Intestinal Obstruction

Dr.Usman Haqqani
TMO
Surgical B
Hayatabad Medical complex peshawar
Classification
According to obstructing site
Small bowel obstruction
Large bowel obstruction

According to presentation
Acute obstruction
Chronic obstruction
Acute on chronic obstruction
Subacute obstruction

According to blood flow

Simple obstuction
Strangulated obstuction
Primary
External
Closed loop obstruction
AETIOLOGY
CAUSES OF INTESTINAL
OBSTRUCTION
Dynamic causes Extramural
Intraluminal bands/adhesions
impaction hernia
Volvulus
foreignbodies
Intussusception
bezoars
gallstones Adynamic causes
Intramural Paralytic ileus
stricture Mesenteric vascular
occlusion
malignancy
Pseudo -obstruct
Common causes of obstruction

ADHESION

TUMOR
Common causes of obstuction
 Incidence
Small Bowel COLON
(85%) (15%)

Adhesions(80%) Cancer (75%)

Hernia(10%) Diverticulos.(10%)
Tumors(5%) Volvulus(10%)
Miscellan.(5%) Miscellan.(10%)
In Eastern Countries& Middle
East volvulus accounts for >
50% of causes of colon
obstruction
etiology:
I. Adhesions(40%of causes)
A. Postoperative:
Commonest after lower abdominal and gynaecological surgery
Patients can present as early as 4 weeks postop.but often 1-5 years
postoperative.
B.Inflamatory:
Cholecystitis
Appendicitis
PID
T.B
Peritonitis
ADHESIVE INTESTINAL OBSTRUCTION
ADHESIVE INTESTINAL
OBSTRUCTION
Etiology(small bowel)

II. Hernia(12% of causes)

A. External:
Inguinal ; Femoral; Umbilical
B. Internal:
Sites
Foramen of Winslow
Defect in the mesentery or transverse mesocolon
Defect in the broad ligament
Diaphragmatic hernia
Duodenal/caecal/appendiceal retroperitoneal fossae
Strangulated small bowel loop(strangulated
inguinal hernia)
 Neoplasms(15% of causes)

Colorectal carcinoma:
75% occure in Rectosigmoid colon
15-20% of colorectal cancer present with obstruction
LT.colon commonest site of obstruction due to constricting
lesion&solid faeces
 strictures
A.Congenital:
Intestinal Atresia
B. Inflammatory:
Crohns Disease
Tuberculosis

C. Neoplastic:
Lymphoma
Carcinoid
Volvulus
Twisting or axial rotation of a portion of bowel about its
mesentery
Primary or secondary
Malrotation & neonatal volvulus
Treatment:
The volvulus is reduced, the
transduodenal band(Ladds band)
divided, the duodenum mobilised & the
mesentry freed.
Appendicectomy is routinely performed
to avoid diagnostic difficulty with
appendicitis in the future.
Infarcted bowel necessitates resection.
 Intussusception:
Invagination of segment of bowel(intussusceptum) into
another(intussuscepien).
it is often antegrade
Most common:
ileocolic(ileocaecal)
Ileo-ileal
A. Primary: infants & young children
Due to lymphoid hypertrophy of terminal ileum

B. Secondary: adult
Due pathological lead point :
Meckles diverticulum ;polyp ;submucous lipoma ; haemangiomas
;Lymphoproliferative disease
Intussusception
JEJUNO-JEJUNAL INTUSSESCEPTION(IN ADULT)
Bolus Obstruction
1. Gall stones
In the elderly
Classically there is impaction about 60 cm proximal to the
ileocaecal valve
2. Food
Occur after partial or total gastrectomy when unchewed
articles can pass into the small bowel

3. Stercolith
In association with jejunal diverticulum or ileal stricture
4. Trichobezoar
Firm masses of undigested hair balls
5. Phytobezoar
Firm masses of fruit or vegetable fibres
6. Worms
In children
Ascaris Lumbricoides
Adynamic obstruction

