Intestinal Obstruction

Armando G. Santos, MD, FPCS

Intestinal Obstruction: Essential Features

Mechanical disruption o passa!e o intestinal contents alon! the bo"el #"o main t$pes:

Small bo"el obstruction %S&O' (ar!e bo"el obstruction %(&O' Partial )s. Complete Simple )s. Stran!ulatin! Open loop )s. Closed loop

Classi ied as:

Age Group

Fre*uent Causes o Obstruction

Etiology
Adhesions

!oun" adults and #iddle$a"ed

Elderly

and bands Incarcerated hernia Granulomatous disease (Crohns disease, TB Colonic cancer Diverticulitis Impacted feces Adhesions Incarcerated hernia

%atholo"ical Deran"ement in Intestinal &bstruction

'luid and electrolyte disturbance Bacterial proliferation (ascular disturbance Bo)el )all chan"es

Intestinal Obstruction: Clinical Dia!nosis

Main s$mptoms:

Abdominal pain +omitin! Abdominal distention Obstipation

Character,onset o S- help determine le)el o obstruction

Intestinal Obstruction: Clinical Dia!nosis

*istory of previous operation+cancer+hernia ,i"ns of stran"ulation+perforation ,i"ns of dehydration+shocAbdominal distention &perative scar (isible peristalsis Borbory"mi Abdominal+rectal mass Incarcerated hernia

(isible %eristalsis

Stran!ulated Femoral .ernia

Clinical Findin!s Su!!esti)e o Stran!ulation

Continuous pain Fe)er #ach$cardia Peritoneal irritation (eu/oc$tosis C0reacti)e protein ele)ation Increase in serum lactate
No clinical parameters or laboratory tests can accurately detect or exclude presence of strangulation in all cases

Intestinal Obstruction: +ital Steps in Clinical Dia!nosis

1.

3. 4.

5.

2eco!nition o presence o intestinal obstruction Attempt to locate its le)el %site' Attempt to detect i stran!ulation present Disco)er$ o etiolo!$ o obstruction

Small &o"el Obstruction: Dia!nostic In)esti!ation

C&C Serum electrol$tes &67,creatinine A&G 8 i complication suspected Supine and erect plain -0ra$ ilms C# scan Abdominal ultrasound &arium radio!raph$

Pro-imal S&O: Plain 2adio!raphs

Distal S&O: Plain 2adio!raphs

Supine

6pri!ht

Distal S&O: Plain 2adio!raph and C#

&arium 2adio!raph: 9e:uno:e:unal Intussusception

9e:uno:enunal Intussusception

C#: Ileal Intussusception "ith #$pical #ar!et Si!n

6#;: Dilated 9e:unal (oops

Causes o S&O in Adults as to Site

E-trinsic to bo"el "all
Adhesions %post0op esp.' .ernia 7eoplasms
Carcinomatosis E-tra0intestinal tumor Intraluminal

Intrinsic to bo"el "all

Congenital
Duplication,c$sts

Inflammatory
#& Di)erticulitis

Neoplastic
Primar$,metastatic tumors

Intra0abdominal Gallstone abscess &e<oar Forei!n bod$

Traumatic
.ematoma

Miscellaneous
Intussusception

S&O due to Adhesi)e &and

S&O due to Dense Adhesions

S&O: Internal .ernia due to Adhesi)e &ands

S&O due to Carcinoid #umor

Causes o S&O in Adults

Cause Adhesion 7eoplasm .ernia +ol)ulus In lammator$ bo"el disease Intussusception Gallstone ileus 2adiation enteritis Intra0abdominal abscess

Incidence (%) =>0?= @01= @01= 4 1 A1 A1 A1 A1 A1

S&O: Mana!ement

Initial resuscitation and decompression Conservative T. reserved for partial ,B& Close monitorin" mandatory if under conservative T. ,ur"ery "enerally indicated for/

Complete ,B& 0o improvement in 12 hours

,ur"ery ur"ent in suspected stran"ulation

$ Abdominal pain $ 0ausea+vomitin" $ Abdominal distention $ &bstipation

MAl!orith m or S&O

$ Clinical history $ %hysical e.amination $ Abdominal radio"raphs

%artial ,B&

Complete ,B&

3ar"e bo)el obstruction

$ Crescendo pain $ 4nrelentin" pain $ Clinical deterioration $ 5adio"raph deterioration

Treat appropriately

0o

!es
&peration

%revious *. of prohibitive reoperative ris-s 6 successful conservative #.

