INTESTINAL OBSTRUCTIONR.NANDINII

GROUP K1

OVERVIEW:

•CLASSIFICATION

•COMMON CAUSES OF OBSTRUCTION

•CLINICAL FEATURES

•INVESTIGATION

•TREATMENT

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

Obstruction is:-Partial or complete-Simple or strangulated

INTRODUCTION

CLASSIFICATION

DYNAMIC OBSTRUCTION DYNAMIC OBSTRUCTION (MECHANICAL)(MECHANICAL)

CAUSES OF I.O (DYNAMIC)CAUSES OF I.O (DYNAMIC)

PATHOPHYSIOLOGY:

OBSTRUCTION BY ADHESIONS

• Peritoneal irritation local fibrin production produces adhesions between apposed surfaces

• As early as 4 weeks post laparotomy. The majority of patients present between 1-5 years

Colorectal Surgery 25%Gynaecological 20%Appendectomy 14%

• Prevention: good surgical technique, washing of the peritoneal cavity with saline to remove clots, etc, minimizing contact w/ gauze, covering anastomosis & raw peritoneal surfaces

TREATMENT OF ADHESIVE OBSTRUCTION

INITIALLY TREAT CONSERVATIVELY PROVIDED THERE IS NO SIGNS OF STRANGULATION; SHOULD RARELY CONTINUE CONSERVATIVE TREATMENT FOR LONGER THAN 72 HOURS

AT OPERATION, DIVIDE ONLY THE CAUSATIVE ADHESION AND LIMIT DISSECTION

LAPAROSCOPIC ADHESIOLYSIS IN CASES OF CHRONIC SUBACUTE OBSTRUCTION

HERNIA

• ACCOUNTS FOR 20% OF SBO

• COMMONEST 1. FEMORAL HERNIA

2. ID INGUINAL

3. UMBILICAL

4. OTHERS: INCISIONAL

• THE 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 ARTERIALC OMPROMISE.

• ATTEMPT TO DISTINGUISH THE DIFFERENCE BETWEEN:• INCARCERATION

• SLIDING

• OBSTRUCTION

• STRANGULATION IS NOTED BY: • PERSISTENT PAIN

• DISCOLOURATION

• TENDERNESS

• CONSTITUTIONAL SYMPTOMS

VOLVULUSA TWISTING OR AXIAL ROTATION OF A PORTION OF BOWEL ABOUT ITS MESENTERY. WHEN COMPLETE IT FORMS A CLOSED LOOP OBSTRUCTION ISCHEMIA

CAN BE PRIMARY OR SECONDARY: 1°: CONGENITAL MALFORMATION OF THE GUT

(E.G: VOLVULUS NEONATORUM, CECAL OR SIGMOID VOLVULUS)

2°: MORE COMMON, DUE TO ROTATION OF A PIECE OF BOWEL AROUND AN ACQUIRED ADHESION OR STOMA

COMMONEST SPONTANEOUS TYPE IN ADULT IS SIGMOID, CAN BE RELIEVED BY DECOMPRESSION PER ANUM

SURGERY IS REQUIRED TO PREVENT OR RELIEVE ISCHAEMIA

Features: palpable tympanic lump (sausage shape) in the midline or left side of abdomen. Constipation, abdominal distension (early & progressive)

ACUTE INTUSSUSCEPTIONACUTE INTUSSUSCEPTIONOCCURS WHEN ONE PORTION OF THE GUT BECOMES INVAGINATED WITHIN AN IMMEDIATELY ADJACENT SEGMENT.

COMMON IN 1ST YEAR OF LIFE

COMMON AFTER VIRAL ILLNESS ENLARGEMENT OF PEYER’S PATCHES

ILEOCOLIC IS THE COMMONEST VARIETY IN CHILD.

COLOCOLIC INTUSSUSCEPTION COMMONEST IN ADULT

An intussusception is composed of three parts : the entering or inner tube; the returning or middle tube; the sheath or outer tube (intussuscipiens).

CLASSICALLY, A PREVIOUSLY HEALTHY INFANT PRESENTS WITH COLICKY PAIN AND VOMITING (MILK THEN BILE).

BETWEEN EPISODES THE CHILD INITIALLY APPEARS WELL.

LATER, THEY MAY PASS A ‘REDCURRANT JELLY’ STOOL.

Red currant jelly stools

LARGE BOWEL OBSTRUCTION

• DISTINGUISHING ILEUS FROM MECHANICAL OBSTRUCTION IS CHALLENGING

• ACCORDING TO LAPLACE’S LAW: MAXIMUM PRESSURE IS AT THE MAXIMUM DIAMETER AREA

CAECUM IS AT THE GREATEST RISK OF PERFORATION

• PERFORATION RESULTS IN THE RELEASE OF FORMED FEACES WITH HEAVY BACTERIAL CONTAMINATION

AETIOLOGY:

1. CARCINOMA:

THE COMMONEST CAUSE, 18% OF COLONIC CA. PRESENT WITH OBSTRUCTION

2. BENIGN STRICTURE:

DUE TO DIVERTICULAR DISEASE, ISCHEMIA, INFLAMMATORY BOWEL DISEASE.

