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Intestinal obstruction by Dr.Usman Haqqani

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Intestinal obstruction

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Intestinal obstruction by Dr.Usman Haqqani

  1. 1. Intestinal Obstruction Dr.Usman Haqqani TMO Surgical B Hayatabad Medical complex peshawar
  2. 2. Classification • According to obstructing site • Small bowel obstruction • Large bowel obstruction • According to presentation • Acute obstruction • Chronic obstruction • Acute on chronic obstruction • Subacute obstruction • According to blood flow • Simple obstuction • Strangulated obstuction • Primary • External • Closed loop obstruction
  3. 3. AETIOLOGY
  4. 4. CAUSES OF INTESTINAL OBSTRUCTION Dynamic causes  Intraluminal impaction foreignbodies bezoars gallstones  Intramural stricture malignancy  Extramural bands/adhesions hernia Volvulus Intussusception Adynamic causes Paralytic ileus Mesenteric vascular occlusion Pseudo -obstruct
  5. 5. Common causes of obstruction ADHESION TUMOR
  6. 6. Common causes of obstuction
  7. 7. Incidence Small Bowel (85%)  Cancer (75%)  Diverticulos.(10%)  Volvulus(10%)  Miscellan.(10%) In Eastern Countries& Middle East volvulus accounts for > 50% of causes of colon obstruction COLON (15%)  Adhesions(80%)  Hernia(10%)  Tumors(5%)  Miscellan.(5%)
  8. 8. etiology: I. 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
  9. 9. ADHESIVE INTESTINAL OBSTRUCTION
  10. 10. ADHESIVE INTESTINAL OBSTRUCTION
  11. 11. Etiology(small bowel) II. Hernia(12% of causes) A. External:  Inguinal ; Femoral; Umbilical B. Internal: Sites Foramen of Winslow Defect in the mesentery or transverse mesocolon Defect in the broad ligament Diaphragmatic hernia Duodenal/caecal/appendiceal retroperitoneal fossae
  12. 12. Strangulated small bowel loop(strangulated inguinal hernia)
  13. 13.  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
  14. 14.  strictures A.Congenital: Intestinal Atresia B.Inflammatory: Crohns Disease Tuberculosis C. Neoplastic: Lymphoma Carcinoid
  15. 15. Volvulus • Twisting or axial rotation of a portion of bowel about its mesentery • Primary or secondary
  16. 16. Malrotation & neonatal volvulus • Treatment: • The volvulus is reduced, the transduodenal band(Ladd’s band) divided, the duodenum mobilised & the mesentry freed. • Appendicectomy is routinely performed to avoid diagnostic difficulty with appendicitis in the future. • Infarcted bowel necessitates resection.
  17. 17.  Intussusception: • Invagination of segment of bowel(intussusceptum) into another(intussuscepien). • it is often antegrade • Most common: ileocolic(ileocaecal) Ileo-ileal A. Primary: infants & young children Due to lymphoid hypertrophy of terminal ileum B. Secondary: adult Due pathological lead point : Meckles diverticulum ;polyp ;submucous lipoma ; haemangiomas ;Lymphoproliferative disease
  18. 18. Intussusception
  19. 19. JEJUNO-JEJUNAL INTUSSESCEPTION(IN ADULT)
  20. 20. Bolus Obstruction 1. Gall stones • In the elderly • Classically there is impaction about 60 cm proximal to the ileocaecal valve
  21. 21. 2. Food Occur after partial or total gastrectomy when unchewed articles can pass into the small bowel 3. Stercolith • In association with jejunal diverticulum or ileal stricture
  22. 22. 4. Trichobezoar • Firm masses of undigested hair balls
  23. 23. 5. Phytobezoar • Firm masses of fruit or vegetable fibres
  24. 24. 6. Worms • In children • Ascaris Lumbricoides
  25. 25. Adynamic obstruction I. Paralytic Ileus:  There is Reflex Inhibition of Peristaltaic Activity of Small intestine due to increase sympathetic Drive. smooth muscle become unresponsive to neural and hormonal stimuli  Causes: 1) Postlaparotomy: after Abd.Pelvic surgery
  26. 26. I. Paralytic ileus( CAUSES) 2) Intra-abdominal Sepsis 3) Abdomino-pelvic Trauma (Retroperitoneal Haematoma) Other Contributing Factors:  Electrolytes Imbalance  Uraemia  Drugs: Narcotics ; Antichlonergices; phenothiazines
