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GIS-K-26

INTESTINAL OBSTRUCTION
Syahbuddin Harahap
Division of Digestive Surgery
Department of Surgery
Faculty of Medicine University of North Sumatera
Adam Malik Hospital

DEFINITION
Bowel /Intestinal obstruction occurs when the normal
propulsion and passage of intestinal contents does not
occur
BO can involve:
SBO Small intestine
LBO Large intestine
Generalized Ileus
via systemic alterations
involving both the small and large intestine

Etiopathogenesis
- Mechanical obstruction
- Non mechanical (Functional ) obstruction
Mechanical obstruction (Dynamic ) ileus refers to a lack
of passage due to an obstruction of the bowel,
which can be located anywhere in the bowel
Non mechanical Obstruction (Paralytic )(adynamic)
(Fungsional) ileus
Paralytic ileus refers to a lack of passage due to
paralysis of the bowel

Intestinal /Bowel Obstruction can also be classified


according to :
Time of presentation and duration of obstruction:
- Acute
- Chronic
The extent of obstruction
-Partial
-Complete
The type of obstruction
-Simple
-Closed-loop
-Strangulation

Nonmechanical Obstruction
Paralytic (adynamic) (Fungsional) ileus due to :
1. After abdominal operations
2. Inflammation Peritonitis
3. Systemic disorders e.g. sepsis, hyponatremia, hypokalemia,
hypomagnesemia
4. Retroperitoneal disorders e.g. ureter, spine fractures ,
hematoma
5. Thoracic conditions e.g. pneumonia, rib fractures
6. Drugs e.g opiates, psychotropics , General anesthesie
Pseudo-Obstruction
Imbalance in the parasympathetic and sympathetic influences
on Colonic motility.
Acute colonic pseudo-obstruction, also known as Ogilvie
syndrome.

MECHANICAL OBSTRUCTION
at each age group
Neonate
Congenital atresia
Volvulus neonatum
Meconeum ileus
Hirschsprungs disease
Imperforate anus
Infant
Stranggulated inguinal hernia
Intussuception
Complication of Meckels diverticulum
Hischsprungs diseases
Young adult
Adhesions and bands
Strangulated ing.hernia

Middle age
Adhesesion and band
Strangulated Ing.hernia
Strangulated fem.hernia

Carcinoma colon
Volvulus
Elderly
Adhesion and bands
Strangulated Ing.hernia
Strangulated fem.hernia
Carcinoma colon
Volvulus
Impacted faeces

Incidence Mechanical Obstruction


May occur at any age
70 percent small bowel obstruction (SBO)
30 percent large bowel obstruction (LBO)

Common Causes SBO

Common Causes of LBO

Adhesion
Neoplasma
Hernia
Crohn
Miscellaneus

Colon cancer
Diverticulitis
Volvulus
Miscellaneous

60%
20%
10%
5%
5%

65 %
20 %
5%
10 %

Etiology?
Extrinsic (Outside the wall )

Intrinsic (Inside the wall )


Inside the lumen

Extrinsic (Outside the wall)


Adhesions
Hernia
-- inguinal, femoral, umbilical

Neoplastic
extraintestinal neoplasm

Volvulus (sigmoid, cecal)

Intrinsic (Inside the wall )


Congenital
Malrotation
Neoplastic
Primary neoplasms
Metastatic neoplasms
Inflammatory
Crohn's disease
Miscellaneous
Intussusception
Radiation

Intraluminal (Inside the lumen)


Gallstone
Enterolith
Bezoar

Foreign body
Parasit Bolus Ascaris

Clinical Picture
Mechanical obstruction
The classic quartet
1. Colicky abdominal pain
2. Abdominal distension
3. Nausea and Vomiting
4. Decreased passage of stool or flatus

Pathophysiology

Dependent upon :
1. Degree of obstruction
2. Duration of obstruction
3. Presence and severity of ischaemia
Result in :
1. Accumulation of fluid and air(Sequestration within the dilated
loop)
Fluid disturbances massive third space losses
8 10 L of fluid are secreted
Hypovolumic shock oliguria, hypotension,hemoconcentration
2. Electrolyte depletion
3. Bacterial overgrowth Rapid colonisation
-Maximal by 24 hrs after obstruction
-Bacterial translocation to node and portal system

4. Bowel distension
-Chest compression by pushing up diaghragma muscle
-Decreases the ability mucosa to absorb ,stasis intestinal content
of fluids and electrolytes
-Increased intraluminal pressure oedematous cyanosis
intraperitoneal exudation necrosis perforationperitonitis
-ACS impediment in venous returnarterial insufficiency
5. LBO
Ileocaecal valve plays prominent role in pathophysiology of LBO.
If competent valve = Closed loop obstruction
In 10 20 % of individual ICV incompetent
Caecal around 10 12 cm the risk of perforation

