Intestinal Obstruction .DR MAHIPAL., INDIA

INTESTINAL OBSTRUCTIONINTESTINAL OBSTRUCTIONDR MAHIPAL REDDY.INDIADR MAHIPAL REDDY.INDIA

IntestinalIntestinal obstructionobstruction

MechanicalMechanical obstructionobstruction

ParalyticParalyticIleusIleus

Paralytic IleusParalytic Ileus After abdominal surgery (laparotomy)After abdominal surgery (laparotomy) Electrolyte imbalances (hypokalemia)Electrolyte imbalances (hypokalemia) Abdominal thraumaAbdominal thrauma Spine fractureSpine fracture Retroperitoneal hemorrhage Retroperitoneal hemorrhage Ureter distension – Acute pancreatitisUreter distension – Acute pancreatitis Ischemia of the intestineIschemia of the intestine Drugs (Narcotics, Psychotropics)Drugs (Narcotics, Psychotropics) Peritonitis (ex. Gangrenous cholecystitis)Peritonitis (ex. Gangrenous cholecystitis) Diabetic comaDiabetic coma Extra abdominal infections (Lung) – SepsisExtra abdominal infections (Lung) – Sepsis IBD (ulcerative colitis)IBD (ulcerative colitis)

IntestinalIntestinal mechanicalmechanical obstructionobstruction

PathogenesisPathogenesis StenosisStenosis Obstruction Obstruction CompressionCompression InvaginationInvagination TorsionTorsion AngulationAngulation StrangulationStrangulation

IntestinalIntestinal obstructionobstructionPattern in AfricaPattern in Africa

40%

16%

14%

14%

10%

3% 3%

Adhesions HerniaSmall Intest volvolusIntussusception Sigmoid volvolusAscarisLarge bowel tumor

70 % of the patients were below the age of 15 years

80% with gangrenous bowel segments

Large gallstones -- cholecystoenteric fistula – Large gallstones -- cholecystoenteric fistula – gallstone ileusgallstone ileus

Bezoars (children, mentally retarded, Bezoars (children, mentally retarded, toothless, after gastrectomy)toothless, after gastrectomy)

Congenital lesions (atresia, stenosis, Congenital lesions (atresia, stenosis, duplication)duplication)

Neoplasms of small bowel – peritoneal Neoplasms of small bowel – peritoneal carcinosiscarcinosis

Inflammation (Chron’s disease- diverticulitis- Inflammation (Chron’s disease- diverticulitis- BK- endometriois)BK- endometriois)

Fecal impaction (bedridden old patient)Fecal impaction (bedridden old patient) MeconiumMeconium Foreign bodiesForeign bodies Iatrogenic strictures (intest. Anastomosis o Iatrogenic strictures (intest. Anastomosis o

RT)RT)

IntestinalIntestinal mechanicalmechanical obstructionobstruction

EEtiologytiology

Accumulation of fluids and gas Accumulation of fluids and gas proximal to the obstructionproximal to the obstruction

Simple mechanicalSimple mechanical obstructionobstruction

PATHOGENESISPATHOGENESIS

Distention of the intestine (self perpetuating)Distention of the intestine (self perpetuating)

Increase intestinal secretionIncrease intestinal secretion Losses of water, Na, Cl, K, HLosses of water, Na, Cl, K, H Dehydratation, ipokalemia, hypochloremiaDehydratation, ipokalemia, hypochloremia Metabolic alkalosisMetabolic alkalosis

Circultory changesCircultory changes

Low central venous pressureLow central venous pressure Reduced cardiac outputReduced cardiac output HypotentionHypotention Hypovolemic shockHypovolemic shock

Rapid proliferation of intestinal bacteriaRapid proliferation of intestinal bacteria ToxiemiaToxiemia

Simple mechanicalSimple mechanical obstructionobstruction


Paralytic IleusParalytic Ileus

MechanicalMechanical obstructionobstruction

Ischemia of the bowelIschemia of the bowel

Strangulation Strangulation obstructionobstruction


Loss of blood and plasma into the strangulated segmentLoss of blood and plasma into the strangulated segment

