intestinal obstruction

1. Amalina Aminuddin
082012100067

2.  Clinical features
 Imaging
 Treatment of acute intestinal
obstruction
INTRODUCTION

3. Vary according to :
• Location of obstruction
• Age of obstruction
• Presence or absence of intestinal ischemia
• Underlying pathology
Classic quartet :
• pain, distension, vomiting and absolute constipation
CLINICAL FEATURES OF DYNAMIC
OBSTRUCTION

4. Based on location of obstruction:
• Small bowel
•High : minimal distension ,early ,profuse
vomiting , rapid dehydration, little evidence
of fluid level
•Low : central distension with pain, delayed
vomiting, multiple central fluid level
• Large bowel :pronounced distension,
mild pain, late vomiting and
dehydration, proximal colon and caecum
distended
CLINICAL FEATURES

5. Based on duration of obstruction:
• Acute
•Sudden severe central abdominal pain, distension, early vomiting and
constipation
• Chronic
•Lower abdominal pain, constipation followed by distension
• Acute on chronic
•Short history of distension and vomiting against a background of pain
and constipation
• Subacute
CLINICAL FEATURES

6. Pain
•Sudden, severe
•Colicky  mild, constant diffuse pain
•On umbilicus or lower abdomen
•Not significant in paralytic ileus
Vomiting
•Appear late in distal obstruction
•Digested food  faeculent material
CLINICAL FEATURES

7. Distension
•SI: Increases the more distal
•LI: Delayed
Constipation
•Absolute or relative
•Does not apply in
•Richter’s hernia,
•Gallstone obstruction,
•Mesentric vascular occlusion,
•Associated with pelvic abscess

8. • Dehydration
• In SI obstruction
• Dry skin and tongue,
sunken eyes, oliguria
• Hypokalemia
• Associated with
strangulation
• Pyrexia
• Indicate ischemic onset,
intestinal perforation or
inflammation
• Hypothermia
• Septicaemic shock
• Abdominal tenderness
• Local – ischemia
• Generalised – infarction
or perforation

9. • Constant pain
• Local tenderness with rigidity
• rebound tenderness (Blumberg’s sign).
• Shock
• Occur suddenly and recur regularly
• Hernia:
• tense, tender, irreducible, no expansile cough and increased size
CLINICAL FEATURES OF STRANGULATION

10. Episodes of
screaming and
drawing up of legs
For a few minutes
and recur
Vomiting
Redcurrant jelly
stool
Sausage- shaped
lump
Sign of Dance
CLINICAL FEATURES OF
INTUSSUSCEPTION

11. PR-
 blood- stained mucus
 Palpable or protruding
apex
Dehydration,
distension, peritonitis
Differential diagnosis
 Acute gastroenteritis
 Henosh- Schoenlein
purpura
 Rectal prolapse

12. Volvulus of small
intestine
Lower ileum
Primary or secondary
Caecal volvulus
May be congenital
More in females
Palpable tympanic
swelling in midline or
left
Sigmoid volvulus
Intermittent
symptoms followed by
passage of large
quantities of flatus
and feces
Early progressive
abdominal distension,
hiccough, retching,
late vomiting,
constipation
CLINICAL FEATURES OF VOLVULUS

13. Erect and supine abdominal films
• Jejunum: valvulae conniventes ( concertina effect)
IMAGING

14. •Ileum: featureless
•Large bowel : haustral folds
• Caecum: rounded gas
shadow in right iliac fossa

15. Fluid levels
• Prominent on erect film
• Physiological: at duodenal
cap and terminal ileum
• More in distal small bowel
obstruction
• May have in high large bowel
obstruction, paralytic ileus or
pseudo-obstruction
• Seen in IBD, acute
pancreatitis and intra-
abdominal sepsis

16. •Gallstone ileus: gas in
biliary tree with stones
• Large bowel obstruction:
large amount of gas in
caecum

17. INTUSSUSCEPTION
 Ileocaecal
intussusception
 Absent caecal gas
shadow
 Claw sign with barium
enema
 Doughnut appearance
on USG abdomen
IMAGING IN

18. VOLVULUS
 Caecal volvulus:
 Gas-filled ileum and distended
caecum
 Bird beak deformity with
barium enema
 Sigmoid volvulus:
 Massive colonic distension
 Dilated loop running
diagonally from right to left
with one fluid level within each
loop
 Volvulus neonatorium:
 Normal or duodenal
obstruction  gasless

19. Measures to treat acute intestinal obstruction
i. Gastrointestinal drainage
ii. Fluid and electrolyte replacement
iii. Relief of obstruction
iv. Surgical treatment
Principles of surgical intervention
 Management of:
 The segment at site of obstruction
 The distended proximal bowel
 The underlying cause of obstruction
TREATMENT OF ACUTE INTESTINAL
OBSTRUCTION

20. i. Gastrointestinal drainage/Nasogastric decompression
 passage of a non-vented (Ryle) or vented (Salem) tube
 4-hourly aspiration, continuous or intermittent suction
ii. Fluid and electrolyte replacement
 Hartmann’s solution or normal saline
iii. Antibiotic therapy
 mandatory for patients undergoing surgery
SUPPORTIVE MANAGEMENT

21. Indications for early surgical intervention:
• Obstructed/strangulated external hernia
• intestinal strangulation
• Acute obstruction
Indication for delay in surgical intervention:
• Complete obstruction with no evidence of intestinal ischemia
• delayed until resuscitation is complete.
• Obstruction secondary to adhesion without pain or tenderness
• Conservative management up to 72 hours
SURGICAL TREATMENT

22. • Adequate exposure is best
achieved by midline incision
• Assessment is directed at :
• Site of obstruction
• Cause of the obstruction
• Viability of the gut

23. Caecum
 Collapsed: small bowel obstruction
 Dilated: large bowel obstruction
To display cause of obstruction:
 Displace small bowel loops and cover with warm moist
abdominal packs
 Operative decompression
 If dilatation of loop prevent exposure
 Viability of gut is threaten
 Closure is compromised
1) ASSESSMENT OF SITE

24. Can be done by:
 Savage’s decompressor
within a purse-string suture
 Nasogastric tube
 Milking the content
retrogradely to stomach
OPERATIVE DECOMPRESSION

25.  Determine the type of
surgical procedure
 Enterolysis
 Excision
 Bypass
 Proximal decompression
2)ASSESSMENT OF CAUSE

26. 3)ASSESSMENT OF VIABILITY
VIABLE INTESTINE NON-VIABLE INTESTINE
Circulation • Dark colour
becomes lighter
• Dark colour remains
• Visible pulsation • No
Peritoneum • Shiny • Dull and lustreless
Musculature • Firm • Flabby, thin and friable
• Peristalsis may be
observed
• No peristalsis
• May have
pressure rings
• Persist pressure rings

27.  Infarcted gut are resected.
 If viability of gut is in doubt:
 Wrap bowel in hot packs for 10 minutes with increased oxygenation
and reassessed.
 Resected: raise both ends of the bowel as stomas
 No resection/ multiple ischemic areas: laparatomy at 24-48 hours
 Note the site of resection, length of resected and residual
bowel

28.  Bailey & Love’s Short Practice of Surgery, 26th Edition.
 https://www.hawaii.edu/medicine/pediatrics/pemxray/v2c08.
html
 http://www.wikiradiography.net/page/The+Abdominal+Plain+
Film-++Differentiating+Large+and+Small+Bowel
 http://www.cdemcurriculum.org/ssm/gi/sbo/sbo.php
REFERANCE