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Intestinal obstruction neo
- 2. 1. Dynamic - mechanical obstruction 1. Adynamic- – Peristalsis –absent – Peristalsis -non- propulsive form
- 4. Pathology Proximal to obstruction – Altered mobility – Distension Distal to obstruction – Normal peristalsis – Absorption
- 5. Pathology Proximal to obstruction – Altered mobility – Distension – Dilates – flaccid – Paralysis • Exhaustion • to prevent Viability
- 6. Distension Gas – Swallowed air – Diffusion from blood – Products of digestion and bacterial activity – O2 & CO2 reabsorbed – Nitrogen 90% and H2S Fluid – Digestive juice – No absorption of food
- 7. • Electrolyte imbalance – Reduced intake – Defective intestinal absorption – Vomitintg – sequestration
- 8. • Distal to obstruction – Normal peristalsis – Absorption – Empty and contracted – immobile
- 9. • Veins compressed first - Edema and hemorrhages • Arterial compression – Haemorrhagic infarction • Translocation of bacteria, toxins and systemic absorption
- 10. Strangulation External Internal • Smaller absorptive surface • Short segment – Less blood and fluid loss • Larger absorptive surface • Large segment – More blood and fluid loss - shock
- 11. Closed loop obstruction • Obstruction both at proximal and distal point – Strangulated loops – Colonic obstruction with a competent ileocecal valve
- 12. Special types • Internal hernia • Entric stricture • Bolus obstruction • Adhesion and bands • Intussusception • volvulus
- 13. Clinical features • Classical qurtet 1. Pain 2. Vomiting 3. Distension 4. Constipation
- 14. pain • Colicky • Mild constant diffuse • severe
- 15. vomiting • Proximal- more vomiting • With time – Undigested food to faeculant
- 16. distension • More distal- more distension
- 17. constipation • Absolute • Relative • Absent in – Richter’s hernia – Gall stone obstruction – Mesentric vascular obstruction – obstruction with pelvic abscess – Partial obstruction- faecolith, neoplasm
- 18. Levels • Small bowel obstruction – High – low • Large bowel obstruction
- 19. Levels • Small bowel obstruction- High – Early vomiting – Rapid dehydration – Minimal distension – X ray -fluid level ?
- 20. Levels • Small bowel obstruction- low – Pain- prominent – Late vomiting – Central distension – X ray -fluid level - multiple
- 21. Levels • Large bowel obstruction – Early distension, severe – Late vomiting, dehydration – Pain mild – X ray –caecum , ascending colon distended
- 22. Nature of presentation • Acute- SB, sudden onset of pain • Chronic- LB, constipation, distension • Acute on Chronic- recurrant • Subacute- constipation?
- 23. Other features • Dehydration • Hypokalemia • Pyrexia – Ischemia/perforation/Inflammatory obs. • Hypothermia • Abdominal tenderness
- 24. Type of presentation • Simple – Intact blood supply • Strangulated – Compromised blood supply
- 26. Signs of strangulation • Continous pain • Localised tenderness, rigidity, rebound tenderness • Shock • Does not respond to conservative management
- 27. Radiology • X – ray abdomen Erect Air fluid levels • X – ray abdomen Supine Distended bowel
- 29. Small bowel • Central and transverse lie • Jejunum – Valvulae conniventes (concertina / Stack of coins) • Ileum – Characterless • Colon – Haustral folds
- 30. Treatment • Gastrointestinal drainage • Fluid and electrolyte replacement • Relief of obstruction
- 31. Timing of surgery • Emergent Obstructed/strangulated Ext hernia Internal intestinal strangulation Acute obstruction • Other cases Atleast within 24 hrs • Adhesions upto 72hrs
- 32. Principles of Surgical intervention • Mt. of the segment at the site of obstruction • The distended proximal bowel • Underlying cause of obstruction
- 33. assessment • Site of obstruction • Nature of obstruction • Viability of gut