GangreneGangrene PerforationPerforation PeritonitisPeritonitis Sistemic absorption of toxic materiaSistemic absorption of toxic materia

Strangulation Strangulation ObstructionObstruction

Simple Simple MechanicalMechanical obstructionobstruction

SurgicalSurgicaltimingtiming

Intestinal obstructionIntestinal obstructionSiteSite

Proximal s.b. Proximal s.b. obstructionobstruction

Greather vomitimg and less intestinal Greather vomitimg and less intestinal distention than distal obstructiondistention than distal obstruction

Colon obstructionColon obstruction Less fluid and electrolyte disturbanceLess fluid and electrolyte disturbance Large distension and perforation riskLarge distension and perforation risk

Intestinal obstructionIntestinal obstructionClinical aspectsClinical aspects

Abdominal painAbdominal pain VomitingVomiting ObstipationObstipation Abdominal distentionAbdominal distention Failure to pass flatusFailure to pass flatus FeverFever DehydratationDehydratation Hypotention – hypovolemic shockHypotention – hypovolemic shock

Intestinal obstructionIntestinal obstructionPainPain

Typical Typical crampy paincrampy pain in paroxysm at 4 to in paroxysm at 4 to 5 minute intervals in proximal 5 minute intervals in proximal obstruction obstruction

Less frequently in distal occlusionLess frequently in distal occlusion After a long period of mechanical After a long period of mechanical

obstruction the obstruction the crampy pain may subsidecrampy pain may subside A strangulation should be suspected A strangulation should be suspected

when when continuus severe paincontinuus severe pain replace replace crampy paincrampy pain

Intestinal obstructionIntestinal obstructionVomitingVomiting

ProximalProximal obstruction produce profuse obstruction produce profuse vomiting and little abdominal vomiting and little abdominal distension distension

DistalDistal obstruction is less frequent but obstruction is less frequent but feculentfeculent

Initial phaseInitial phase byliary aspect byliary aspect Late phaseLate phase feculent feculent

BUTBUT

Intestinal obstruction - Intestinal obstruction - LevelLevel

HIGHHIGH LOWLOW

PAINPAIN Crampy pain in Crampy pain in paroxismparoxism

Less intensityLess intensity

VOMITINGVOMITING Early, profuse, Early, profuse, biliarybiliary

Late, feculent may Late, feculent may be absentbe absent

METEORISMMETEORISM ++ ++++++

BEGINNINGBEGINNING AcuteAcute Slow, insidiousSlow, insidious

ABDOMINAL ABDOMINAL DISTENTIONDISTENTION

Moderate, upper Moderate, upper quadrantquadrant

Early, intenseEarly, intense

GENERAL GENERAL CONDITCONDIT

Early Early compromissioncompromission

preservedpreserved

ELECTOLYTESELECTOLYTES Cl, K, Na rapid lossCl, K, Na rapid loss Late hydro Late hydro electrolytic electrolytic imbalanceimbalance

Intestinal obstruction Clinical Intestinal obstruction Clinical examinationexamination

PalpationPalpation abdominal masses can suggest abdominal masses can suggest neoplasms, intussusception, abscess neoplasms, intussusception, abscess

Incarcerated herniasIncarcerated hernias may be obscure (obese) may be obscure (obese) Surgical scarsSurgical scars can suggest adhesions can suggest adhesions Abdominal auscultationAbdominal auscultation period of increasing period of increasing

separated by periods of quite bowel sounds separated by periods of quite bowel sounds (high pitched, tinkling or musical) in (high pitched, tinkling or musical) in mechanical obstructionmechanical obstruction

Rectal examinationRectal examination to seek luminal masses. to seek luminal masses. Blood in the feces suggest mucosal lesion Blood in the feces suggest mucosal lesion (cancer, intussusception, infarction)(cancer, intussusception, infarction)

Key pointsKey points

Intestinal obstruction Clinical Intestinal obstruction Clinical examinationexamination