3. VOLVULUS:

-SIGMOID VOLVULUS/ CAECAL VOLVULUS

4. HERNIA.

5. CONGENITAL : HIRSCHPRUNG, ANAL STENOSIS AND AGENESIS

HIGH SMALL BOWEL OBSTRUCTION VOMITING OCCURS EARLY AND IS PROFUSE WITH RAPID DEHYDRATION.

DISTENSION IS MINIMAL WITH LITTLE EVIDENCE OF FLUID LEVELS ON ABDOMINAL RADIOGRAPHY

LOW SMALL BOWEL OBSTRUCTIONPAIN IS PREDOMINANT WITH CENTRAL DISTENSION.

VOMITING IS DELAYED.

MULTIPLE CENTRAL FLUID LEVELS ARE SEEN ON RADIOGRAPHY

LARGE BOWEL OBSTRUCTIONDISTENSION IS EARLY AND PRONOUNCED.

PAIN IS MILD AND VOMITING AND DEHYDRATION ARE LATE.

THE PROXIMAL COLON AND CAECUM ARE DISTENDED ON ABDOMINAL RADIOGRAPHY

CLINICAL FEATURESCLINICAL FEATURESCARDINAL FEATURES:

Colicky painVomitingAbd distentionConstipation

OTHER FEATURES: DehydrationHypokalaemiaPyrexiaAbd tenderness

PHYSICAL EXAMINATIONPHYSICAL EXAMINATIONINSPECTION

ABDOMINAL DISTENTION, SCARS, VISIBLE PERISTALSIS.

PALPATION

MASS, TENDERNESS, GUARDING

PERCUSSION

TYMPHANIC, DULLNESS

AUSCULTATION

BOWEL SOUND ARE HIGH PITCH AND INCREASE IN FREQUENCY

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, MRI, CONTRAST STUDIES)

Fluid levels with gas above; ‘stepladder pattern’. Ileal obstruction by adhesions; patient erect.

 Supine radiograph from a patient with complete small bowel obstruction shows distended small bowel loops in the central abdomen with prominent valvulae conniventes (small white arrow)

 Figure 3. Lateral decubitus view of the abdomen, showing air-fluid levels consistent with intestinal obstruction (arrows).

THE DIFFERENCE BETWEEN SMALL AND LARGE BOWEL OBSTRUCTION

Large bowel Small Bowel•Peripheral ( diameter 6 cm max)•Presence of haustration

•Central ( diameter 3 cm max)•Vulvulae coniventae•Ileum: may appear tubeless

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 PATIENT’S LEFT (YELLOW ARROWS), WITH DECOMPRESSED DISTAL SMALL BOWEL ON THE PATIENT’S 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 Family Physicians (AAFP), 83: 2 (160-164)

ROLE OF BARIUM GASTROGRAFIN STUDIES

• 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.

• CAN BE USED TO DISTINGUISH ADYNAMIC AND MECHANICAL OBSTRUCTION

Barium should not be used in a patient with peritonitis

Source: Jackson, PG. & Raiji M., Evaluation and Management of Intestinal Obstruction, January 2011, American Academy of Family Physicians (AAFP), 83: 2 (160-164)

Source: Jackson, PG. & Raiji M., Evaluation and Management of Intestinal Obstruction, January 2011, American Academy of Family Physicians (AAFP), 83: 2 (160-164)

• SUPPORTIVE

1. RESUSCITATION

2. RYLE TUBE FREE FLOW WITH 4 HOURLY ASPIRATION

-DECOMPRESSION OF PROXIMAL TO THE OBSTRUCTION, REDUCE SUBSEQUENT ASPIRATION DURING INDUCTION OF ANESTHESIA AND POST EXTUBATION.

3. IV DRIP NORMAL SALINE / HARTMANN (SODIUM & WATER LOSS DURING IO)

4. BROAD SPECTRUM ANTIBIOTIC (NOT MANDATORY BUT NEED IN ALL PATIENT UNDERGOING SURGERY.

TREATMENT OF INTESTINAL OBSTRUCTION

• SURGICAL

IND: OBSTRUCTED / STRANGULATED EXTERNAL HERNIA, INTERNAL INTESTINAL STRANGULATION AND ACUTE OBSTRUCTION

1.MIDLINE INCISION USUALLY LOOK ON CAECUM

2.OPERATIVE DECOMPRESSION

3.LOOK AT VIABILITY OF INTESTINE

4.LARGE BOWEL OBSTRUCTION: COLOSTOMY

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

MANAGEMENT FOR LARGE BOWEL OBSTRUCTION

All patients require•Adequate resuscitation•Prophylactic antibiotics•Consenting and marking for potential stoma formation

