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Discuss intestinal obstruction

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Discuss intestinal obstruction

  3. 3. Introduction Definition• Stoppage of the cranio-caudal movement of bowel contents due to narrowing or complete blockage of the bowel lumen.• It is one of the commonest surgical emergencies worldwide.5/19/2012
  4. 4. Introduction• It is commoner in the small bowel than the large bowel.• It is important to make early and correct diagnosis.• Treatment must be prompt & appropriate5/19/2012
  5. 5. Classification • Dynamic / Adynamic • Acute / Chronic / Acute on chronic • High / Low • Simple / Strangulated / Close loop • Complete / Partial5/19/2012
  6. 6. Adynamic Ileus• Paralytic ileus• It is due to paralysis of intestinal musculature• Characterized by absence of peristalsis & pain5/19/2012
  7. 7. Dynamic Ileus• Peristalsis is working against a mechanical obstruction.• It may be acute or chronic.• Associated with abdominal pain5/19/2012
  8. 8. Aetiology5/19/2012
  9. 9. Aetiology 1. Extramural i. Strangulated Hernia ii. Adhesions & Bands iii. Volvolus5/19/2012
  10. 10. Strangulated External Hernia5/19/2012
  11. 11. Adhesions & Bands5/19/2012
  12. 12. Volvolus5/19/2012
  13. 13. Annular pancreas5/19/2012
  14. 14. Aetiology 2. Intraluminal i. Ascariasis ii. Gallstone iii. Faecal impaction iv. Foreign bodies5/19/2012
  15. 15. Gallstone ileus5/19/2012
  16. 16. Ascariasis5/19/2012
  17. 17. F.B in GIT5/19/2012
  18. 18. Aetiology 3. Intramural i. Atresia ii. Anorectal anomalies iii. Intussusception iv. Aganglionic megacolon v. Tumours vi. Inflammatory lesions5/19/2012
  19. 19. Intussusception5/19/2012
  20. 20. Small & Large bowel tumors5/19/2012
  21. 21. Multiple atresia5/19/2012
  22. 22. Duodenal web5/19/2012
  23. 23. Crohn’s dx & Diverticulitis5/19/2012
  25. 25. Causes of Adynamic Ileus Metabolic Medications Post. Operative ileus cases Response to localized Neuropathic Inflammatory disorders process Diffuse Retroperitoneal peritonitis process5/19/2012
  26. 26. Metabolic Causes1.Hypokalemia.2.Hypomagnesemia.3.Hyponatremia.4.Ketoacidosis.5.Uremia.6.Porphyria.7.Heavy metal poisoning.5/19/2012
  27. 27. Medications1.Narcotics.2.Antipsychotics.3.Anticholinergics.4.Ganglionic blockers.5.Agents used to treat Parkinson’s disease.5/19/2012
  28. 28. Retroperitoneal process1.Retroperitoneal hematoma.2.Pancreatitis.3.Spinal or pelvic fracture.5/19/2012
  29. 29. Neuropathic disorders1.Diabetes.2.Multiple sclerosis.3.Scleroderma.4.Lupus erythromatosis.5.Hirshsprungs disease.5/19/2012
  30. 30. Intra-abdominal surgery Motility usually returns for the:• small bowel within 24 – 48 hrs.• gastric within 48 hrs.• colonic within 3-5 days.5/19/2012
  31. 31. Pathophysiology5/19/2012
  32. 32. Simple Obstruction• Below the obstruction, the bowel exhibits normal peristalsis and absorption until it becomes empty, when it contracts and becomes immobile.5/19/2012
  33. 33. Simple Obstruction• Above the obstruction, peristalsis is increased to overcome the obstruction, If the obstruction is not relieved the bowel begins to dilate resulting in flaccidity and paralysis.5/19/2012
  34. 34. Simple Obstruction• The gases are mostly from swallowed air and products of putrefaction & of intestinal contents by bacteria.• The fluids are mainly digestive juices5/19/2012
  35. 35. Simple Obstruction• The fluids accumulate due to loss of the absorbing surface of bowel & disordered fluid & electrolyte transport in the obstructed segment.5/19/2012
