Intestinal ObstructionZeeshan Razzaq MRCS Ire, MRCS Ed, MRCS EngColorectal Registrar12-October-2015

M.C – 80 yr Female

ED 1/7 History of: Abdominal pain

Intermittent, Colicky, Periumbilical Abdominal distension

Progressively worsening Vomiting

Non-Projectile, 2-3 times / day Constipation

Passing flatus

PAST HISTORY

MEDICAL: Hypertension

SURGICAL: Open Appendicectomy at age of 30

Years Caesarean Sections x 2

On Examination

Vitals Pulse:70/min, Regular BP: 130/80 Temp: 36.5 C RR: 15/min

Dehydrated CNS: GCS 15/15 CVS: S1 + S2 + 0 Chest: Bilateral NVB

Abdominal Exam

Grid Iron + Pfennensteil incisions Distended No Guarding or Tenderness Non Peritonitic No Hernias Bowel Sounds: Hyperdynamic Per Rectum: Empty Rectum

Investigations

FBC: Hb: 12 gm/dl WCC: 9000 Platelets: 299,000

U&E K: 4 meq/l

CRP: 17 Lactate: 1.3

Investigations

PFA

Investigations

CT Abdomen / Pelvis

Investigations

CT Abdomen / Pelvis (With Oral & IV Contrast) Dilated proximal small bowel loops with

collapsed distal small bowel Transition point at Right Lower quadrant

at level of Mid to Terminal ileum No features suggesting bowel

Perforation / Ischaemia

Management

Conservative Drip & Suck NG

Wide Bore Left on free drainage

Intake-Output Record IV Fluids Foleys Catheter to aim Urine output > 1ml/kg/hour

Analgesia Thrombo-Prophylaxis

TEDS Tinzaparin

Management

Failed to respond to conservative management

High NG tube outputs Abdominal distension not settling No flatus or Bowel movements

Management

Laparoscopy

Distended proximal small bowel loops with collapsed distal loops

Dense adhesions at right lower quadrant Free fluid Proximal small bowel viability

Questionable

Management

Converted to Laparotomy

Band adhesion at terminal ileum: Divided Adhesions at Right lower quadrant: Adhesiolysis Hot packs for proximal segment of small bowel

Good peristalsis Good Mesenteric blood flow Colour changed to pink

Distended small bowel decompressed proximally via NG

INTESTINAL OBSTRUCTION

Classification Dynamic

Where peristalsis is working against a mechanical obstruction

In Small Bowel High Low

Large Bowel Intra Luminal Intra Mural Extra Mural

Adynamic

Dynamic Obstruction

Causes Intraluminal

Impaction Foreign bodies Bezoars Gall stones Worms

Dynamic Obstruction

Intramural Stricture Malignancy

Dynamic Obstruction

Extramural Bands Adhesions Hernia Volvulus Intussusception

Etiology

Adynamic Obstruction

Absent Peristalsis Paralytic Ileus

Present but non-propulsive form Mesenteric vascular Occlusion Pseudo-obstruction

Classification of Intestinal Obstruction

By Surgical Pathology Simple

Where blood supply is intact Strangulated

Where there is direct interference of the blood supply

By Nature of Presentation Acute Subacute Chronic Acute on Chronic

Pathophysiology

Simple occlusion Peristalsis increases then

uncoordinated then absent Increase secretion and

decreased absorption leads to loss of fluids and electrolytes

Proximal distension is because of:

Gas Nitrogen 90 % H2S

Fluid collection Excessive fluid collection Retarded absorption

Pathophysiology

Causes for dehydration and electrolyte loss

Reduce oral intake Defective intestinal absorption Losses due to vomiting Sequestration in bowel lumen

Pathophysiology

In closed Loop Obstruction

Occlusion occurs at both ends of loop

Classic cause: tumour of Right Colon and competent Ilocaecal valve

Pathophysiology

In strangulation End result of closed

loop obstruction Results in gangrene

Clinical Features: Look for following questions

Is it obstruction and if so at what level?

Is strangulation present? Is dehydration present? What is the cause? What is the treatment of individual

cause?