•At operation•Full laparotomy should be performed•Liver should be palpated for metastases•Colon should be inspected for synchronous tumours

•Appropriate operations include:•Right sided lesions – right hemicolectomy•Transverse colonic lesion – extended right hemicolectomy•Left sided lesions – various options

Source: http: Surgical Tutor.co.uk

Three-staged procedure•Defunctioning colostomy•Resection and anastomosis•Closure of colostomy

Two-staged procedure•Hartmann’s procedure•Closure of colostomy

One-stage procedure•Resection, on-table lavage and primary anastomosis•Three stage procedure will involve 3 operations!•Associated with prolonged total hospital stay•Transverse loop colostomy can be difficult to manage•With two-staged procedure only 60% of stomas are ever reversed•With one-stage procedure stoma is avoided•Anastomotic leak rate of less than 4% have been reported•Irrespective of option total perioperative mortality is about 10%

Source: http: Surgical Tutor.co.uk

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.

Source: http://www.surgeryencyclopedia.com/Fi-La/Intestinal-Obstruction-Repair.html

PARALYTIC ILEUS

A STATE IN WHICH THERE IS A FAILURE OF TRANSMISSION OF PERISTALTIC WAVES 2° TO NEUROMUSCULAR FAILURE ( IN AUERBACH’S AND MEISSNER’S PLEXUSES)

STASIS LEADS TO ACCUMULATION OF FLUID AND GAS WITHIN BOWEL A/W DISTENSION, VOMITING, ABSENCE OF BOWEL SOUND AND ABSOLUTE CONSTIPATION

VARIETIES FACTORS: POSTOPERATIVE, INFECTION, REFLEX ILEUS AND METABOLIC

RADIOLOGICAL: GAS FILLED LOOPS OF INTESTINES WITH MULTIPLE FLUID LEVELS

MANAGEMENT:ESSENCE OF TREATMENT PREVENTION WITH USE OF NASOGASTRIC SUCTION AND RESTRICTION OF ORAL INTAKE UNTIL BOWEL SOUND AND PASSAGE OF FLATUS RETURN

MAINTAIN ELECTROLYTE BALANCE

SPECIFIC TREATMENT:• REMOVED PRIMARY CAUSE

• DECOMPRESSED GI DISTENSION

• IF PROLONG PARALYTIC ILEUS , CONSIDER LAPAROTOMY EXCLUDE HIDDEN CAUSE AND FACILITATE BOWEL DECOMPRESSION

PSEUDO-OBSTRUCTION

OBSTRUCTION USUALLY COLON- OCCUR IN THE ABSENCE OF MECHANICAL CAUSE OR ACUTE INTRA-ABDOMINAL DISEASE.

ASSOCIATED WITH A VARIETY OF SYNDROMES IN WHICH THERE IS UNDERLYING NEUROPATHY AND/OR A RANGE OF OTHER FACTORS

IDIOPATHIC SEPTICAEMIA

Metabolic Retroperitoneal irritation

Severe trauma at lumbar area

Drugs

Shock Secondary GI involvement

Small intestinal pseudo-obstruction

Colonic pseudo-obstruction (Ogilvie’s syndrome, )

This condition may be primary (i.e. idiopathic or associated withfamilial visceral myopathy) or secondary. The clinical picture consists of recurrent subacute obstruction. The diagnosis is made by the exclusion of a mechanical cause.Treatment consists ofinitial correction of any underlying disorder. Metoclopramide anderythromycin may be of use.

This may occur in an acute or a chronic form.

presents as acute large bowelobstruction.

Abdominal radiographs show evidence of colonic obstruction, with marked caecal distension being a commonfeature.

AXR shows colonic obstruction with marked caecal distension

Confirmation of absence mechanical cause by colonoscopy or single contrast water soluble barium enema or CT.

Once confirmed, treated by colonoscopic decompression

ACUTE MESENTERIC OCCLUSION• ACUTE ISCHEMIC OF MESENTERIC VESSEL. COMMONLY SMA

• CAUSES: AF, MURAL THROMBOSIS, ATHEROMATOUS PLAQUE FROM AORTIC ANEURYSM AND VALAVE VEGETATION FROM ENDOCARDITIS

• FEATURES: -SUDDEN ONSET OF SEVERE ABD. PAIN IN PT WITH AF AND ATHEROSCLEROSIS

-PERSISTENT VOMITING AND DEFECATION THEN PASSAGE OF ALTERED BLOOD

-HYPOVOLUMIC SHOCK

• INVESTIGATIONS: - NEUTROPHIL LEUKOCYTOSIS

- ABD XRAY: ABSENCE OF GAS IN THICKENED SMALL INTESTINES

• TREATMENT: - ANTI-COAGULANT

- EMBOLECTOMY

- REVASCULARIZATION

- COLECTOMY