$ 0GT decompression $ ,erial %E $ ,erial radio"raphs $ 'luid 6 electrolyte #.

Causes o (&O in Adults

Cancer: B>C +ol)ulus: 1>01=C Di)erticulitis: 1>01=C .ernia Ischemia,radiation induced stricture Carcinomatosis Pel)ic recurrence o rectal cancer Intussusception Forei!n bod$ In lammator$ bo"el disease Fecal impaction

(&O: Dia!nostic In)esti!ation

Supporti)e blood tests Supine and erect plain radio!raphs C# scan Dater0soluble contrast enema Colonoscop$ Abdominal ultrasound &arium radio!raph$

(&O: Mana!ement Strate!$

2esuscitation promptl$ administered D- should !uide appropriate #Initial non0sur!ical #-, i possible, "ith electi)e de initi)e sur!er$ 7on0operati)e and sur!ical #tailored to cause I indicated, emer!enc$ sur!er$ must: 2elie)e obstruction #reat underl$in! patholo!$ i easible

Obstructed Colorectal Ca: M

I uncomplicated: Endoscopic stent placement and electi)e resection I complicated or "ith ailed endoscopic stentin!: 2esection and anastomosis %i easible' 2esection and colostom$

Obstructed Distal #rans)erse Colon "ith Competent Ileocecal +al)e

Obstructed Pro-imal #rans)erse Colon "ith Incompete nt Ileocecal +al)e

Obstructi)e .epatic Fle-ure CA

+ol)ulus o the Colon: Predisposin! Factors

2edundant mobile colon se!ment "ith narro" base Distention o colon b$ eces or !as

Si!moid +ol)ulus

+ol)ulus o the Colon: #$pes

Si!moid )ol)ulus %EB=C o cases' Cecal )ol)ulus #rans)erse colon )ol)ulus

Si!moid +ol)ulus: Plain 2adio!raph

Cecal +ol)ulus: Plain 2adio!raph

Contrast Enema: F&irdGs &ea/H at (e)el o Cecal +ol)ulus

Si!moid +ol)ulus: Sur!ical M

I uncomplicated: Endoscopic decompression and electi)e resection o redundant si!moid I complicated or "ith ailed endoscopic decompression: resection and colostom$

Si!moid +ol)ulus: Pre and Post0decompression I0ra$

Gan!renous Si!moid +ol)ulus

Cecal +ol)ulus

Intestinal Obstruction: Summar$

#horou!h .-,P.E. plus plain -0ra$ usuall$ ade*uate to ma/e D- and #plan Further tests indicated or uncertain cases Supporti)e measures pro)ided in all cases Complete S&O !enerall$ re*uires sur!er$ Operation ur!ent or stran!ulation

Intestinal Obstruction: Summar$

(&O lar!el$ caused b$ colorectal cancer, si!moid )ol)ulus and di)erticulitis M- o (&O should be non0operati)e initiall$ ollo"ed b$ electi)e de initi)e sur!er$, i easible Emer!enc$ operation or (&O should aim to treat underl$in! patholo!$

Stran!ulated S&O "ith Gan!rene due to Adhesion

&arium Enema: Ileocecal #&

Cecum and ascending colon fibrotic and retracted craniad, scarred and sacculated (curved arrows); terminal ileum relatively patulous (straight arrows) and probably nodular. v ileocecal valve.

Ileocecal #&

C#: Complete S&O due to Incisional .ernia

C#: S&O "ith Fluid0 illed, Dilated Small &o"el (oops %"hite arro"s'J Collapsed 2i!ht Colon %red arro"' K

Mid0si!moid Obstruction due to Adhesi)e &and

Have a Nice Day!