  36. 36. Simple Obstruction• When raised intraluminal pressure is more than venous pressure, there would be venous congestion, oedema of the wall, & mvt of fluid from the plasma into the gut lumen & peritoneal cavity.• Death from intestinal obstruction is due to loss of water & electrolytes5/19/2012
  37. 37. Simple Obstruction• The higher the level of obstruction, the earlier the onset of fluid & electrolytes imbalance.• In high obstruction, metabolic acidosis is common because the fluid loss is acid.• In low obstruction, metabolic acidosis is likely bcs the sequestered fluid alkaline.5/19/2012
  38. 38. Strangulation Obstruction• When the pressure of the occluding band exceeds the venous pressure• Venous engorgement of gut wall• Dilatation of intramural lymph channels that carry multiplying bacteria from mucosa surface into systemic circulation.5/19/2012
  39. 39. Strangulation obstruction• If the strangulated loop is long, release of the obstruction may cause severe endotoxic shock because of faster absorption of toxins & bacteria from the devitalized gut.• Increased venous pressure ► rupture of capillaries ► bleeding into the lumen, wall of the gut & peritoneal cavity.5/19/2012
  40. 40. Strangulation obstruction • Necrosis of tissues may be due to i. Tight occluding band obstruct arterial supply ii. Reflex arterial spasm to venous congestion iii. Thrombosis of intramural & mesenteric veins due to stasis of venous engorgement iv. Hypoxia enhances the growth of anaerobic bacteria5/19/2012
  41. 41. Closed Loop Obstruction • Afferent & efferent limbs of bowel are obstructed. • Typically seen in colonic obstruction with competent iliocaecal valve5/19/2012
  42. 42. Closed loop obstruction • The rich bacterial floral adds to the production of gases • Rapid distension ► ↑luminal pressure ► circulation impairment ► bowel necrosis & perforation ► fulminant peritonitis.5/19/2012
  43. 43. Clinical Presentation5/19/2012
  44. 44. Clinical presentation The cardinal features of obstruction are pain, vomiting, distension & constipation but clinical presentation varies according to: • Site of obstruction . • Age of Presentation. • Underlying pathology. • The presence or absence of ischemia.5/19/2012
  45. 45. Clinical presentation1. Abdominal pain 1st symptom, colicky, intermit tent , central in small bowel obstruction, waxes rapidly & wanes slowly, relief in between spasm but persistent pain between spasms of colicky5/19/2012 pains.
  46. 46. Clinical presentation2. Abdominal distension • The lower the site of obstruction the more the distension. • It varies inversely as the vomiting.5/19/2012
  47. 47. Clinical presentation2. Abdominal distension • Central in small bowel obstruction. • More in the flanks in colonic obstruction5/19/2012
  48. 48. Clinical presentation3. Vomiting Frequency & nature of vomitus depends on the level of obstruction.5/19/2012
  49. 49. Clinical presentationPyloric ObstructionWatery and acidic vomitusHigh Small Bowel Obstruction Bile-Stained vomitusLower Small Bowel Obstruction Feculent VomitusLarge Bowel Obstruction Uncommon & late symptom.5/19/2012
  50. 50. Clinical presentation 4. Absolute constipation • Occurs Early in “lower” Large Bowel Obstruction. • Occurs Late in “High” Small Bowel Obstruction.5/19/2012
  51. 51. Examination findings5/19/2012
  52. 52. Examination Findings• Dehydration Common in small bowel obstruction Vomiting and fluid sequestration5/19/2012
  53. 53. Examination FindingsPyrexiamay indicate: • the onset of ischaemia; • intestinal perforation; • inflammation associated with the obstructing disease.Hypothermia indicates septicaemic shock.5/19/2012
