This document discusses intestinal obstruction, including its definition, types, causes, classification, pathophysiology, clinical features, investigations, and treatment. Intestinal obstruction can be dynamic, caused by mechanical blockage, or adynamic, where peristalsis is absent. Common causes include adhesions, tumors, hernias, and fecal impaction. Clinical exam and imaging help evaluate for mechanical obstruction or paralytic ileus. Treatment involves relieving the obstruction through surgery if needed, along with supportive measures like IV fluids and nasogastric decompression.
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INTESTINAL OBSTRUCTION
1. INTESTINAL OBSTRUCTION
LT COL SM SHAHADAT HOSSAIN
MCPS,FCPS(surgery)FCPS(Thoracic Surgery)
Adv Trg on Thoracoscopy CNU, South Korea
2. Definition
When the normal propulsion and passage of
intestinal contents does not occur.
Dynamic Adynamic
Types
3. CLASSIFICATION
Dynamic:
Peristalsis is working against a mechanical
obstruction.
It may be acute or chronic.
Adynamic:
There is no mechanical obstruction.
Peristalsis is absent or inadequate (e.g.
paralytic ileus or pseudo-obstruction).
4. CLASSIFICATION
A. Simple obstruction (no vascularimpairment)
B. Closed loop ( both ends are obstructed e.g.
volvulus)
C. Strangulation obstruction
13. PATHOPHYSIOLOGY
In dynamic obstruction :
1. Above the obstruction:
Peristalsis increases Intestine dilate
Reduction in peristaltic strength Flaccidity and
paralysis
2. Below the obstruction:
Normal peristalsis & absorption Until it
becomes empty It contracts & becomes
immobile.
14. Distension due to
Gas: Mainly nitrogen (90%) and hydrogen
sulphide.
Fluid:
Saliva 500 ml.
Bile 500 ml.
Pancreatic secretions 500 ml.
Gastric secretions 1 litre – all per 24 hours.
15. Dehydration and electrolytes loss are due
to
Reduced oral intake.
Defective intestinal absorption.
Vomiting.
Sequestration in the bowel lumen.
Transudation of fluid into the peritoneal cavity.
22. INTERNAL HERNIA
1. Framen of Winslow
2. Defect in the mesentery
3. Defect in the transverse mesocolon
4. Defects in the broad ligament
5. Diaphragmatic hernia
6. Duodenal retroperitoneal fossae
7. Caecal/appendiceal retroperitoneal
8. Intersigmoid fossa.
23. OBSTRUCTION FROM ENTERIC
STRICTURES
Small bowel strictures usually due to
tuberculosis or Crohn’s disease.
Malignant strictures: lymphoma are
uncommon, whereas carcinoma and
sarcoma are rare.
27. CLINICAL FEATURES
Vary according to:
● Location of the obstruction;
● Duration of the obstruction;
● Underlying pathology;
● Presence or absence of intestinal
ischaemia.
28. Pain
Pain is the first symptom.
Occurs suddenly and is usually severe.
Colicky in nature.
Usually centred on the umbilicus (small
bowel).
Lower abdomen (large bowel).
29. Vomiting
More distal the obstruction, longer the
interval between the onset of symptoms and
appearance of nausea and vomiting.
30. Distension
In small bowel degree of distension is
dependent on the site of obstruction and
more distal the lesion.
Distention is much less in high small bowel
obstruction.
Visible peristalsis may be present
31. Constipation
This may be
• Absolute (i.e. neither faeces nor flatus is
passed) or
• Relative (where only flatus is passed).
50. TREATMENT
Supportive:
Nasogastric aspiration by ryles tube.
IV fluids- hartmnn’s solution or normal
saline.
Urinary catheter.
Check temp. And pulse 2 hourly.
Abdominal examination 8 hourly.
Broad spectrum antibiotics.
51. Indications for surgery:
a. Obstructed external hernia.
b. Intestinal strangulation.
c. Obstruction in a ‘virgin’ abdomen
Surgery depends on cause:
Division of bands.
Adhesiolysis.
Excision and exteriorization.
