2. 68yr/M from Armala ,Ex Army by profession was admitted
through GMC ER on 27th of Asad 2073( @ 10:20 PM) with chief
complaints of:
• pain abdomen for 3 days
• Dyspepsia for 3 days
• Abdominal distention for 3 days
3. HOPI
• Pain - in RIF
gradual on onset
burning sensation
continuous
started in the morning
non radiating
no known aggravating factor
relieved by shifting position
4. Pain is associated with
abdominal distention
water brash
nausea
burning micturation
H/O loss of appetite
5. • H/O passage of hard stool
• No H/O fever ,headache ,trauma
• No H/0 cough ,weight loss
• No H/0 vomiting.
6. PAST HISTORY
• H/0 appendectomy 40 yrs ago
• From than ,he started to develop abdominal
pain of similar nature .
• According to him, he experiences similar
problem once in every year.
• Last time on Bhadra 2072 he was admitted to
GMCTH for abdominal pain ,admitted ,treated
conservatively and relieved.
10. • GENERAL EXAMINATION
Pt .was concious, well oriented to T,P,P lying comfortably in supine
position with cannula fitted in the left hand
- Vitals
R/R:-25/min
BP:- 110/70 mm of Hg in rt brachial Artery.
Pulse-84beats/min
Temp 98 F
12. GI EXAMINATION
Inspection
-umbilicus centrally placed and abdomen is
distended.
-visible scar in rt iliac fossa
-all quadrants move equally with respiration
-no visible pulsation and peristalsis
-hernial sites intact
-ext. genitilia-normal
13. Palpation
-Abdominal girth :90 cm(01) -86 cm(02) -72 cm (04/04)
-local temprature normal
-tenderness on lower abdominal region
-no palpable mass
-no organomegaly
-hernial sites intact and normal ext. genital
14. Percussion – resonant note
- tender RIF
-shifting dullness –ve
auscultation – normal bowel sound heard
-no vascular bruits heard
P/R exm- no mass, no blood, faeces present.
17. Differential Diagnosis
D/d For Against
Meckels
Diverticulitis
Pain abdomen No antecedent
h/o of lower GI
bleeding
Rt. Ureteric colic Abdominal Pain
Aggravated on
movement
No history of
hematuria
no radiation to
loin
18. D/D For Against
Perforated peptic
ulcer
Severe pain in
RIF
history of
dyspepsia
pain is not
related to food
intake.
Crohns diseases Pain abdomen No diarrhoea and
wt loss
22. Definition:
• Intestinal Obstruction(IO) is a condition in
which there is a sudden stoppage of the
onward passage of intestinal contents-i.e. Gas,
digestive juices and food
25. Peristalsis is working against
a mechanical obstruction
DYNAMIC
(MECHANICAL)
Result from atony of the
intestine with loss of normal
peristalsis, in the absence of a
mechanical cause.
or it may be present in a non-
propulsive form (e.g. mesenteric
vascular occlusion or pseudo-
obstruction)
ADYNAMIC
(FUNCTIONAL)
26. Small or Large bowel
High (Proximal) or Low (Distal) small bowel
According to LEVEL
27. High IO- near the ampulla- jejunum and
proximal ileum.
Low IO- distal to the ampulla- distal ileum
and colon.
28.
29. According to nature of Obstruction:
1. Simple Obstruction- the bowel lumen is occluded ,blood supply remains
intact. The source of obstruction is usually intra-abdominal. ( Eg. Intra-
abdominal adhesions, very rarely gallstones, ball of worms, bezoars).
2. Strangulation- the bowel lumen together with its blood supply is cut-off.
Eg. Strangulated inguinal hernias. Pure strangulation without bowel
luminal narrowing is usually due to mesenteric embolism/thrombosis.
30. 3. Closed loop obstruction- The bowel is
obstructed both proximally and distally. Here
the blood supply may be impaired.
A classic example is seen in an obstruction of
the colon with a competent ileo-caecal valve.
NB: All the 3 types spoken about can occur at
the same time for example in a strangulated
inguinal hernia.
32. According to onset:
-Chronic Obstruction-Usually seen in large
bowel obstruction. The symptoms may arise
from the cause and the subsequent obstruction.
-Acute on Chronic Obstruction- sudden
obstruction in a previously incomplete
obstruction.
Sub-acute Obstruction- There is a partial
obstruction.
38. Clinical presentation
The clinical presentation varies according to;
- The location of the obstruction
- The age of the obstruction
- Underlying pathology
- Presence or absence of intestinal ischaemia.
39. Clinical features
• Abdominal pain
• Vomiting
• Distension
• Constipation
• Dehydration
• Feature of toxemia and septicemia
• Feature of strangulation
• Temperature
• Bowel sound
• Per rectal examination
42. A. Investigations
(i) Supportive- FBC, BU+Cr. Other investigations may be
requested on the basis of clinical suspicion.
(ii)Diagnostic
-Plain abdominal x-rays
Erect and supine
-CXR
-Enema
-Endoscopic techniques
43. Managmenet
I.V fluids and electrolytes rescusitation
N.G tube if repeated vomiting
Antibiotics
Exploratory laparatomy
Hernia operation
Adhesions Adhesiolysis
Obstruction remove
Volvulus derotate and or operate
Mesenteric ischemia operate
Abscess or peritonitis drain and treat
Intussusception pneumatic or barium reduction or operate
44. • SRB’s Manual of surgery, 4E
• Bailey & Love’s Short practice of surgery, 25th
Edition
• Principles of surgery
• Internet
REFRENCES: