for MBBS students

1. Dr. Md. Majedul Islam
FCPS(Surgery)

2.  One of the common causes of acute
abdomen
 May lead to high morbidity and mortality if
not treated correctly

3. Classification
• According to obstructing site
1. Small bowel obstruction
2. Large bowel obstruction
• According to presentation
1. Acute obstruction
2. Chronic obstruction
3. Acute on chronic obstruction
4. Subacute obstruction
• According to blood flow
• Simple obstuction
• Strangulated obstuction
1. Primary 2. External 3. Closed loop obstruction

7. Incidence
 Small Bowel(85%)
1. Adhesions(80%)
2. Hernia(10%)
3. Tumors(5%)
4. Miscellan.(5%)
 COLON(15%)
1. Cancer (75%)
2. Diverticulos.(10%)
3. Volvulus(10%)
4. Miscellan.(10%)

8. Adhesions(40%of causes)
A. Postoperative:
• Commonest after lower abdominal and gynaecological
surgery.
Patients can present as early as 4 weeks postop.
But often 1-5 years postoperative.
B.Inflamatory:
• Cholecystitis
• Appendicitis
• PID
• T.B
• Peritonitis

12. Neoplasms(15% of causes)
 Colorectal carcinoma:
 75% occure in Rectosigmoid colon
 15-20% of colorectal cancer present with obstruction
 LT.colon commonest site of obstruction due to
constricting lesion&solid faeces

13. strictures
A. Congenital:
 Intestinal Atresia
B. Inflammatory:
 Crohns Disease
 Tuberculosis
C. Neoplastic:
 Lymphoma
 Carcinoid

14. Acute colonic pseudo obstruction
 It is massive colonic dilatation affecting caecum and
Rt.colon with presentation of colonic obstruction
without mechanical blockage.
Occurs in : Elderly hospitalised patients with
1. Major TRAUMA;
2. ILLENESS;
3. MAJOR NON-INTESTINAL SURGERY

15. Symptom
 The cardinal features of bowel obstruction are,
 1. Pain
 2. Vomiting
 3. Constipation
 4. Distension

16. The clinical features vary according to:
 • the location of the obstruction;
 • the duration of the obstruction;
 • the underlying pathology;
 • the presence or absence of intestinal ischaemia.

17. Features of obstruction
 In high small bowel obstruction, vomiting occurs
early, is profuse and causes rapid dehydration.
Distension is minimal with little evidence of dilated
small bowel loops on abdominal radiography
 In low small bowel obstruction, pain is
predominant with central distension. Vomiting is
delayed. Multiple dilated small bowel loops are seen
on radiography

18. Features of obstruction
 In large bowel obstruction, distension and
pronounced. Pain is less severe and vomiting and
dehydration are later features. The colon proximal to
the obstruction is distended on abdominal
radiography. The small bowel will be dilated if the
ileocaecal valve is incompetent

19. STARANGULATED OBSTRUCTION :
 Strangulating obstruction is obstruction with
compromised blood flow; it occurs in nearly 25% of
patients with small-bowel obstruction.
 It is usually associated with hernia, volvulus, and
intussusceptions.
 Strangulating obstruction can progress to infarction
and gangrene in as little as 6 h.

20. Strangulated small bowel loop(strangulated
inguinal hernia)

21.  Clinical features of strangulation
 Constant pain, severe pain
 Tenderness with rigidity and peritonism
 Shock

22. Character of pain in Obstruction
 Pain - Sudden, severe
 Colicky in nature
 Central , around umbilicus in small bowel obstruction
 Lower abdomen in large bowel obstruction
 Continuous if perforation or strangulation is present
 Absent in paralytic ileus

23. Vomiting
 Early in high small bowel obstruction,
 Late in low small bowel obstruction ,
 Delayed or absent in large bowel obstruction.
 Character : initially clear ,becomes discolored , and
finally feculent (dark and foul smiling).

24.  Constipation
1. Early in large bowel obstruction
2. Absolute in complete obstruction
Distension
1. Epigastric or hypogastric in small bowel
obstruction
2. Generalized in large bowel obstruction

25. Clinically
 Inspection:
1. Scar ,
2. Distension, central in small bowel obstruction and
3. peripheral in large bowel obstruction
4. Visible peristalsis 25
Palpation :
1. Abdominal mass may suggest carcinoma or
strangulated bowel.
2. Rigidity and rebound tenderness , indicates
ischemia & peritoneal irritation

26. Clinically
 Percussion: Resonance because of gas filled bowel,
Tenderness on percussion indicates the presence of
peritonitis.
 Auscultation: Bowel sounds Tympanic Metallic clicks
as pressure is raised if much gas is present in the
bowel. Gurgling borborygmi if gas and fluid are
present in the bowel. Silence if generalized peritonitis
or paralytic ileus is present.

27. DRE
 On rectal examination:
 Impacted feces
 In rectal cancer - Blood on finger which maybe
present with mesenteric artery occlusions,
intussusception or Volvulus.

28. Laboratory Examination
 1. Complete blood count (WBC)
 2. Serum electrolytes and amylase determination
 3. Arterial blood gas analysis

29. Imaging
 Radiological features of obstruction (on plain x-ray)
 The obstructed small bowel is characterised by straight
segments that are generally central and lie transversely.
No/minimal gas is seen in the colon
 The jejunum is characterised by its valvulae conniventes,
which completely pass across the width of the bowel and
are regularly spaced, giving a ‘concertina’ or ladder effect
 Ileum – the distal ileum has been piquantly described by
Wangensteen as featureless
 Caecum – a distended caecum is shown by a rounded gas
shadow in the right iliac fossa
 Large bowel, except for the caecum, shows haustral folds,
which, unlike valvulae conniventes, are spaced irregularly,
do not cross the whole diameter of the bowel and do not
have indentations placed opposite one another

30. Gas-filled small bowel loop; patient supine.

31. Fluid levels with gas above; ‘stepladder pattern’. Pt erect

32. CT scan
 Used very widely to investigate all forms of intestinal
obstruction.

33. TREATMENT OF ACUTE INTESTINAL
OBSTRUCTION
 Treatment of acute intestinal obstruction
1. Gastrointestinal drainage via a nasogastric tube
2. Fluid and electrolyte replacement
3. Relief of obstruction
4. Surgical treatment is necessary for most cases of
intestinal obstruction but should be delayed until
resuscitation is complete,provided there is no sign of
strangulation or evidence of closed-loop obstruction

34. Principles of surgical intervention for
obstruction
Management of:
 The segment at the site of obstruction
 The distended proximal bowel
 The underlying cause of obstruction

35. viability of the gut.

36. Intussusception
 when one portion of the gut invaginates into an
immediately adjacent segment; almost invariably, it is
the proximal into the distal
 Most common in children
 M:F = 3:1
 Age : 2 month to 2 year but commonly from five
month to ten month

37. Pathology of Intussusception
 For infant:
 90 % cases are idiopathic, but an associated upper
respiratory tract infection or gastroenteritis may
precede the condition. (Because of hyperplasia of
Peyer’s patches in the terminal ileum may be the
initiating event)
 Weaning, loss of passively acquired maternal
immunity and common viral pathogens have all been
implicated in the pathogenesis of intussusception in
infancy.

38. Pathology of Intussusception
 For Children with intussusception associated with a
pathological lead point such as
 Meckel’s diverticulum,
 polyp,
 duplication,
 Henoch–Schönlein purpura or
 appendix

39.  Adult cases are invariably associated with a lead point,
which is usually
a polyp (e.g. Peutz–Jeghers syndrome),
a submucosal lipoma or
other tumour.
Pathology of Intussusception

40.  An intussusception is composed of three parts :
 • the entering or inner tube (intussusceptum);
 • the returning or middle tube;
 • the sheath or outer tube (intussuscipiens).

