Small bowel

Obstruction

Outline

• Definition

• Types

• Presentation

• Deferential Diagnosis

• Management

• Blockage of the flow of GI contents through the small

intestine

Classification

• Functional VS mechanical

• Partial VS complete

• Simple VS complicated

• Proximal VS distal

• Functional ( ileus )

✴Retroperitoneal hematoma

✴Post operative

✴Medications ( Narcotics )

✴Peritonitis

• Mechanical

✴Intraluminal ( Foreign body , Gallstone ileus)

✴Intramural ( intramural hematoma , malignancy,

strictures , Crohns disease )

✴External compression ( Adhesions, hernia,

carcinomatosis)

• Partial VS complete ;

✴Pathophysiology :

✴blockage of passage ==> increased intraluminal fluid

and gas

✴ ==> increased intraluminal pressure ==> decreased

venous return==> venous congestion and decrease

blood supply ==> ischemia and death of involved

intestine

• Simple VS complicated ( strangulation and ischemia ,

perforation ).

• Proximal VS distal .

Clinical presentation

• Abdominal pain ( characters ? )

• Constipation or Obstipation.

• Nausea and vomiting.

• ? fever ? BPR

• O/E ;

✴V/S ( signs of dehydration or sepsis ) .

✴Abdominal examination ( scars , HERNIA , peritonitis,

distention , hyperactive bowel sounds or silent

abdomen)

Laboratory Workup

• CBC.

• BMP and electrolytes.

• Lactate.

• Blood gas analysis.

Alarming findings

• Localized pain.

• Fever.

• Tachycardia.

• Peritonitis

• Elevated lactate after resuscitation

• Leukocytosis.

Imaging

• Plain films ( Abdominal X-rays supine and erect )

• Which one is more important ?

• Dilated small bowel loops ( > 3 cm )

• Paucity of air in the colon and rectum.

• Gas in the small intestine.

• Multiple air fluid levels on upright films

CT scan

• More sensitive and specific. ( 70-90%)

• Helps identify transition point.

• Can detect areas of compromised blood supply or

strangulation ( thickened wall, pneumatosis

intestinalis or perforation).

• Helps identify closed loop obstruction.

Enterolysis ( Small bowel

contrast study )

Treatment

• NPO.

• IVF ( maintenance and deficit ).

• NGT drainage.

• Serial abdominal examination

• Serial laboratory work up

Surgery

• Indications ;

• Non adhesive mechanical small bowel obstruction.

• Bowel ischemia or perforation.

• Closed loop obstruction ( emergency )

• Failure of adhesive SBO to resolve ( 48-72 hrs ?).