  54. 54. Inspection i. Surgical Scars ii. Hernias iii. Distention iv. Visible Peristalsis5/19/2012
  55. 55. Palpation i. Masses ii. Hernias iii. Tenderness  Perform Rectal Exam.5/19/2012
  56. 56. Percussion• Percuss to hear any Dullness or Resonance related to site of obstruction.5/19/2012
  57. 57. Auscultation• Bowel Sounds are Initially Loud and frequent→ Then as bowel distends the sounds become more resonant and high pitched→ Eventually becoming Amphoric5/19/2012
  58. 58. Investigations5/19/2012
  59. 59. Plain Abdominal X-rays usually diagnostic of bowel obstruction in more than 60% of the cases, but further evaluation (possibly by CT or barium ) may be necessary in 20% to 30% of cases.5/19/2012
  60. 60. X-RAY5/19/2012
  61. 61. X-RAY  Small Bowel Obstruction with characteristic air- fluid levels. The air rises above the fluid and there is a flat surface at the air- fluid interface.5/19/2012
  62. 62. X-RAY• Distended Large bowel tends to lie peripherally and to show the hustrations of the Taenia Coli.5/19/2012
  63. 63. Barium Studies are recommended in patients with a history of recurring obstruction or low- grade mechanical obstruction to precisely define the obstructed segment and degree of obstruction.5/19/2012
  64. 64. Barium meal • Jejunojejunal Intussusception5/19/2012
  65. 65. CT Scan• CT examination is particularly useful in patients with a history of abdominal malignancy, in postsurgical patients, and in patients who have no history of abdominal surgery and present with symptoms of bowel obstruction.5/19/2012
  66. 66. CT Scan• Rt colonic tumour5/19/2012
  67. 67. Other Investigations CBC Group & Xmatch blood Urea and Electrolyte RBS.5/19/2012
  68. 68. Treatment5/19/2012
  69. 69. Aim of Rx Aim is to relieve obstruction as soon as possible before strangulation occurs or before systemic complications set in.5/19/2012
  70. 70. Supportive Treatment• Nil per os• Fluid and electrolyte• Nasogastric aspiration• Urethral catheterization• Antibiotics• Analgesics• Correct anaemia5/19/2012
  71. 71. Conservative treatment• Partial obstruction• Early post op obstruction• Obstruction secondary to Crohn’s disease• Recurrent obstruction Open surgery if no improvement after 24hrs5/19/2012
  72. 72. Operative Treatment• Procedure depends on cause of obstruction• Non-viable gut must be resected• Questionable gut should be checked for viability5/19/2012
  73. 73. Non-viable bowel I. Loss of peristalsis II. Loss of Sheen III. Greenish or Black (Not Purple) IV. Loss of Pulsation in supplying vessels5/19/2012
  74. 74. Specific Rx • Adhesion obstruction: non operative • Strangulated Int. / Ext. hernia: release of obstruction, resection of gangrenous bowel, repair of defect5/19/2012
  75. 75. Specific Rx• Intussusception: Hydrostatic / Pneumatic reduction under fluoroscopy.• Volvolus: (viable) enema saponis for detorsion (nonviable appropriate resection & anastomosis)5/19/2012
  76. 76. Specific Rx • Hirshsprungs- pull through • Intestinal atresia- resection + anastomosis • Duodenal atresia- duodenoduodenostomy • Meconium ileus - resection + anastomosis • Pyloric stenosis - pyloromyotomy5/19/2012
  77. 77. Complications• Fluid and dyselectrolytaemia• Hypovolemic / Endotoxic Shock• Peritonitis• Adhesion/ Garres’ obstruction• Acute Renal Failure• Multiple organ5/19/2012
  78. 78. Prognosis• Type of obstruction• Duration of obstruction• Cause of obstruction• Age of the patient• Length of gangrenous bowel5/19/2012
  79. 79. THANK YOU FOR YOUR AUDIENCE “Never let the sun rise or set on small- bowel obstruction”5/19/2012