Bypass.
58. Clinical features of intussusception
Screaming and drawing up of the legs in a
previously well male infant.
During attacks the child appears pale;
between episodes he may be listless.
Vomiting may or may not occur but bile-
stained.
59. Clinical features
Initially, the passage of stool may be
normal, later, blood and mucus are
evacuated – the ‘redcurrant jelly’ stool.
A lump that hardens on palpation
associated feeling of emptiness in the right
iliac fossa (the sign of Dance).
60. Clinical features
On rectal examination:
Blood-stained mucus
The apex of intussusception may be
palpable.
61. DIFFERENTIAL DIAGNOSIS
1. Acute gastroenteritis
Abdominal pain, vomiting with occasional
blood and mucus in the stool.
2. Henoch–schönlein purpura
Characteristic rash and abdominal pain.
3. Rectal prolapse
The projecting mucosa can be felt in
continuity with the perianal skin whereas in
intussusception the finger may pass
indefinitely into the depths of a sulcus.
66. Triad of small bowel obstruction in plain
x-ray
1. Dilated small bowel loops > 3 cm.
2. Multiple air fluid levels in erect x-ray.
3. Paucity of air in the colon.
67. Treatment of intussusception
1. Intravenous fluids
2. Broad-spectrum antibiotics
3. Nasogastric drainage
4. Non-operative reduction using an air or
barium enema
68. SURGERY
Transverse right sided abdominal incision
Reduction is achieved by gently
compressing the most distal part of the
intussusception toward its origin not to
pull.
69. Treatment of sigmoid volvulus
NG suction
IV fluids
Antibiotics
Catheterisation
Sigmoidoscopy and insertion of a flatus
tube to allow deflation of the gut.
70. 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).
71. Types of Volvulus
Primary:
Volvulus neonatorum
Caecal volvulus
Sigmoid volvulus
Secondary: Common and is due to rotation of
a segment of bowel around an acquired
adhesion or stoma.
74. PRESENTATION
Fulminant:
Sudden onset
Severe pain
Early vomiting, rapidly deteriorating clinical
course.
Indolent:
Insidious onset,
Slow progressive course
Less pain, late vomiting.
75. Treatment of sigmoid volvulus
NG suction
IV fluids
Antibiotics
Catheterisation
Sigmoidoscopy and insertion of a flatus
tube to allow deflation of the gut.
78. Surgical options
1. Fixation of sigmoid colon to the posterior
abdominal wall.
2. Paul–mikulicz procedure.
3. Hartmann’s procedure.
79. Surgical options
A flatus tube or Sigmoidoscope is passed in
operation theatre.
If derotation does not occur, laparotomy
If viable, it can be fixed to the lateral wall of
abdomen or pelvis—sigmoidopexy.
80. Surgical options
If gangrene, it is resected and proximal cut end
brought out as colostomy and distal end brought
out as mucous fistula, (Paul-Mikulicz Operation).
Resection of the gangrenous sigmoid done;
proximal cut is brought out as end colostomy:
distal end closed—Hartmann’s operation.
Primary resection and anastomosis.
81. ADYNAMIC OBSTRUCTION
Failure of transmission of peristaltic waves
secondary to neuromuscular failure in the
myenteric (Auerbach’s) and submucous
(Meissner’s) plexuses).
82. CAUSES
Postoperative: hypoproteinaemia or
metabolic abnormality
Infection: intra-abdominal sepsis
Reflex ileus: fractures of the spine or ribs,
retroperitoneal haemorrhage.
Metabolic: uraemia and hypokalaemia
83. CLINICAL FEATURES
1. No passage of flatus.
2. No bowel sounds.
3. Marked abdominal distension.
4. Vomiting of large volume of fluid.
5. Tachycardia.
6. Respiratory distress
7. High-pitched tinkling note ‘like bells at
evening pealing’.
8. Dull abdominal pain (not colicky).
85. TREATMENT
a. Nasogastric aspiration.
b. IV fluids.
c. Electrolyte management.
d. Catheterisation and urine output measurement.
e. The primary cause is treated.