INTESTINAL

OBSTRUCTION
Methas Arunnart MD.

The common Scenario

A 50 year old gentleman presents
with abdominal pain, distension and
absolute constipation. With
repeated episodes of vomiting.
His vital sign were stable, abdomen
distended with diffuse tenderness
but minimal peritonism. Bowel
Sounds are hyperactive.
The plain abdominal xray was taken
on admission.

Introduction and Definitions

Accounts for 5% of all acute surgical admissions
Patients are often extremely ill requiring prompt
assessment, resuscitation and intensive
monitoring

Obstruction A mechanical blockage arising from a

structural abnormality that presents a
physical
barrier to the progression of gut
contents.
Ileus
is a paralytic or functional variety of
obstruction

Patho-physiology I

8L of isotonic fluid received by the small

intestines (saliva, stomach, duodenum, pancrea
s and hepatobiliary )
7L absorbed
2L enter the large intestine and 200 ml excreted
in the faeces
Air in the bowel results from swallowed air ( O 2
& N2) and bacterial fermentation in the colon ( H2
, Methane & CO2), 600 ml of flatus is released

If mucosal barrier is breached it may

result in translocation of bacteria and
toxins resulting in bactaeremia,
septaecemia and toxaemia.

Patho-physiology II
Obstruction results in:
1.
2.
3.
4.
5.
6.
7.
8.

Initial overcoming of the obstruction by

increased paristalsis
Increased intraluminal pressure
Vomiting
Lymphatic and venous congestion resulting
in edematous tissues
sequestration of fluid into the lumen from
the surrounding circulation
Factors 3,4,5 result in hypovolaemia and
electrolyte imbalance
Further: localised anoxia, mucosal depletion
necrosis and perforation and peritonitis.
Bacterial over growth with translocation of
bacteria and its toxins causing bacteraemia
and septicaemia.

HOW TO
APPROACH?

WHAT ARE YOUR OBJECTIVES?

You should be able to address these questions
1.
2.
3.
4.
5.

Is this bowel obstruction?

Partial or complete obstruction?
Site of obstruction?
Cause of this obstruction?
Is this a complicated or simple obstruction?

1. IS THIS BOWEL
OBSTRUCTION?

Clinical Findings

1. History

The Universal Features

Colicky abdominal pain
Vomiting
Constipation/obstipation
.Abdominal distension

Clinical Findings

2. Examination
Others
Systemic examination
If deemed necessary.
CNS
Vascular
Gynaecological
muscuoloskeltal

Abdominal
Abdominal
distension and its
pattern
Hernial orifices
Visible peristalsis
Cecal distension
Tenderness,
guarding and
rebound
Organomegaly
Bowel sounds
High pitched
Absent

Rectal examination

General
Vital signs:
P, BP, RR, T, Sat
dehydration
Anaemia, jaundice,
LN
Assessment of
vomitus if possible
Full lung and heart
examination

Radiological Evaluation
Normal Scout
Always request:
Supine, Upright and CXR
Gas pattern:

Gastric,
Colonic and 1-2 small bowel

Check gasses in 4 areas:

1.
2.
3.
4.

Caecal
Hepatobiliary
Free gas under diaphragm
Rectum

Look for calcification,soft tissue masses,

psoas shadow
Look for fecal pattern

X-ray finding

Different height
in the same loop

Step ladder pattern

Ileus

Associated with the following conditions:

Metabolic abnormalities:

Hypokalaemia

Hyponatremia

Uraemia

Hypomagnesemia
Postoperative and bowel resection
Intraperitoneal infection or inflammation
Ischemia
Extra-abdominal: Chest infection, Myocardia infarction
Endocrine: hypothyroidism, diabetes
Spinal and pelvic fractures
Retro-peritoneal haematoma
Bed ridden
Drug induced: morphine, tricyclic antidepressants

Is this an ileus or obstruction

Clinical features

Is there an under lying cause?

Is the abdomen distended but tenderness is not marked.

Is the bowel sounds diffusely hypoactive.

Radiological features:

Is the bowel diffusely distended

Is there gas in the rectum

Are further investigasions (CT or Gastrografin studies)

helpful in showing an obstruction.

Does the patient improve on conservative measures

Example of ileus

2.PARTIAL OR COMPLETE
OBSTRUCTION?

3. SITE OF
OBSTRUCTION?

Clinical Findings
Colonic

Distal small bowel

Pain: central and

colicky
in bowel habit
Vomitus is feculunt
Colicky in the lower
abdomin
Distension is severe
Vomiting is late
Visible peristalsis
Distension prominent May continue to pass
flatus and feacus
Cecum ? distended
before absolute
constipation

? Preexisting change

High
Pain is rapid
Vomiting copious and
contains bile jejunal
content
Abdominal distension
is limited or localized
Rapid dehydration

Persistent pain may be a sign of strangulation

Relative and absolute constipation

The Difference between small

and large bowel obstruction
Small Bowel
Central ( diameter 5 cm max)
Vulvulae coniventae
Ileum: may appear tubeless

Large bowel
Peripheral ( diameter 8 cm max)
Presence of haustration

4. CAUSE OF
OBSTRUCTION?
Small bowel VS Large bowel obstruction

Causes- Small Bowel

Extralumina Mural
l

Luminal

Postoperati
ve
adhesions

F. Body
Bezoars
Gall stone
Food
Particles

Congenital
adhesions
Hernia
Volvulus

Neoplasm
lymphoma
carcinoid
carinoma
lipoma
polyps
leiyomayoma
hematoma
secondary
Tumors
TB
Crohns
Stricture
Intussusception
Congenital

A. lumbricoides

Small Bowel Adhesions

Accounts for 60-70% of All SBO

Results from peritoneal injury, platelet activation
and fibrin formation.
As early as 4 weeks post laparotomy. The majority
of patients present between 1-5 years
Colorectal Surgery 25%
Gynaecological
20%
Appendectomy
14%
70% of patients had a single band
Readmission in surgically treated patients is 35%

Hernia

Accounts for 10% of SBO

Commonest
1. Femoral hernia

2. ID inguinal
3. Umbilical
4. Others: incisional and internal H.

Site of obstruction is the neck of hernia

The compromised viscus is with in the

sac.