Symptomatology

Pain First symptom Colicky in nature Centered around umbilicus --- Small

bowel Lower abdomen-----Large bowel With increasing distension, colicky is

replaced by diffuse pain Severe pain is indicative of strangulation Does not occur in Paralytic ileus

Symptomatology

Vomiting The more distal the obstruction, the

longer the interval between symptoms and development of the nausea and vomiting

With progression, the vomitus alters from digested food to ---- Faeculent material

Symptomatology

Distension In small bowel dependent on the Site of obstruction Visible peristalsis may be present Delayed in colonic obstruction Absent in mesenteric vascular occlusions

Symptomatology

Constipation Absolute: Neither faeces nor flatus is passed Relative: Where flatus only is passed

Constipation is not present in Richter's Hernia Gallstone ileus Mesenteric vascular occlusion Obstruction associated with pelvic abscess Partial obstruction (faecal impaction/colonic neoplasm)

where diarrhoea may often occur

Examination General

Dehydration Repeated vomiting Fluid sequestration Urea and haematocrit rise

Pyrexia Onset of ischemia Intestinal obstruction Inflammation associated with obstructing

diseases Hypothermia indicates septicemia

Examination

Abdomen Inspection

Scars Site of distention Visible peristalsis Irreducible swellings

Examination

Palpation Abdominal mass Tenderness

Indicates pending or established gangrene Peritonism indicates overt infarction or

perforation Rigidity Hernial Orifices

Examination

Percussion Resonance

Auscultation Hyper-resonant Silence

DRE Impacted faeces Rectal tumor Blood on finger

Features of Strangulation Presence of shock Pain Symptoms commence suddenly and recur

regularly Localised tenderness Rebound tenderness Rigidity Raised WCC & CRP Metabolic acidosis: Rising Lactate & Base

deficit

Investigations

Supine Abdominal X-ray (PFA) Jejunum: Valvulae Conniventes Ileum: Feature less Caecum: Round gas Shadow in RIF Large bowel: Haustral Folds F.B and Gall stones could be seen

PFA

PFA

CT Abdomen / Pelvis

Management Principles

Gastrointestinal Drainage Fluid & Electrolyte replacement Relieve of Obstruction

Management

Initial management Pass NG I/V fluids: Saline or Hartmanns Catheterise Antibiotic are not necessary but many

clinicians give because of overgrowth of the bacteria

Management

Monitor Pulse Temp BP Respiratory rate Urine out put Abdominal girth Abdominal tenderness WCC, CRP & Lactate

Conservative Management

Done in In 2-10 days of previous Surgery Multiple prior attacks of adhesive obstruction Poor general condition Patient unfit for Surgery

Look for signs to stop conservative treatment

Surgical Management

The sun should not both rise and set on a case of unrelieved intestinal obstruction

Conservative management may be continued for 72 hours

Surgical Management

Indication for early interventions Obstructed or strangulated external

hernia Internal intestinal strangulation Acute obstruction

Surgical Management

Contra indications to Surgery Paralytic ileus Impacted faeces Volvulus No strangulation seen on previous

exploration

Surgical Management

Operative assessment is directed to Site of obstruction Nature of obstruction Viability of the gut

Midline incision gives the best exposure

Surgical Treatment

Principles of surgical intervention Management of the segment at the site

of obstruction The distended proximal loop The viability of the gut

Differences between Viable and Nonviable

bowel Bowel Viable Nonviable

Circulation Dark color becomes lighter

Mesentery bleeds if pricked

Dark color remains

No bleeding if mesentery is pricked

Peritoneum Shiny Dull and lustless

Bowel musculature Firm

Pressure ring may or may not disappear

Peristalsis may be observed

Flabby, thin and friable

Pressure rings persist

No peristalsis

Dilated Viable bowel

Nonviable Gangrenous bowel

Large Bowel Obstruction

Causes Carcinoma Diverticular disease Volvulus Pseudo-obstruction

Types Acute Chronic

Management of Large bowel obstruction

Full resuscitation

Lesions on Right side Emergency right hemicolectomy If not Removable

Proximal stoma Ilio-transverse internal bypass

Management of Large bowel obstruction

For left side Lesions Primary resection with one of following

Left hemicolectomy Double barreled colostomy (Paul-Mikulicz) Hartmann’s procedure On table lavage of colon with primary

anastomosis Primary anastomosis with proximal covering

stoma

Rare Causes

Rare Causes

Rare Causes

Rare Causes

Rare Causes

Rare Causes

Thank You