  27. 27. II. 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 major TRAUMA;ILLENESS; MAJOR NON-INTESTINAL SURGERY
  28. 28. ETIOLOGICAL FACTORES  Major non-operative TRAUMA  SEPSIS  Myocardial infarction ; Heart Failure  Major Abdomino-pelvic Surgery  Orthopedic Surgery  Gynecological ; Neurosurgical Procedures  Cerebrovasular accident ; Spinal cord Injury  Advanced Malignancy  Respiratory ; Renal Failure  Drugs: Opiates; phenothiazines ;Chanel blockers
  29. 29. III. Acute mesenteric ischemia 1. Embolic: (50%) • Affects SMA • Occur secondary to MI; Atrial Fibrilation 2. Trombotic(20%) due to acute thrombosis on top of pre-existing atherosclerosis of visceral artery 3. SHOCK: • hypovolemic & septic
  30. 30. HISTORY • Acute obstruction • Sudden onset of central abdominal colicky pain • Vomiting (party digested food>>mucoid>>greenish>>feculant) • Abdominal distention • Absolute constipation • Chronic obstruction • Constipation • Abdominal distention • Abdominal pain( bouts of colic pain in hyopogastrium) • VOMITING DELAYED FOR 2-3 DAYS
  31. 31. PHYSICAL EXAMINATION INSPECTION Abdominal distention, scars, visible peristalsis. PALPATION Mass, tenderness, guarding PERCUSSION Tymphanic, dullness AUSCULTATION Bowel sound are high pitch and increase in Frequency DIGITAL RECTAL EXAMINATION
  32. 32. INVESTIGATIONS: • Lab: • FBC (leukocytosis, anaemia, hematocrit, platelets) • Clotting profile • Arterial blood gasses • U& Crt, Na, K, Amylase, LFT and glucose, LDH • Group and save (x-match if needed) • Optional (ESR, CRP, Hepatitis profile) • RadiOlogical: • Plain ABDOMINAL xrays • USS ( free fluid, masses, mucosal folds, pattern of paristalsis, Doppler of mesenteric vasulature, solid organs) • Other advanced studies (CT, Contrast studieS)
  33. 33. Errect abdomen x ray with air fluid levels Supine radiograph distended small bowel loops in the central abdomen with prominent valvulae conniventes ( white arrow) Figure 3. Lateral decubitus view of the abdomen, showing air-fluid levels (arrows).
  34. 34. The Difference between small and large bowel obstruction Small BowelLarge bowel •Central ( diameter 3 cm max) •Vulvulae coniventae •Peripheral ( diameter 6 cm max) •Presence of haustration
  35. 35. Abdominal X-Ray What is Diagnosis? (1) Dilated Colon >6cm (2) Effacement of Haustrae Peripherally located (3) Multiple Air Fluid Levels Large Bowel Obstruction Rule of 3,6,9:  suspect obstruction if small bowel dilated >3cm; large bowel >6cm, cecum >9cm.
  36. 36. Cecalvolvulus • Sigmoid volvulus
  37. 37. • Intussusception
  38. 38. Role of CT • Used with iv contrast, oral and rectal contrast (triple contrast). • Able to demonstrate abnormality in the bowel wall, mesentery, mesenteric vessels and peritoneum. • It can define: • the level of obstruction • The degree of obstruction • The cause: volvulus, hernia, luminal and mural causes • The degree of ischaemia • Free fluid and gas • Ensure: patient vitally stable with no renal failure and no previous alergy to iodine • Figure: Axial computed tomography scan showing dilated, contrast-filled loops of bowel on the patient’s left (yellow arrows), with decompressed distal small bowel on the patient’s right (red arrows). The cause of obstruction, an incarcerated umbilical hernia, can also be seen (green arrow), with proximally dilated bowel entering the hernia and decompressed bowel exiting the hernia. Source: Jackson, PG. & Raiji M., Evaluation and Management of Intestinal Obstruction, January 2011, American
  39. 39. Role of barium gastrografin studies • As: follow through, enema • Useful in recurrent and chronic obstruction • Can be used to distinguish adynamic and mechanical obstruction Barium should not be used in a patient with peritonitis
  40. 40. intussuseption• Bird beak sign in cecal volvulus
  41. 41. Intussuseption
  42. 42. Source: Jackson, PG. & Raiji M., Evaluation and Management of Intestinal Obstruction, January 2011, American
