: a. Developing continuous violently rather than intermittent pain b. Crisis rapidly and presence of toxemia (elevated temperature and leukocyte count), shock and rapid pulse c. Obvious peritoneal irritation d. A palpable tender abdominal mass with asymmetric distention

26. e. Bloody gastrointestinal contents f. Single distending gut loop or pseudo-neoplasm sign on plain abdominal film g. A large amount of bloody ascites h. No relieving evidence to intensive nonoperative treatment

27. 4. Whether the obstruction is high or low: Vomiting, in proximal intestinal obstruction. Distention in low obstruction Abdominal radiography is helpful. 5. Whether the obstruction is complete or incomplete: frequency of vomiting, extent of distention, and radiography.

28. 6.Which causes leads to obstruction : According to the age, history, symptoms and signs, radiography. Postoperative adhesions, Postinflammatory origin Henias Congenital malformations Intestinal intussusception Obstruction of parasite origin Carcinomas and dry feces.

29. Treatment Principles: Correcting of fluid and electrolytes imbalance and acid-base disturbance Relief of intestinal distention, and removing the cause of obstruction

30. A. Basic Treatment Fluid and electrolytes replacement Volume restoration: colloid liquid Acidosis correction: sodium bicarbonate or sodium lactate Potassium deficit

31. Gastrointestinal decompression Intubation with gastrointestinal tube (gastrointestinal tube suction) is the important step in the management of obstruction.

32. Antibiotics Antibiotic treatment plays an important role in the management of obstruction. Antibiotic would be given in any type of obstruction The principle is giving the broad spectrum (aerobic and anaerobic) with large dose and short course and taking the less cost

33. Symptomatic treatment giving tranquilizer Antispasmodic Sedative

35. B.Nonoperative Treatment Indications: Nonstrangulated adhesive obstruction Obturative obstruction resulting of ascariasis and constipation Incomplete obstruction Intussusception in child Inguinal hernia

36. Methods: a. Emollient: paraffin oil b. Enema: suds c. Traditional Chinese Herb intake d. Acupuncture e. Physical treatment

37. close observation is very important. worsed, transferred to surgical intervention.

38. C. Surgical Treatment Indication: strangulated obstruction closed-loop obstruction simple obstruction without respond to nonoperation more than 96 hours

39. The surgical procedures includes: 1)Lysis of adhesion, reduction of intussusception, torsion. 2)Enterectomy and anastomosis. 3)Bypass procedure for nonresectable lesions. 4)Enterostomy Treatment of obstructing carcinoma colon

40. 1). Lysis of adhesion

41. reduction of torsion

42. 2)Enterectomy and 3)Bypass procedure for anastomosis. nonresectable lesions.

43. 4)Enterostomy

44. Postoperative care: Gastrointestinal decompression Electrolyte management Nutrition support Antibiotics

46. The Common Types Of Intestinal Obstruction

47. Peritoneal Adhesions and Bands----Adhesive Obstruction

48. Etiology Previous laparotomy Abdominal inflammatory Trauma Congenital diseases

49. Pathology strangulated easily by band formation

50. Classification diffuse adhesion adhesion angulation band compression internal hernia

51. 1. band compression 2. adhesion angulation

52. Diagnosis intestinal obstruction previous laparotomy abdominal infection trauma

53. Prophylaxis avoiding any unnecessary trauma, strangulation of tissue, contamination, and foreign body such as excessive suture. modifying the propensity of patient

54. Treatment nonoperative: nasogastric intubation emollient filling stomach enema with traditional Chinese herb

55. operative: lysis of adhesions or bands enterectomy for strangulated intestinal loop or adhesive loop mass bypass anastomosis for difficult situation or critical case placation for recurrent case

56. Placation for recurrent case

58. Volvulus Definition: It is a twisting or rotation of the bowel upon its mesentery and induces strangulation when it twist more than 180°with a high mortality.

59. Etiology too long mesentery too heavy intestinal contents Malrotation adhesion

60. Pathology Rotation around the mesenteric axis closed-loop obstruction

61. Classification sigmoid colon volvulus in the elder with constipation small bowel volvulus in the younger with strenuous exercises after full dinner

62. small bowel volvulus sigmoid colon volvulus

63. Clinical Features sudden severe abdominal pain Others like SBO

64. Diagnosis sigmoid colon volvulus: indentation (bird beak sign) while enema small bowel volvulus: shock in early stage and difficulty to differentiate from other types until laparotomy

65. Volvulus of sigmoid colon The coffee bean sign . The greatly dilated sigmoid almost fills the entire abdomen.

66. Volvulus of sigmoid colon The bird sign

67. Treatment fiber colonoscopic reduction for the early stage of the sigmoid vulvulus and then rectal tube fixed in place for 2-3 days surgical intervention immediately in small bowel volvulus and most of sigmoid vulvulus: reduction for nonstrangulation situation Resection the gangrenous bowel (short bowel syndrome, sigmoid colostomy)

69. Intussusception Definition: It is the invagination of a part of the intestinal tract into the lumen of the adjacent intestine.