Clinical Manifestations
Altered mental state
Vital Sign
Hypovolumic shock
Tachicardia
Hypotension
Tachipnoe
Fever
Oliguria

Abdominal Examination
Patient Supine position with the legs flexed at the hip
Abdominal Colicky pain
The periodicity of pain:
3 to 4 minutes pain from proximal intestinal obstruction
15 to 20 minutes pain from distal small bowel or colon
On Inspection
Abdominal distension
Proximal obstructions may cause little or no distention
Distended small bowel loops usually occupy the central
abdomen Distended large bowel loops are typically seen
around the periphery .
Visible peristalsis which are indicative of acute small bowel
obstruction
Abdominal Scars Adhesion

On Auscultation
Performed for at least 3 to 4 minutes
Metallic sound
Borborygmi
The absence of bowel tones :
Is typical of intestinal paralysis .
LateQuiet abdomen (may also indicate
intestinal fatigue from long-standing
obstruction).

On Palpation
Inguinal ,Femoral , Umbilical ,Incisional Hernias
Palpable mass Abdominal asymmetry or a protruding mass
suggests an underlying malignancy, an abscess, or closed-loop
obstruction.
Peritoneal irritation
On Percuss
Dull Fluid or Mass
Tympanic Air (Intraluminal or not )
Peritoneal irritation

DRE (Digital Rectal Examination )


For Mass , Impacted faeces

Vomiting NG Aspirates
Consists food and gastric chyme bile
faeculent
GOO Clear , food and gastric chyme
Mid to distal SBO Bilious/Bile
Distal SBO to LBO Feculent

Mechanical Obstruction

Nonmechanical Obstruction

Abdominal
Pain

colicky pain severity may decrease over time as a


result of bowel fatigue and atony.
3 to 4 minutes from proximal SBO
15 to 20 minutes distal SBO or LBO

Diffuse , usually mild

Inspection

Abdominal distension
Visible peristalsis

Abdominal distension

Auscultation

Metalic Sound
Borborygme
Late Quiet Abdomen

Quiet abdomen

Abd.X Ray
Erect
Supine

Large small intestinal loops


gas less in colon
Step ladder A/F levels

Gas diffusely through


intestine, incl. colon
May have large diffuse A/F
levels

Barium
Enema

Obvious transition point on contrast study

No obvious transition point


on contrast study

Exudate

No peritoneal exudate

Peritoneal exudate if
peritonitis

Fluid resuscitation
HYPOVOLEMIC SHOCK <-> ARF
ACUTE RENAL FAILURE
PRERENAL
INTRARENAL
POSTRENAL
ARF : OLIGURIA < 500 ML/d
SERUM CREATININ > 3MG/dL

TREATMENT PRE RENAL ARF


INITIAL FLUID THERAPY
RESPON TO URINARY OUTPUT 0,5 1 cc /kg bw

Return of normal vital sign but NO RESPON TO URINARY OUTPUT OLIGURIA


CVP ------CVP 8-12 cm of water (or 10-15 cm of water in mechanically
ventilated patients).
VC RENAL VASCULATURE
TREATMENT
DIURESIS -- FUROSEMIDE 80-200 MG IV/TWD
INOTROPIC AGENTS LOW DOSE DOPAMIN /DOBUTAMIN 0,5 -3 ug/kg bw/min
VD RENAL VASCULATURE
INCREASE MYOCARDIAL CONTRACTILITY

EVALUATION OF FLUID RESUSCITATION

RETURN OF NORMAL VITAL SIGNS


MENTAL STATUS
URINARY OUTPUT
ACID/BASE BALANCE
CVP

Diagnoctic Studies
Laboratory test

Fecal Occult Blood Test


CBC
Serum electrolyte concentrations
The serum creatinine concentration / BUN
The coagulation profile
Urinalysis should be done to check for hematuria
Liver function profile

Sigmoidoscopy
Exclude a rectal or distal sigmoid obstruction.

Imaging / X ray examination


Chest x-ray
Exclude a pneumonic process
To look for subdiaphragmatic air.
Plain abdominal X ray
Erect and lying down routinely
Water soluble enema to exclude
colonic obstruction.
Colonic pseudo obstuction
LBO + incompetent
ileocecal thereby
mimicking small
bowel obstruction.

Barium enema X ray


transition point on contrast study

SIGMOID VOLVULUS
bent inner tube = Coffe bean appearance

Bird Beak

Management of Bowel Obstruction


Principles
Fluid resuscitation
Requirements = Deficit + Maintenance + Ongoing losses
Close monitoring hemodinamic
Foley catheter urine output
CVP
Electrolyte, acid-base correction
NGT decompression
Antibiotics
Diagnostic study
Informed concent
Exploratory laporotomy