Management of intestinal obstruction

Dr Shehu H�Lecturer/Paediatric Surgeon

Bhuth, Jos.

Outline

• Introduction
• Classifications
• Aetiology
• Pathophysiology
• Clinical presentations

• Management
• Complications
• Conclusion

Introduction

Definition

• Failure of cranio-caudal movement of bowel contents due to an impediment

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• May also result from functional impairment without mechanical obstruction

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• It is a common medical emergency occurring worldwide. Account for 5% of acute surgical admissions

Introduction

• It is commoner in the small bowel than large bowel ( 80% )

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• Early diagnosis is important and correct diagnosis even better

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• Treatment should be prompt and appropriate as mortality with strangulation is up to 30%

CLASSIFICATION

● DYNAMIC:- Where peristalsis is working against a mechanical obstruction.

According to the site of obstruction it is further classified into

♦ Intraluminal

♦ Intramural

♦ Extramural

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● ADYNAMIC:- It may occur in two forms:-

♦ Peristalsis absent ( e.g. Paralytic ileus )

♦ Peristalsis present in non-propulsive form(e.g. Mesenteric

vascular occlusion)

Adynamic

2/22/2022

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DYNAMIC

Trico bezoar

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Gallstones ileus

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Crohn’s disease

CLASSIFICATION

Intussusceptions

CLASSIFICATION :- Depending on site of obstruction

CLASSIFICATION :- According to Pathological Changes

• Simple – only a single limb is involved

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• Strangulated – where there is direct interference to

blood flow

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• Closed loop obstruction – when bowel obstructed

both at proximal and distal points

�����Aetiology

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Hernia(EXTERNAL/INTERNAL)

2/22/2022

ADHESIONS

2/22/2022

VOLVOLUS

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INTUSSUSCEPTION

2/22/2022

ASCARIASIS

2/22/2022

FOREIGN BODY

2/22/2022

TUMOURS

2/22/2022

INTESTINAL ATRESIAS

2/22/2022

DUODENAL WEB

2/22/2022

CROHN’S DISEASE

2/22/2022

DIVERTICULITIS

COMMON CAUSES OF INTESTINAL OBSTRUCTION ACCORDING TO AGE

2/22/2022

����Pathophysiology

2/22/2022

Intra abdominal surgery

Motility post operation is as follows:

• Small bowel within 24-48 hours

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• Gastric within 48hours

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• Colonic within 3-5 days

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Simple obstruction

• Below the obstruction
• Normal peristalsis and absorption
• Becomes empty and collapse

Contracted and becomes immobile

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• Constipation

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• Spurious diarrhea

Simple obstruction

• Above the obstruction
• Increasing peristalsis
• If this fail bowel distension occurs
• Resulting in flaccidity and paralysis

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Simple obstruction

• The gases are mostly swallowed

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• Also from products of putrefaction

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• Normal intestinal digestive juices ( 8-10 Liters/24 hours)

Simple obstruction

• Accumulation of fluid occurs proximally

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• Hypovolemia and dyselectrolytaemia

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• Raised intraluminal pressure

Simple obstruction

• The lymphatic and venous pressure are exceeded first
• Venous congestion
• Edema of wall occur
• Movement of fluid from plasma into gut lumen and peritoneal cavity
• Death occur in simple intestinal obstruction from hypovolemia and dyselectrolytaemia

Simple obstruction

• The higher the level of obstruction, the earlier the onset of vomiting and fluid and electrolyte imbalance

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• In high obstruction, metabolic alkalosis results because acid rich fluid is lost

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• In low obstruction, metabolic acidosis result as the sequestered fluid is alkaline

Strangulated obstruction

• When the pressure of the occluding band exceeds venous pressure

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• Venous engorgement of gut wall occurs

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• Dilatation of intramural lymph channels that carry multiplying bacteria from mucosa into systemic circulation

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Strangulated obstruction

• Translocation of bacteria causes endotoxaemia

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• Increase venous pressure progressed to rupture of capillaries and then bleeding into lumen, wall or peritoneal cavity

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• Arterial compromise cause necrosis and perforation

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Closed Loop Obstruction

• Afferent & efferent limbs of bowel are obstructed

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• Typically seen in external hernias

2/22/2022

Closed loop obstruction

• Seen also in colonic obstruction with competent iliocaecal valve

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• The rich bacterial floral adds to the production of gases

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• Rapid distension ► ↑luminal pressure ► circulation impairment ► bowel necrosis & perforation ► fulminant peritonitis.