71. Etiology Irregular peristalsis in child less than 2 years old Intestinal neoplasm and abdominal inflammatory causing chronic recurrent intussusceptions

72. Classification small intestine to small intestine colon to colon ileocecal intussusception (Dance sign: empty in right low quadrant)

73. small intestine to small intestine ileocecal intussusception Ileum, cecum to colon colon to colon

74. Clinical Features abdominal pain abdominal mass melena (currant jelly stool)

75. Diagnosis colonic intussesception shows the glass sign while the enema

76. barium enema Intussusception

77. A 47-year-old man presenting with features of small-bowel obstruction. Image shows a coiled-spring appearance in the region of the cecum suggestive of an intussusception. At laparotomy, an ileocecal intussusception was found in association with a carcinoid tumor of the terminal ileum.

78. A complex mass of concentric rings of alternating low- and high-attenuating layers surrounding a very high attenuation center due to intraluminal Gastrografin. At laparotomy, a chronic jejunojejunal intussusception was found.

79. Computed tomography Anatomic segment involved Tumor mass as lead point Three concentric circles indicating segment of bowel invaginated into another

80. Treatment enema reduction for children and some early stage cases: barium enema with hydrostatic pressure or air enema with high-pressure

81. surgical intervention for adult patients, the failure of enema reduction, and the case with peritonitis: reduction for nonstrangulation situation resection the gangrenous bowel (short bowel syndrome, colostomy) remove the cause in adult

84. Obturation Definition: It refers to intestinal lumen blockage by an intraluminal foreign body.

85. Etiology impacted feces Gallstone Gutstone Group of ascarids foreign body

86. Pathology simple mechanical obstruction

87. Clinical Features severe abdominal pain and abdominal tender mass

88. Diagnosis the differentiation between symptom and sign by different causes

89. A case of ascariasis in the small intestine found by barium meal examination

90. Ascarids in small intestine

91. obstruction caused by ascarids

92. Treatment symptomatic management oxygen filling to stomach (100 ml/years old, total <1500 ml) for ascarids paraffin filling to stomach or enema for bezoar (stone in stomach) laparotomy for broken of obstructive mass, enterotomy for obstructive body

94. Other disese in small intestine

95. tumor in small intestine

96. trauma of small intestine

99. small intestine diverticulum

100. small intestine diverticulum and perforation

101. Aneurysm type B-cell lymphoma of the jejunum with remarkable wall thickening

102. A case of a metastatic jejunal tumor originating from pulmonary giant cell carcinoma in a patient whose chief complaint was melena.

103. Discussion

104. CASE HISTORY A 47-year-old male is admitted to the emergency room with a 36- hour history of lower abdominal pain, nausea, and vomiting. The patient describes the pain as crampy in nature and notes that his abdomen has become distended over the last 12 hours. His last bowel movement was three days prior to presentation.

105. His past medical history is remarkable in that he underwent an appendectomy for acute appendicitis eight months ago. He is otherwise healthy and takes no medications.

106. Physical exam reveals a temperature of 38℃. His abdomen is distended. There is mild tenderness periumbilically but no guarding or rebound. High-pitched bowel sounds are present and rectal exam reveals no stool in the rectum.

107. Admitting laboratory date A hemoglobin of 16, hematocrit 48, white blood cell count 12,200 with 74 polys. Serum electrolytes are normal An abdominal X-RAY reveals multiple dilated loops of small bowel with numerous air fluid levels. There is no gas or stool visible in the colon

108. Symptoms of the patients Pain Vomiting Obstipation Abdominal distention

109. Signs of the patients Vital Signs: temperature of 38℃ His abdomen is distended. Mild tenderness periumbilically but no guarding or rebound. High-pitched bowel sounds Rectal exam reveals no stool in the rectum

110. Laboratory Study A hemoglobin of 16, hematocrit 48, show hemoconcentration White blood cell count 12,200 with 74 polys and 5 bands, show inflammation. Serum electrolytes are normal