- 34. Site of obstruction Caecum Dilated Not dilated Large bowel Small bowel Trace distally Trace proximally
- 36. Viability of bowel Viable Dark color – Light Dark persists Mesentery bleeds on pricking No bleeding Peritoneum – Shiny Dull & Lustreless Int Musc – Firm, Peristalsis seen Flabby, thin, friable Non viable Mesenteric pulsation + Absent
- 37. Doubtful – Resected ends as stomas No resection / Multiple ischaemic areas (Mesenteric Vasc Occlusion) 2nd look laparotomy after 24-48hrs
- 38. Surgical procedure • Adhesiolysis • Excision / Resection • Bypass / Proximal decompression
- 39. Operative decompression • Compromise of Exposure / Viability / Closure • Septic complications of spillage • Savage’s decompressor / NG tube • Replace fluid
- 40. Large bowel obstruction Caecum to Prox trans colon – Rt. Hemicolectomy, if resectable – Ileotransverse bypass if not resectable Splenic flexure – Extended Rt.Hemicolectomy
- 41. Left colon / Rectosigmoid • Decompression proximal colostomy • Resection with – Anastamosis with covering colostomy – Paul Mikulicz procedure – Hartmann’s procedure
- 43. SPECIAL TYPES • internal hernia • Enteric Stricture • Bolus obstruction – Gallstone – Food – Bezoars • Adhesion and bands • Intussusception • volvulus
- 44. INTERNAL HERNIA • Internal hernia – Retroperitoneal fossa • Duodenal fossa- – Left – right • Caecal/appendicaeal fossa – Superior – Inferior – retrocaecal • Intersigmoid fossa – Congenital peritoneal defect • Foramen of winslow • Hole in mesentry, mesocolon, broad ligament – Diaphragmatic hernia
- 45. • Duodenal fossa- – Left – right
- 46. • Caecal/appendicaeal fossa – Superior
- 47. • Caecal/appendicaeal fossa – Inferior
- 49. intersigmoid
- 51. • Release the constriction agent by division • Donot- • Duodenal fossa- • Foramen of winslow • Hole in mesentry, mesocolon, broad ligament • Decompress and reduce
- 52. Enteric Stricture • Benign – TB – Chrohn’s • Malignant – Lymphoma – Ca – sar
- 53. Enteric Stricture • t/t – RA – stricturoplasty
- 54. bolus • Gall stone • Food • Bezoars • Stercolith • worms
- 55. Gall stone • Fistula • 60 cm proximal to IC • Ball valve effect • t/t – Crush – Milk – Enterotomy – Faceted stone
- 56. food • Post gastrectomy • t/t – same
- 59. worms • Ascariasis • Follow anti helminthic therapy • perforation • X ray- medusa head • t/t
- 60. Adhesions • Most common cause • Difficult to differentiate from paralytic ileus
- 61. Causes • Ischaemic areas • Foreign material – Talc – Starch – gauze – silk • Infection – Peritonotis – TB • Inflammatory conditions- • Radiation enteritis • Drugs – Practolol
- 62. Peritoneal irritation Local fibrin production Adhesion between apposed surfaces Early fibrinous adhesions Late fibrous adhesions
- 63. Prevention • Good Surgical technique • Peritoneal wash • Minimizing contact with gauze • Covering anastamosis & raw peritoneal surfaces
- 64. Classification • Early / Flimsy • Late/ Dense
- 65. Bands • Congenital • Acquired – Peritonitis – Greater omentum adherent to parietes
- 66. Treatment • Conservative – NPO – RT aspiration – IV fluids – Vital signs & Abd. girth monitoring – Signs of strangulation – Maximum 72hrs
- 67. Surgery • Adhesiolysis – Only those causing obstruction – Covering with omental grafts – Constriction sites
- 68. Recurrent adhesive obstruction • Repeat Adhesiolysis • Noble’s plication procedure • Charles phillip Transmesenteric plication • Intestinal intubation
- 69. intussusception • Telescoping • Proximal to distal • Children- 5-10 yr • follow URTI • weaning
- 71. types
- 72. • Strangulating • t/t • Radiological reduction • Sx
- 73. volvulus • Primary – Volvulus neonatorum – Sigmoid – Caecal – Gastric – midgut • Secondary
- 74. Sigmoid volvulus • Anticlockwise • BONE
- 75. • X-ray • Inner tube • Cofee bean • t/t • Endoscopic reduction • Sx
- 77. Compound volvulus • Ileosigmoid knotting