I. Paralytic Ileus:
There is Reflex Inhibition of Peristaltaic Activity of Small intestine due
to increase sympathetic Drive. smooth muscle become unresponsive to
neural and hormonal stimuli
Causes:
1) Postlaparotomy: after Abd.Pelvic surgery
I. Paralytic ileus( CAUSES)
2) Intra-abdominal Sepsis
3) Abdomino-pelvic Trauma (Retroperitoneal Haematoma)
Other Contributing Factors:
Electrolytes Imbalance
Uraemia
Drugs: Narcotics ; Antichlonergices; phenothiazines
II. Acute colonic pseudo-
obstruction
It is massivecolonic dilatation affecting caecum and Rt.colon with
presentation of colonic obstruction without mechanical blockage
Occurs in
Elderly hospitalised patients with major TRAUMA;ILLENESS; MAJOR
NON-INTESTINAL SURGERY
ETIOLOGICAL FACTORES
Major non-operative TRAUMA
SEPSIS
Myocardial infarction ; Heart Failure
Major Abdomino-pelvic Surgery
Orthopedic Surgery
Gynecological ; Neurosurgical Procedures

Cerebrovasular accident ; Spinal cord Injury

Advanced Malignancy
Respiratory ; Renal Failure
Drugs: Opiates; phenothiazines ;Chanel blockers
III. Acute mesenteric ischemia

1. Embolic: (50%)
Affects SMA
Occur secondary to MI; Atrial Fibrilation

2. Trombotic(20%)
due to acute thrombosis on top of pre-existing atherosclerosis of
visceral artery

3. SHOCK:
hypovolemic & septic
HISTORY
Acute obstruction
Sudden onset of central abdominal colicky pain
Vomiting (party digested food>>mucoid>>greenish>>feculant)
Abdominal distention
Absolute constipation
Chronic obstruction
Constipation
Abdominal distention
Abdominal pain( bouts of colic pain in hyopogastrium)
VOMITING DELAYED FOR 2-3 DAYS
PHYSICAL EXAMINATION
INSPECTION
Abdominal distention, scars, visible peristalsis.
PALPATION
Mass, tenderness, guarding
PERCUSSION
Tymphanic, dullness
AUSCULTATION
Bowel sound are high pitch and increase in
Frequency
DIGITAL RECTAL EXAMINATION
INVESTIGATIONS:
Lab:
FBC (leukocytosis, anaemia, hematocrit, platelets)
Clotting profile
Arterial blood gasses
U& Crt, Na, K, Amylase, LFT and glucose, LDH
Group and save (x-match if needed)
Optional (ESR, CRP, Hepatitis profile)

RadiOlogical:
Plain ABDOMINAL xrays
USS ( free fluid, masses, mucosal folds, pattern of
paristalsis, Doppler of mesenteric vasulature, solid organs)
Other advanced studies (CT, Contrast studieS)
 Figure 3. Lateral decubitus
Errect abdomen x ray view of the abdomen,
with air fluid levels Supine radiograph showing air-fluid levels
distended small bowel (arrows).
loops in the central
abdomen with prominent
valvulae conniventes (
white arrow)
The Difference between small and large bowel
obstruction
Large bowel Small Bowel
Peripheral ( diameter 6 Central ( diameter 3 cm
cm max) max)
Presence of haustration Vulvulae coniventae
Abdominal X-Ray
What is Diagnosis?
(1) Dilated Colon >6cm
(2) Effacement of Haustrae
Peripherally located
(3) Multiple Air Fluid Levels

Large Bowel Obstruction

Rule of 3,6,9:
suspect obstruction if small
bowel dilated >3cm; large
bowel >6cm, cecum >9cm.
Cecal volvulus Sigmoid volvulus
 Intussusception
 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 alergy to iodine

Figure: Axial computed tomography scan

showing dilated, contrast-filled loops of
bowel on the patients left (yellow arrows),
with decompressed distal small bowel on the
patients right (red arrows). The cause of
obstruction, an incarcerated umbilical hernia,
can also be seen (green arrow), with
proximally dilated bowel entering the hernia
and decompressed bowel exiting the hernia.
Source: Jackson, PG. & Raiji M., Evaluation and Management of Intestinal Obstruction, January 2011, American Academy of
Role of barium gastrografin studies
Barium should not be used in
a patient with peritonitis