Young children and Young children and babies babies

AtresiaAtresia VolvolusVolvolus Anal imperforationAnal imperforation Meconial ileusMeconial ileus Intestinal DuplicationIntestinal Duplication MalrotationMalrotation IntussusceptionIntussusception Ascaris infestationAscaris infestation HerniaHernia

Patient age Patient age and sexand sex

Adults Adults HerniaHernia AdhesionsAdhesions NeoplasmNeoplasm InflammationInflammation RT RT EndometriosisEndometriosis Gynecological Gynecological

pathologypathology

Intestinal obstructionIntestinal obstruction

Abdominal direct X ray exhaminationAbdominal direct X ray exhamination Barium enemaBarium enema CTCT EndoscopyEndoscopy Ecography (very difficult because of the massive presence of gas)Ecography (very difficult because of the massive presence of gas)

Radiological Radiological examinationexamination


GasGas abnormally large quantities of gas in the bowel abnormally large quantities of gas in the bowel Multiple gas-fluid levelsMultiple gas-fluid levels in the upright or lateral in the upright or lateral

decubitus positiondecubitus position

Abdominal direct X ray Abdominal direct X ray exhaminationexhamination


Multiple gas-fluid levelsMultiple gas-fluid levels does not always mean intestinal obstruction does not always mean intestinal obstruction

Abdominal pain and Abdominal pain and diarrheadiarrhea can be found in gastroenteritis can be found in gastroenteritis (cytomegalovirus infection as well as salmonellosis) expecially if (cytomegalovirus infection as well as salmonellosis) expecially if profuse watery for 12 or more hours.profuse watery for 12 or more hours.

Abdominal direct X ray Abdominal direct X ray exhamination exhamination RememberRemember


Identify the distended tractIdentify the distended tract Small bowelSmall bowel ColonColon Both plus stomachBoth plus stomach

Radiological Radiological examinationexamination

What can we seeWhat can we see


Gas in the small Gas in the small bowel outlines bowel outlines the valvulae the valvulae conniventes, conniventes, which usually which usually occupy the entire occupy the entire trasverse trasverse diameter of the diameter of the bowel imagebowel image

Radiological Radiological examinationexaminationSmall bowel Small bowel


Colonic haustral Colonic haustral marking marking occupy only a occupy only a portion of the portion of the transverse transverse diameter of diameter of the bowelthe bowel

Radiological Radiological examinationexaminationlarge bowel large bowel

Intestinal obstructionIntestinal obstructionRadiological Radiological examinationexaminationTypical the small bowel pattern

occupies the more central portion of the abdomen, the colon

shadow is on the periphery of the abdominal film or in the pelvis

Intestinal obstructionIntestinal obstructionRadiological Radiological examinationexamination

During paralytic ileus gaseous distention occurs somewhat

uniformly in the stomach, small intestine and colon


Helpful in distal occlusion may Helpful in distal occlusion may be operative in intussusception be operative in intussusception

Barium EnemaBarium Enema


Is sensitive for diagnosing complete Is sensitive for diagnosing complete obstruction of the small bowel and obstruction of the small bowel and determining the localization and cause of determining the localization and cause of obstructionobstruction

CT scanCT scan

Proximal Proximal obstructioobstructio

nn

Distal Distal obstructioobstructio

nn


HematocritHematocrit WBCWBC ElectrolytesElectrolytes PCR (C reactive protein)PCR (C reactive protein) AST -ALT – GGT- LDHAST -ALT – GGT- LDH

Laboratory testLaboratory test


Fluid and electrolytes therapyFluid and electrolytes therapy Intestinal decompression (NG tube)Intestinal decompression (NG tube) Diuresys monitoringDiuresys monitoring Correct surgical timing for relief of obstructionCorrect surgical timing for relief of obstruction

TreatmentTreatment


Duration of obstructionDuration of obstruction Severity of fluid, electrolyte and acid base abnormalitiesSeverity of fluid, electrolyte and acid base abnormalities Opportunity to improve vital organ functionOpportunity to improve vital organ function Consideration of the risk of strangulationConsideration of the risk of strangulation

Timing of operation Timing of operation depends depends

Intestinal Obstruction .DR MAHIPAL., INDIA

Health & Medicine

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