41. Types
 In children : Ileocolic is commonest
 In adult : Colocolic variety

42. Clinical features of intussusception
 episodes of screaming and drawing up of the legs in a
previously well male infant.
 The attacks last for a few minutes and recur repeatedly
 Vomiting less common
 Blood mixed mucous stool(red current jelly)

43. Clinical finding
 Distended abdomen
 Sausage shaped mass in upper abdomen
 Empty right iliac fossa(sign of Dance)
 Blood stained mucous in DRE

44. Diagnosis
 History, Clinical Examination
 Investigation:
 Plain X ray : Feature of obstruction(multiple air fluid
level), absent caecal gas shadow.
 USG: Target sign(typical doughnut appearance of
concentric rings in transverse section)
 Barium enema : Claw sign
 CT scan of abdomen : ‘target’ or ‘sausage’- shaped soft-
tissue mass with a layering effect,

46. Treatment of Intussusception
 For infant
 Resuscitation with intravenous fluids,
 broad-spectrum antibiotics and
 nasogastric drainage,
 non-operative reduction can be attempted by using an
air or barium enema(Hydrostatic reuction)
 Surgery by resection and primary anstomosis ,,if non
operative reduction failed and after reduction segment
found gangrenous.

47. Volvulus
 A volvulus is a twisting or axial rotation of a portion of
bowel about its mesentery.
 The rotation causes obstruction to the lumen (>180°
torsion) and if tight enough also causes vascular
occlusion in the mesentery (>360° torsion).

49.  May involve the small intestine, caecum or sigmoid
colon; neonatal midgut volvulus secondary to midgut
malrotation is life-threatening
 The most common spontaneous type in adults is
sigmoid , Sigmoid volvulus can be relieved by
decompression per anum
 Surgery is required to prevent or relieve ischaemia

50. Types
 Volvulus neonatarum
 Volvulus of small intestine
 Caecal volvulus
 Sigmoid volvulus(most common in adult)
 Gastric vovulus
 Compound volvulus : This is a rare condition also
known as ileosigmoid knotting. The long pelvic
mesocolon allows the ileum to twist around the
sigmoid colon, resulting in gangrene of either or
both segments of bowel.

52. Clinical features of volvulus
 The symptoms are of large bowel obstruction.
 Abdominal distension is an early and progressive sign,
which may be associated with hiccough and retching.
 Constipation is absolute.
 In some patients, the grossly distended torted left
colon is visible through the abdominal wall.

53. X Ray of sigmoid volvulus
 The classic appearance is of a dilated loop of bowel,
the two limbs are seen running diagonally across the
abdomen from right to left, with two fluid levels seen,
one within each loop of bowel (if an erect film is
taken).

55. Treatment of sigmoid volvulus
 Non Operative :
Decompression by sigmoidoscopy or by flatus tube
and asses by doing X ray after 24 hour.
Operative:
Sigmoid colcectomy with primary anastomosis
Hartman procedure
Paul–Mikulicz procedure

56. Volvulus of the sigmoid colon (a) before and (b) after
untwisting

57. CHRONIC LARGE BOWEL OBSTRUCTION
 The causes of obstruction may be organic:
 • intraluminal (rare) – faecal impaction;
 • intrinsic intramural – strictures (Crohn’s disease,
ischaemia, diverticular), anastomotic stenosis;
 • extrinsic intramural (rare) – metastatic deposits
(ovarian), endometriosis, stomal stenosis;
 functional: Hirschsprung’s disease, idiopathic
megacolon, pseudoobstruction.

58. 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).

59. Causes of paralytic ileus
 Post operative(self limiting)
 Infection(Intra abdominal sepsis)
 Reflex ileus( by fracture(spine, ribs,Pelvis)
retroperitoneal Hge, application of plaster jacket)
 Metabolic(uraemia, hypokalemia)

60. Clinical feature
 Abdominal distesion but no colicky pain
 No bowel sound
 No passage of flatus
 Radiologically, the abdomen shows gasfilled loops of
intestine with multiple fluid levels

61. Mx of paralytic ileus
 Keep NPO
 IV fluid
 NG suction
 Electrolyte balance
 Sepsis control by Antibiotic
 Surgery if there mechanical obstruction in CT scan or
non operative measure failed.