111. Radiography exam An abdominal X-RAY reveals multiple dilated loops of small bowel with numerous air fluid levels. There is no gas or stool visible in the colon To confirm the diagnosis

112. Diagnosis Intestinal obstuction

113. Whether the obstruction is mechanical or dynamic : the crampy abdominal pain and high-pitched bowel sounds

114. Whether the obstruction is simple or strangulation obstruction: Indications for strangulation: a. Developing continuous violently rather than intermittent pain b. Crisis rapidly and presence of toxemia (elevated temperature and leukocyte count), shock and rapid pulse c. Obvious peritoneal irritation d. A palpable tender abdominal mass with asymmetric distention

115. e. Bloody gastrointestinal contents f. Single distending gut loop or pseudo-neoplasm sign on plain abdominal film g. A large amount of bloody ascites h. No relieving evidence to intensive nonoperative treatment

116. Whether the obstruction is complete or incomplete: complete

117. Postoperative adhesions, Postinflammatory origin Henias Congenital malformations Intestinal intussusception Obstruction of parasite origin Carcinomas and dry feces. Which causes leads to obstruction : His past medical history is remarkable in that he underwent an appendectomy for acute appendicitis eight months ago.

118. Adhesive obstruction: diagnosis based on not finding any other cause of obstruction Obstruction due to carcinomatosis: mass or bowel wall thickening along serosa of bowel at the transition zone Crohn's disease: inflammatory mesenteric mass or discrete loculated fluid collection Sigmoid volvulus: whirl sign

119. Acute cholecystitis: enlarged thick walled gallbladder Pancreatitis: swelling and fluid around pancreas Mesenteric ischemia: thickened bowel wall, focal dilatation, pneumatosis Acute appendicitis: inflammatory changes in fat around appendix

120. Treatment Nonoperative Treatment Correcting of fluid and electrolytes imbalance and acid-base disturbance Gastrointestinal decompression Antibiotics Symptomatic treatment

121. By close observation Exacerbated, transferred to surgical intervention.

122. Surgical treatment: if doubt strangulated obstruction Lysis of adhesion Enterectomy and anastomosis

123. Conclusion

124. Diagnosis must make clear the following questions: 1. Whether intestinal obstruction exists 2. Whether the obstruction is mechanical or dynamic

125. 3. Whether the obstruction is simple or strangulation obstruction: Indications for strangulation: a. Developing continuous violently rather than intermittent pain b. Crisis rapidly and presence of toxemia (elevated temperature and leukocyte count), shock and rapid pulse c. Obvious peritoneal irritation d. A palpable tender abdominal mass with asymmetric distention

126. e. Bloody gastrointestinal contents f. Single distending gut loop or pseudo-neoplasm sign on plain abdominal film g. A large amount of bloody ascites h. No relieving evidence to intensive nonoperative treatment

127. 4. Whether the obstruction is high or low 5. Whether the obstruction is complete or incomplete 6. Which causes leads to obstruction

128. Treatment Basic Treatment Fluid and electrolytes replacement Gastrointestinal decompression Antibiotics Symptomatic treatment

129. Surgical Treatment Indication: strangulated obstruction closed-loop obstruction simple obstruction without respond to nonoperation more than 96 hours

130. The surgical procedures includes: 1)Lysis of adhesion, reduction of intussusception, torsion. 2)Enterectomy and anastomosis. 3)Bypass procedure for nonresectable lesions. 4)Enterostomy and exteriorization of intestine. Treatment of obstructing carcinoma colon

131. The Common Types Of Intestinal Obstruction

132. Adhesive Obstruction

133. Diagnosis intestinal obstruction previous laparotomy abdominal infection trauma

134. Treatment nonoperative: operative:

135. Volvulus Definition: It is a twisting or rotation of the bowel upon its mesentery and induces strangulation when it twist more than 180°with a high mortality.

136. Classification sigmoid colon volvulus in the elder with constipation small bowel volvulus in the younger with strenuous exercises after full dinner

137. Intussusception Definition: It is the invagination of a part of the intestinal tract into the lumen of the adjacent intestine.

138. Etiology Irregular peristalsis in child less than 2 years old Intestinal neoplasm and abdominal inflammatory causing chronic recurrent intussusceptions

139. Clinical Features abdominal pain abdominal mass melena (currant jelly stool)

140. Obturation Etiology impacted feces Gallstone Gutstone Group of ascarids foreign body