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GIS-K-26

INTESTINAL OBSTRUCTIONSyahbuddin Harahap

Division of Digestive Surgery

Department of SurgeryFaculty of Medicine University of North Sumatera

Adam Malik Hospital

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DEFINITION

Bowel /Intestinal obstruction occurs when the normalpropulsion and passage of intestinal contents does not

occur

BO can involve:

SBO Small intestine

LBOLarge intestine

Generalized Ileus

via systemic alterations

involving both the small and large intestine

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Etiopathogenesis

-Mechanical obstruction

- Non mechanical (Functional ) obstruction

Mechanical obstruction (Dynamic ) ileus refers to a lack

of passage due to an obstruction of the bowel,which can be located anywhere in the bowel

Non mechanical Obstruction (Paralytic )(adynamic)

(Fungsional) ileusParalytic ileus refers to a lack of passage due to

paralysis of the bowel

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Intestinal /Bowel Obstruction can also be classifiedaccording to :

Time of presentation and duration of obstruction:- Acute- Chronic

The extent of obstruction

-Partial-Complete

The type of obstruction-Simple-Closed-loop-Strangulation

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Nonmechanical ObstructionParalytic (adynamic)(Fungsional) ileus due to :

1. After abdominal operations

2. InflammationPeritonitis3. Systemic disorders e.g. sepsis, hyponatremia, hypokalemia,

hypomagnesemia

4. Retroperitoneal disorders e.g. ureter, spine fractures ,

hematoma5. Thoracic conditions e.g. pneumonia, rib fractures

6. Drugs e.g opiates, psychotropics , General anesthesie

Pseudo-Obstruction

Imbalance in the parasympathetic and sympathetic influenceson Colonic motility.

Acute colonic pseudo-obstruction, also known as Ogilvie

syndrome.

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MECHANICAL OBSTRUCTION

at each age group

NeonateCongenital atresia

Volvulus neonatum

Meconeum ileus

Hirschsprungs disease

Imperforate anus

Infant

Stranggulated inguinal hernia

Intussuception

Complication of Meckels diverticulum

Hischsprungs diseases

Young adult

Adhesions and bands

Strangulated ing.hernia

Middle ageAdhesesion and band

Strangulated Ing.hernia

Strangulated fem.hernia

Carcinoma colon

Volvulus

ElderlyAdhesion and bandsStrangulated Ing.herniaStrangulated fem.herniaCarcinoma colonVolvulus

Impacted faeces

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Incidence Mechanical Obstruction

May occur at any age

70 percent small bowel obstruction (SBO)

30 percent large bowel obstruction (LBO)

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Common Causes SBO

Adhesion 60%

Neoplasma 20%

Hernia 10%Crohn 5%

Miscellaneus 5%

Common Causes of LBO

Colon cancer 65 %

Diverticulitis 20 %

Volvulus 5 %Miscellaneous 10 %

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Etiology?

Extrinsic (Outside the wall )

Intrinsic (Inside the wall )

Inside the lumen

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Extrinsic (Outside the wall)

Adhesions Hernia

-- inguinal, femoral, umbilical

Neoplastic extraintestinal neoplasm

Volvulus (sigmoid, cecal)

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Intrinsic (Inside the wall )

Congenital Malrotation

Neoplastic

Primary neoplasms

Metastatic neoplasms

Inflammatory

Crohn's disease

Miscellaneous

Intussusception

Radiation

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Intraluminal (Inside the lumen)

Gallstone

Enterolith

Bezoar Foreign body

ParasitBolus Ascaris

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Clinical Picture

Mechanical obstruction

The classic quartet

1. Colicky abdominal pain

2. Abdominal distension

3. Nausea and Vomiting

4. Decreased passage of stool or flatus

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Pathophysiology

Dependent upon :

1. Degree of obstruction

2. Duration of obstruction3. Presence and severity of ischaemia

Result in :

1. Accumulation of fluid and air(Sequestration within the dilated

loop)

Fluid disturbances massive third space losses

810 L of fluid are secreted

Hypovolumic shock oliguria, hypotension,hemoconcentration

2. Electrolyte depletion3. Bacterial overgrowth Rapid colonisation

-Maximal by 24 hrs after obstruction

-Bacterial translocation to node and portal system

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4. Bowel distension

-Chest compression by pushing up diaghragma muscle

-Decreases the ability mucosa to absorb ,stasis intestinal content

of fluids and electrolytes-Increased intraluminal pressure oedematouscyanosis

intraperitoneal exudation necrosisperforationperitonitis

-ACSimpediment in venous returnarterial insufficiency

5. LBO

Ileocaecal valve plays prominent role in pathophysiology of LBO.

