INTESTINAL

OBSTRUCTION
M. IQBAL RIVAI
 Classification
Dynamic
peristalsis working against mechanical
obstruction

Adynamic
peristalsis may be absent
 Causes of intestinal obstruction
Dynamic Adynamic
Intraluminal Paralytic ileus
Impaction Mesentric vascular occlusion
Foreign bodies
Pseudo-obstruct
Gallstones
Intramural
Stricture
Malignancy
Extramural
Bands/adhesion
Hernia
Volvulus
Intussusception (discussed later)
 patophysiology
Dynamic obstruction below obst. bowel has
normal peristalsis until empty contracts and
becomes immobile
Proximal peristalsis becomes increased if
obst. is not relieved bowel dilates reduction
in peristaltic strength flaccidity and paralysis

Proximal distention caused by: GAS and FLUID

 Strangulation
Causes of strangulation
External
Hernial orifices
Adhesions/bands

Interrupted blood flow

Volvulus
Intussusception

Increased intraluminal pressure

Closed loop obstruction

Primary
Mesentric infarction
CLOSED-LOOP OBSTRUCTION
Carcinomatous stricture of the
hepatic flexure
 SPECIAL TYPES OF MECHANICAL
INTESTINAL OBSTRUCTION

Internal Hernia
portion of the small intestine becomes entrapped in
retroperitoneal fossae or congenital mesentric defect

Location
Foramen winslow
A hole in the mesentery or transverse mesocolon
Diaphragmatic hernia
Defects in broad ligament
Duodenal retroperitoneal fossae
Intersigmoid fossa
 SPECIAL TYPES OF MECHANICAL
INTESTINAL OBSTRUCTION

Obstruction of enteric strictures

Small bowel strictures secondary to tuberculosis or Crohns
disease
Malignant structures associated with lymphoma

Bolus Obstruction
Gallstones
Food
Trychobezoars and phytobezoars
Stercoliths
Worms
Obstruction due to ascaris l.
 Obstruction by adhesions/bands

Adhesions
Common cause: ischaemic areas, foreign material, infection,
inflammatory conditions, radiation enteritis
Prevention of adhesions
Good surgical technique
Washing peritoneal cavity with saline
Minimising contact with gauze
Covering anastomosis and raw peritoneal surfaces

Bands
Congenital
Following bacterial peritonitis
A portion of greater omentum
 Acute intussusception

Proximal portion of intestine into the distal

Mostly in children 5 to 10 months old
90% of cases are idiopathic
Hyperplasia of Peyers patches may be the initiating
event
ileocolic is the commonest variety
Can lead to ischaemic segment
Radiological reduction is indicated in most cases
The remainder require surgery
 Volvulus
Twisting or axial rotation of a portion of bowel
about its mesentery.
Volvulus may be:
Primary: secondary to malrotation of the gut,
congenital bands
Secondary: rotation of a piece of bowel around an
acquired adhesion or stoma
 Volvulus
Volvulus neonatorum
Occurs secondary to intestinal malrotation

Sigmoid volvulus
Rotation occurs in an anticlokwise direction
Causes predisposing volvulus
 CLINICAL FEATURES OF INTESTINAL
OBSTRUCTION
high small bowel obstruction
Vomiting
Rapid dehydration
Distention minimal
Low small bowel obstruction
Pain is predominant
Central distention
Vomiting is delayed
Multiple central fluid levels
Large bowel obstruction
Distention is early
Pain is mild
Vomiting and dehydration are late
Proximal colon and caecum are distended on abdominal radiography
CLINICAL FEATURES OF INTESTINAL
OBSTRUCTION

Types of obstruction:
Acute small bowel obstruction
Chronic large bowel obstruction
Acute on chronic short history of distention
and vomiting
Subacute incomplete obstruction
 CLINICAL FEATURES OF INTESTINAL
OBSTRUCTION
Abdominal pain
Vomiting
Distention
Constipation
Other manifestation
Dehydration
Hypokalemia
Pyrexia
Abdominal tenderness
Clinical features of strangulation

Constant pain
Tenderness with rigidity
Shock
In impending strangulation, pain is never
completely absent
Symptoms usually commence suddenly and
recur regularly
Clinical features of instussusception

Episodes of screaming and drawing up the legs

Child may appear pale
Vomiting becomes conspicuous and bile-
stained with time
Redcurrant jelly stool
Associated feeling emptiness in the right iliac
fossa (Dances sign)
Rectal examination: pseudoportio
 Clinical features in volvulus
Caecal volvulus
May occur as part of volvulus neonatorum
Usually a clockwise twist
More common in females

Sigmoid volvulus
Symptoms are of large bowel dilatation
 Imaging
Radiological features of obstruction
Obstructed small bowel
Straight segments that are generally central and lie
transversely. No gas seen in the colon
Jejunum is characterized by valvulae conniventes
Ileum
Distal ileum has been described by Wagensteen as featureless
Caecum
Shown by a rounded gas shadow in the right iliac fossa
Large bowel
Shows haustral folds which are spaced irregularly
 Imaging of intussusception
Plain abdominal radiograph can differ small or
large bowel obstruction
Barium enema may be used for diagnosis
(claw sign)
Ultrasonography: doughnut appearance
CT Scan can also be useful
 Imaging in volvulus
Caecal volvulus
May reveal a gas filled ileum and distended caecum
Barium enema : bird beak deformity, absence of barium in
caecum

Sigmoid volvulus
Plain radiograph shows massive colonic distention

Volvulus neonatorum
Abdomen becomes relatively gasless
Claw Sign
 TREATMENT OF ACUTE INTESTINAL
OBSTRUCTION

Gastrointestinal drainage
Fluid and electrolyte replacement
Relief obstruction
Surgical treatment is necessary for most of
cases but should be delayed UNTIL
rescuscitation is complete, provided there is
no sign of strangulation or evidence of closed-
loop obstruction
 Principles of surgical intervention for
obstruction
Management of:
The segment at the site of obstruction
The distended proximal bowel
The underlying cause of obstruction
 Supportive management
Nasogastric decompression
To help decompress
To prevent aspiration during induction of
anaesthesia and post extubation
Correction of dehydration
Correction of electolyte imbalance
Broad spectrum antibiotics
 SURGICAL TREATMENT
Indications for early surgical intervention
Obstructed or strangulated external hernia
Internal intestinal strangulation
Acute obstruction
TREATMENT OF ADHESIONS
Initially treat conservatively (max 72 hours) if
there are no signs of strangulation
at operation, divide only the causative
adhesions and limit dissection
Cover serosal tears
Resect areas of doubtful viability
Laparoscopic adhesiolysis may have a role in
chronic cases
 Treatment of reccurent obstruction
caused by adhesions

Repeat adhesiolysis
Nobles plication operation
Charles-Phillips transmesentric plication
Intestinal intubation
Nobles plication
Charles-Phillips procedure
Bakers tube via witzel jejunostomy
 TREATMENT OF INTUSSUSCEPTION

Resuscitation with IV fluids

Broad spectrum antibiotics
Nasogastric drainage
Non operative reduction barium enema or air
Successful free reflux of air or barium into the small
bowel, together with resolution of symptoms and
signs
If peritonitis is presented CONTRAINDICATION
 TREATMENT OF INTUSSUSCEPTION

Surgical approach:
Reducing terminal part of the
intussusception
 Treatment of acute large bowel
obstruction
Resuscitation
Nasogastric tube
Surgery
If the lesion is removable resect and direct
anastomosis
If the lesion is irremovable stoma
 Treatment of sigmoid volvulus

Sigmoidoscopy for deflation of the gut

If successful elective surgery
Failure early laparotomy
Untwisting of the loop decompression
Assess bowel viability
if viable, fixate sigmoid to posterior abdominal wall
If not viable resection by Mikulicz procedure
Mikulicz procedure
 Adynamic Obstruction
PARALYTIC ILEUS
A state in which there is failure of transmission
of peristaltic waves secondary to
neuromuscular failure
 Types of paralytic ileus
Postoperative
After abdominal procedure
Self limiting
Duration 24-72 hours
Infection
Intra-abdominal sepsis may give rise to ileus
Reflex ileus
Following fractures of spine or ribs, retroperitoneal
haemorrhage
Metabolic
Uraemia
hypokalemia
 Clinical features
Abdominal distention is more marked and
tympanic
Pain is minimal
Effortless vomiting may occur
Radiologically
Gas-filled loops of intestine
Multiple air fluid levels
 Management
Remove primary cause
Nasogastric tube to decompress
Maintain electrolyte balance
If paralytic ileus is prolonged and threatens life
Laparotomy! (to exclude any hidden cause)