As: follow through, enema

Useful in recurrent and chronic
obstruction
Can be used to distinguish
adynamic and mechanical
obstruction
 Bird beak sign in cecal intussuseption
volvulus
Intussuseption
Source: Jackson, PG. & Raiji M., Evaluation and Management of Intestinal Obstruction, January 2011, American Academy of
TREATMENT
URGENT RESUSCITATION
NBM
NG tube(bowel decompression)
Cathetrization
IV fluids (correct fluid and electrolyte disturbances)
Start IV antibiotics (if indicated)
Optimise Cardio respiratory status
Consenting
Bowel preparation
Workup for surgery
Close clinical and Radiological monitoring
II. SURGICAL INTERVENTION

1. URGENT:
Strangulation / Suspected Strangulation
Closed-Loop Obstruction
Complete Obstruction
Pnumoperitonium/ Peritonitis
2. Elective Cases
Adhesive Small intestine Obstruction NO Strangangulation
( Observe&Mointoring For 48-Hours )

Incomplete Small intestine or Colonic Obstruction:

Investigate With Contrast Studies
3. NOT TO OPERATE

PARALYTIC ILEUS
ACUTE COLONIC PSEUDO-OBSTRUCTION
INDICATIONS FOR SURGERY
Absolute
Generalised peritonitis
Localised peritonitis
Visceral perforation
Irreducible hernia
Relative
Palpable mass lesion
'Virgin' abdomen
Failure to improve
Trial of conservatism
Incomplete obstruction
Previous surgery
Advanced malignancy
Diagnostic doubt - possible ileus
Source: http: Surgical Tutor.co.uk
General steps of Surgery

At first most importantly the caecum is identified

collapsed distended
(small gut obstruction) (large gutobstruction)
 Site of obstruction is identified

Nature of the obstruction is identified & removed

Viability of the gut is assesed

Gut is viable it is not viable

Gut is put inside the ResectionAnastomosis

Abdomen.

Abdomen closed in layers using Non-absorbable sutures.

Comparison between Viable &
Non-viable Gut
Features of viable gut Features of non-viable gut
Pinkish Blackish
Luster-present Absent
Peristaltic movement-
present Absent
When pricked by a
needle-bleeding from There Is no bleeding
the surface
No pulsation
Pulsation-present in
mesenteric vessels
If still we are doubtful-
Warm saline soaked mop over the doubtful area & 100% O2 is
administered

If colour becomes normal with peristalsis,then it is viable.

Other means of checking
Viability
1. Doppler study

2. Fluorescence study
Management of bowel
obstruction
Intussusception
Reduction by hydrostatic pressure
Operative reduction

Volvulus neonatorum
Early laprotomy
Whole Midgut is delivered
Untwisting is done in opposite direction
Transduodenal band of lad is devided
 Cecal volvulus
Laprotomy
Balooned cecum defalted by needle
Untwisting in anticlockwise direction
Cecostomy is performed

Sigmoid volvulus
Deflation sigmoidoscopy
Operative
Laprotomy
Untwisted in clockwise direction
Rectal tube passed simultaneously to deflate
 Paralytic ileus
Remove primary cause
Decompress GI distension
Fluid and electrolyte balance
If not relieved laparotomy exclude hidden cause

Acute Mesenteric Occlusion

Anti-coagulant
Embolectomy
Revascularization
Colectomy

Adhesions
Conservative treatment should not be prolonged beyond 72
hours.
divide only the causative adhesion(s) and limit dissection
MANAGEMENT FOR LARGE
BOWEL OBSTRUCTION
(IF Lesion/Mass is removable)
Right sided lesions right hemicolectomy
Transverse colonic lesion extended right hemicolectomy

(if lesion/Mass is irremovable)

Proximal stoma
Colostomy
Ileostomy if ileocecal valve is incompetent
Ileotransverse enterostomy

Left sided lesions various options

Two-staged procedure
Resection and anastomosis with defunctioning colostomy
Closure of colostomy

Two-staged procedure
Hartmanns procedure
Closure of colostomy

One-stage procedure
Resection, on-table lavage and primary anastomosis
Complications associated with
intestinal obstruction repair
include excessive bleeding
infection
formation of abscesses (pockets of pus)
leakage of stool from an anastomosis
adhesion formation
paralytic ileus (temporary paralysis of the intestines)
reoccurrence of the obstruction.