If competent valve = Closed loop obstruction

In 1020 % of individual ICV incompetent

Caecal around 1012 cmthe risk of perforation

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Clinical Manifestations

Altered mental stateVital Sign

Hypovolumic shock

Tachicardia

Hypotension

TachipnoeFever

Oliguria

http://en.wikipedia.org/wiki/Glasgow_Coma_Scalehttp://en.wikipedia.org/wiki/Glasgow_Coma_Scale

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Abdominal Examination

PatientSupine position with the legs flexed at the hip

Abdominal Colicky painThe periodicity of pain:

3 to 4 minutes pain from proximal intestinal obstruction

15 to 20 minutes pain from distal small bowel or colon

On Inspection

Abdominal distension

Proximal obstructions may cause little or no distention

Distended small bowel loops usually occupy the central

abdomen Distended large bowel loops are typically seen

around the periphery .Visible peristalsis which are indicative of acute small bowel

obstruction

Abdominal ScarsAdhesion

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On AuscultationPerformed for at least 3 to 4 minutes

Metallic soundBorborygmi

The absence of bowel tones :

Is typical of intestinal paralysis .

LateQuiet abdomen (may also indicateintestinal fatigue from long-standing

obstruction).

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OnPalpation

Inguinal ,Femoral , Umbilical ,Incisional Hernias

Palpable mass Abdominal asymmetry or a protruding mass

suggests an underlying malignancy, an abscess, or closed-loopobstruction.

Peritoneal irritation

On Percuss

DullFluid or Mass

Tympanic Air (Intraluminal or not )

Peritoneal irritation

DRE(Digital Rectal Examination )

For Mass , Impacted faeces

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Vomiting NG Aspirates

Consistsfood and gastric chymebilefaeculent

GOOClear , food and gastric chymeMid to distal SBOBilious/Bile

Distal SBO to LBOFeculent

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Mechanical Obstruction Nonmechanical Obstruction

Abdominal

Pain

colicky pain severity may decrease over time as a

result of bowel fatigue and atony.

3 to 4 minutes from proximal SBO

15 to 20 minutes distal SBO or LBO

Diffuse , usually mild

Inspection Abdominal distension

Visible peristalsis

Abdominal distension

Auscultation Metalic SoundBorborygme

Late Quiet Abdomen

Quiet abdomen

Abd.X Ray

Erect

Supine

Large small intestinal loops

gas less in colon

Step ladder A/F levels

Gas diffusely through

intestine, incl. colon

May have large diffuse A/Flevels

Barium

Enema

Obvious transition point on contrast study No obvious transition point

on contrast study

Exudate No peritoneal exudate Peritoneal exudate if

peritonitis

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Fluid resuscitation

HYPOVOLEMIC SHOCK ARF

ACUTE RENAL FAILURE

PRERENAL

INTRARENAL POSTRENAL

ARF : OLIGURIA < 500 ML/dSERUM CREATININ > 3MG/dL

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TREATMENT PRE RENAL ARF

INITIAL FLUID THERAPY

RESPON TO URINARY OUTPUT0,51 cc /kg bw

Return of normal vital sign but NO RESPON TO URINARY OUTPUT OLIGURIA

CVP ------CVP 8-12 cm of water (or 10-15 cm of water in mechanically

ventilated patients).

VC RENAL VASCULATURE

TREATMENT

DIURESIS --FUROSEMIDE 80-200 MG IV/TWD

INOTROPIC AGENTS LOW DOSE DOPAMIN /DOBUTAMIN 0,5 -3 ug/kg bw/min

VD RENAL VASCULATURE

INCREASE MYOCARDIAL CONTRACTILITY

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EVALUATION OF FLUID RESUSCITATION

RETURN OF NORMAL VITAL SIGNS

MENTAL STATUS

URINARY OUTPUT

ACID/BASE BALANCE

CVP

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Diagnoctic Studies

Laboratory test Fecal Occult Blood Test

CBC

Serum electrolyte concentrations

The serum creatinine concentration / BUN

The coagulation profile

Urinalysis should be done to check for hematuria

Liver function profile

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Sigmoidoscopy

Exclude a rectal or distal sigmoid obstruction.

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Imaging/ X ray examination

Chest x-ray

Exclude a pneumonic processTo look for subdiaphragmatic air.

Plain abdominal X rayErect and lying downroutinely

Water soluble enema to excludecolonic obstruction.

Colonic pseudo obstuction

LBO + incompetent

ileocecal thereby

mimicking smallbowel obstruction.

Barium enema X ray

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Barium enema X raytransition point on contrast study

SIGMOID VOLVULUS

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bent inner tube = Coffe beanappearanceBird Beak

SIGMOID VOLVULUS

Management of Bowel Obstruction

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Management of Bowel Obstruction

Principles

Fluid resuscitation

Requirements = Deficit + Maintenance + Ongoing losses

Close monitoring hemodinamic

Foley catheterurine output

CVP Electrolyte, acid-base correction

NGT decompression

Antibiotics Diagnostic study

Informed concent

Exploratory laporotomy