  43. 43. TREATMENT • URGENT RESUSCITATION • NBM • NG tube(bowel decompression) • Cathetrization • IV fluids (correct fluid and electrolyte disturbances) • Start IV antibiotics (if indicated) • Optimise Cardio respiratory status • Consenting • Bowel preparation • Workup for surgery • Close clinical and Radiological monitoring
  44. 44. II. SURGICAL INTERVENTION 1. URGENT: • Strangulation / Suspected Strangulation • Closed-Loop Obstruction • Complete Obstruction • Pnumoperitonium/ Peritonitis
  45. 45. 2. Elective Cases • Adhesive Small intestine Obstruction NO Strangangulation ( Observe&Mointoring For 48-Hours ) • Incomplete Small intestine or Colonic Obstruction: Investigate With Contrast Studies
  46. 46. 3. NOT TO OPERATE • PARALYTIC ILEUS • ACUTE COLONIC PSEUDO-OBSTRUCTION
  47. 47. INDICATIONS FOR SURGERY • Absolute • Generalised peritonitis • Localised peritonitis • Visceral perforation • Irreducible hernia • Relative • Palpable mass lesion • 'Virgin' abdomen • Failure to improve • Trial of conservatism • Incomplete obstruction • Previous surgery • Advanced malignancy • Diagnostic doubt - possible ileus Source: http: Surgical Tutor.co.uk
  48. 48. Generalsteps of Surgery • At first most importantly the caecum is identified collapsed distended (small gut obstruction) (large gutobstruction)
  49. 49. Site of obstruction is identified Nature of the obstruction is identified & removed Viability of the gut is assesed
  50. 50. Gut is viable it is not viable Gut is put inside the ResectionAnastomosis Abdomen. • Abdomen closed in layers using Non-absorbable sutures.
  51. 51. Comparison between Viable & Non-viable Gut Features of viable gut • Pinkish • Luster-present • Peristaltic movement- present • When pricked by a needle-bleeding from the surface • Pulsation-present in mesenteric vessels Features of non-viable gut • Blackish • Absent • Absent • There Is no bleeding • No pulsation
  52. 52. If still we are doubtful- • Warm saline soaked mop over the doubtful area & 100% O2 is administered • If colour becomes normal with peristalsis,then it is viable.
  53. 53. Other means of checking Viability 1. Doppler study 2. Fluorescence study
  54. 54. Management of bowel obstruction • Intussusception • Reduction by hydrostatic pressure • Operative reduction • Volvulus neonatorum • Early laprotomy • Whole Midgut is delivered • Untwisting is done in opposite direction • Transduodenal band of lad is devided
  55. 55. • Cecal volvulus • Laprotomy • Balooned cecum defalted by needle • Untwisting in anticlockwise direction • Cecostomy is performed • Sigmoid volvulus • Deflation sigmoidoscopy • Operative • Laprotomy • Untwisted in clockwise direction • Rectal tube passed simultaneously to deflate
  56. 56. • Paralytic ileus • Remove primary cause • Decompress GI distension • Fluid and electrolyte balance • If not relieved  laparotomy exclude hidden cause • Acute Mesenteric Occlusion • Anti-coagulant • Embolectomy • Revascularization • Colectomy • Adhesions • Conservative treatment should not be prolonged beyond 72 hours. • divide only the causative adhesion(s) and limit dissection
  57. 57. MANAGEMENT FOR LARGE BOWEL OBSTRUCTION  (IF Lesion/Mass is removable) •Right sided lesions – right hemicolectomy •Transverse colonic lesion – extended right hemicolectomy  (if lesion/Mass is irremovable) •Proximal stoma •Colostomy •Ileostomy if ileocecal valve is incompetent •Ileotransverse enterostomy •Left sided lesions – various options
  58. 58. Two-staged procedure •Resection and anastomosis with defunctioning colostomy •Closure of colostomy Two-staged procedure •Hartmann’s procedure •Closure of colostomy One-stage procedure •Resection, on-table lavage and primary anastomosis
  59. 59. Complications associated with intestinal obstruction repair • include excessive bleeding • infection • formation of abscesses (pockets of pus) • leakage of stool from an anastomosis • adhesion formation • paralytic ileus (temporary paralysis of the intestines) • reoccurrence of the obstruction.

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