Download - Intestinal obstruction by Dr.Usman Haqqani
Intestinal Obstruction
Dr.Usman HaqqaniTMO
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
Intraluminal
impaction
foreignbodies
bezoars
gallstones
Intramural
stricture
malignancy
Extramural
bands/adhesions
hernia
Volvulus
Intussusception
Adynamic causes
Paralytic ileus
Mesenteric vascular occlusion
Pseudo -obstruct
Common causes of obstruction
ADHESION
TUMOR
Common causes of obstuction
IncidenceSmall Bowel
(85%)
Cancer (75%)
Diverticulos.(10%)
Volvulus(10%)
Miscellan.(10%)In Eastern Countries& Middle
East volvulus accounts for > 50% of causes of colon obstruction
COLON(15%)
Adhesions(80%)
Hernia(10%)
Tumors(5%)
Miscellan.(5%)
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(Ladd’s 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. FoodOccur after partial or total gastrectomy when unchewedarticles 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 massive colonic 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)
Errect abdomen x ray
with air fluid levels Supine radiograph
distended small bowel
loops in the central
abdomen with prominent
valvulae conniventes (
white arrow)
Figure 3. Lateral decubitus view of the abdomen, showing air-fluid levels (arrows).
The Difference between small and large bowel obstruction
Small BowelLarge bowel
•Central ( diameter 3 cm max)
•Vulvulae coniventae
•Peripheral ( diameter 6 cm max)
•Presence of haustration
Abdominal X-RayWhat 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 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
• Useful in recurrent and chronic obstruction
• Can be used to distinguish adynamic and mechanical obstruction
Barium should not be used in
a patient with peritonitis
intussuseption• Bird beak sign in cecalvolvulus
Intussuseption
Source: Jackson, PG. & Raiji M., Evaluation and Management of Intestinal Obstruction, January 2011, American
Academy of Family Physicians (AAFP), 83: 2 (160-164)
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
• Pinkish
• Luster-present
• Peristaltic movement-present
• When pricked by a needle-bleeding from the surface
• Pulsation-present in mesenteric vessels
Features of non-viable gut
• Blackish
• Absent
• Absent
• There Is no bleeding
• No pulsation
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•Hartmann’s 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.