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Closed loop obstruction

• Types of Loop obstruction
• Type 1
• A- colonic obstruction with competent iliocaecal valve
• B- colonic obstruction with very competent iliocaecal valve
• Type 2
• Colonic obstruction with incompetent iliocaecal valve

���� Clinical Presentation

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Clinical presentation

The cardinal features of obstruction are pain, vomiting, distension & constipation but clinical presentation varies according to:

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• Site of obstruction
• Duration before Presentation
• Underlying pathology
• The presence or absence of ischemia

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2/22/2022

Clinical presentation

1. Abdominal pain
1. Usually 1^st
2. Colicky, intermittent
3. In SBO central, waxes rapidly

But wanes slowly

• Last 3-5 minutes
• May persist in between

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2/22/2022

Clinical presentation

1. Abdominal pain
1. LBO is Cramping
2. Lower abdomen/ flank
3. Last 15- 30 minutes
4. Pain may be absent

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2/22/2022

Clinical presentation

2. Abdominal distension

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• The lower the site of obstruction the more the distension.

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• It varies inversely as the vomiting.

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2/22/2022

Clinical presentation

2. Abdominal distension

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• Central in small bowel obstruction.

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• More in the flanks in colonic obstruction

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2/22/2022

Clinical presentation

3. Vomiting

• In High SBO- bilious & early
• In Low SBO- feculent
• In LBO- delayed and feculent

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2/22/2022

Clinical presentation

4. Constipation

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• Occurs Early in “lower” Large Bowel Obstruction.

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• Occurs Late in

“High” Small Bowel Obstruction.

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2/22/2022

���� Examination findings

2/22/2022

Examination Findings

• Dehydration

Common in small bowel obstruction

Vomiting and fluid sequestration

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Pyrexia

may indicate:

• the onset of ischemia

• intestinal perforation

• inflammation associated with the obstructing disease

Hypothermia indicates septicemic shock

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2/22/2022

Clinical examination

• Incarcerated hernias may be obscure (obese)
• Surgical scars can suggest adhesions
• Palpation abdominal masses can suggest neoplasms, intussusception, abscess
• Abdominal auscultation period of increasing separated by periods of quite bowel sounds (high pitched, tinkling or musical) in mechanical obstruction
• Rectal examination to seek luminal masses. Blood in the feces suggest mucosal lesion (cancer, intussusception, infarction)

���Investigations

Radiological features of plain X - Ray

• Small bowel – straight segments generally central and lie transversely
• Jejunum – valvulae conniventes, spaced regularly, concertina or ladder effect
• Ileum – characteristically unremarkable
• Caecum – rounded gas shadow in right iliac fossa
• Large bowel except caecum – haustral folds, spaced irregularly

Erect abdominal X-ray

• Upright view of abdomen in a patient with intestinal obstruction,
• Showing multiple air fluid levels

Supine abdominal X-ray

• Dilated loops of small bowel are visible(arrows)
• Transversely oriented
• Valvulae conniventes

Lateral decubitus abdominal X-ray

• Showing air fluid levels consistent with intestinal obstruction (arrows)

Barium follow - through�Following features may assist in diagnosis

• Delay in the transit time
• Clawhand appearance
• Beak sign
• Springcoil sign
• Friedman Dhal sign

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Barium meal

• Jejunojejunal Intussusception

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CT Scan

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• Rt colonic tumour

2/22/2022

Ultrasonography

• It is of particular value in looking at the dynamics of the small bowel
• Used to assess peristalsis

Other Investigations

• CBC
• Group & crossmatch blood
• Urea and Electrolyte
• RBS

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����� Treatment

Aim of Rx

Aim is to relieve obstruction as soon as possible before strangulation occurs or before systemic complications set in

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�Resuscitation

• Nil per oral/ Nasogastric tube
• Fluid and electrolyte imbalance correction
• Urethral catheterization
• Antibiotics
• Analgesics
• Correct anaemia

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Conservative treatment

• Partial obstruction
• Early post op obstruction
• Obstruction secondary to Crohn’s disease
• Recurrent obstruction

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Open surgery if no improvement after 24hrs

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�Operative Treatment

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• Procedure depends on cause of obstruction
• Non-viable gut must be resected
• Questionable gut should be checked for viability

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Surgery types

• Resection- The diseased part of the small intestine (ileum) is removed. The two healthy ends are then sewn back together and the incision is closed.

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Indications

• Gangrenous bowel

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Surgeries

• In cases of strangulated Inguinal/femoral hernias the standard groin incision is given & the weakness repaired using hernioplasty or herniorrhaphy, with bowel resection if required.

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Surgeries

• In adhesive obstructed cases, laproscopic adhesiolysis (adhesive band lysis) is carried out

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• Bypass: Anastomosis of proximal small bowel or large intestine distal to the obstruction may be a good procedure in some cases of carcinoma or radiation injury

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Specific Rx

• Hirshsprung's- pull through
• Intestinal atresia- resection + anastomosis
• Duodenal atresia- duodenoduodenostomy
• Meconium ileus - resection + anastomosis

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Complications

• Fluid and dyselectrolytaemia
• Hypovolemic / Endotoxic Shock
• Peritonitis
• Adhesion/ Garres’ obstruction
• Acute Renal Failure
• Multiple organ failure

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Prognosis

• Type of obstruction
• Duration of obstruction
• Cause of obstruction
• Age of the patient
• Length of gangrenous bowel

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“Never let the sun rise or set on small-bowel obstruction” �