Ischaemia occurs initially by venous

occlusion, followed by oedema and arterial
compromise.

Hernia

Followed by oedema and arterial compromise.

Attempt to distinguish the difference between:

Incaceration

Sliding

Obstruction

Strangulation is noted by:

Persistent pain
Discolouration
Tenderness
Constitutional symptoms

Intussusecption

Intussusception is an "internal prolapse" of the

bowel
This occurs when a mass or lead point in the bowel
is pulled forward by normal peristalsis
Intussusception is rare in adults, 1-5% of SBO.
Adult intussusception commonly involves a distinct
pathologic lead point, which is malignant in over hal
f of the cases.
Pediatric intussusception is usually due to a benign
etiology and can usually be managed with non-oper
ative reduction.

Intussusecption

Symptoms are often chronic; intermittent abdominal

pain is the most common presentation in adults.
The diagnosis is most often made with CT
A "target sign" may be seen on CT on perpendicular
view, while the intussusception will appear as a
sausage shaped mass when the CT beam is parallel
to the longitudinal axis.
An increased incidence of intussusception has been
reported in patients with AIDS. This is due to the hig
h incidence of conditions, such as lymphoid hyperpl
asia, Kaposi's sarcoma, and non-Hodgkin's lymphom
a.

Intussuseption in CT

Other causes

Intussusception

Gall stone Ileus

IBD

Large Bowel Obstruction

Distinguishing ileus from mechanical obstruction is challenging
According to Leplacs law: maximum pressure is at the its
maximum diameter. Cecum is at the greatest risk of perforation

Aetiology:
1. Carcinoma:
The commonest cause, 18% of CA colon
present with obstruction
2. Benign stricture: Due to Diverticular disease, Ischemia,
Inflammatory bowel disease.
3. Volvulus:
1. Sigmoid Volvulus
2. Caecal Volvulus
4. Hernia:
5. Congenital :
Hirschusbrung, anal stenosis and agenesis

Sigmoid Volvulus

Colonic Obstruction

Sigmoid volvulus

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 allergy to iodine

CT SCAN

Role of barium gastrografin

studies
Barium should not be used in
a patient with peritonitis

As: follow through, enema

Limited use in the acute setting
Gastrografin is used in acute
abdomen but is diluted
Useful in recurrent and chronic
obstruction
May able to define the level and
mural causes.

5. IS THIS A SIMPLE
OR COMPLICATED
OBSTRUCTION?

Who suspected complicated

obstruction?
Patients suspected on admission of
having complicated obstruction with
complete or closed-loop obstruction
patients with fever, leukocytosis,
tachycardia, metabolic acidosis
continuous abdominal pain or peritonitis
those who develop these signs and
symptoms during the course of nonopera
tive Mx.

Closed loop obstruction

Small bowel

Large bowel

MANAGEMENT

INITIAL MANAGEMENT
The primary goals in the initial management
of patients with SBO are to determine:

The degree of volume depletion and metabolic

derangement
The severity, cause, extent and location of the
obstruction
Whether nonoperative management can be
considered
The need for and timing of operative
intervention

INITIAL MANAGEMENT

Adequate intravenous (IV) access should be

obtained for fluid resuscitation. should be given u
ntil the patient makes urine or is clinically euvole
mic.

A Foley catheter should be placed to monitor urine

output. If necessary, a central venous catheter or Sw
an-Ganz catheter can be inserted

Bowel decompression NPO +NG tube insertion

Antibiotics are not indicated in the routine.
Patients who indicate the need for surgery should
receive prophylactic antibiotics perioperatively.

OPERATIVE
MANAGEMENT

The timing of surgical intervention requires careful consideration. Approximately

one-quarter of patients admitted for small bowel obstruction will require
operation. Patients suspected on admission of having complicated obstruction w
ith complete or closed-loop obstruction, patients with fever, leukocytosis, tachyc
ardia, metabolic acidosis, continuous abdominal pain or peritonitis, or those who
develop these signs and symptoms during the course of nonoperative managem
ent warrant prompt surgical exploration [45
]. Although prophylactic antibiotics are not routinely administered for uncomplic
ated small bowel obstruction, antibiotics may be warranted for patients with co
mplications (eg, perforation) (table 2) [52-54].

Every patient considered for exploration due to a suspected small bowel

obstruction, whether open or laparoscopically, should be appropriately resuscita
ted prior to surgery with IV fluids and have their electrolytes repleted, as indicat
ed. This is especially important for patients with copious emesis resulting from
more proximal obstruction, obstruction lasting several days, or obstruction causi
ng large-volume intraluminal fluid sequestration. These patients may have sever
e metabolic acidosis, volume depletion, and electrolyte abnormalities, and need
resuscitation prior to operation.