Intestinal Obstruction Dr Bina Ravi Associate Professor and Consultant Department of Surgery

Not present- Abdomen- Bowel sound Present- Mechanical obstruction Adynamic obstruction (no gas under diaphragm) Perforation (gas under diaphragm)

Objectives Pathophysiology – dynamic, adynamic Cardinal features – history, examination Causes – small, large gut obstruction Indications – contraindications for conservative Mx

Obstruction Dynamic – peristalsis, mechanical obstruction Adynamic- paralytic ileus, non propulsive Mesenteric vascular obstruction or, pseudo obstruction

Dynamic Obstruction Pain, distention, vomiting, absolute constipation Two- small gut – high , low Large gut Acute , chronic, acute on chronic or, sub-acute Simple – intact vascularity Strangulated – compromised vascularity

Intestinal obstruction: Causes

Causes –Dynamic obstruction Intra-luminal –impaction, FB, Bezoars, gallstones Intramural- strictures, malignancy Extra-luminal- bands/adhesions, hernia, volvulus, intussusception

Adynamic obstruction-causes Paralytic ileus Mesenteric vascular occlusion Pseudo obstruction

Pathophysiology Proximal gut dilates- altered motility Below the obstruction – normal motility, immobile Proximal – increased peristalsis, dilates, reduced peristalsis, flaccid Gas- bacteria. Aerobic/anaerobic, 90% N2 Fluid- dig. Juices,

Pathophysiology Dehydration and electrolyte imbalance Reduced intake Defective absorption Vomiting Sequestration in gut

Strangulation Blood supply compromised Venous return first affected, arterial Hemorrhagic infarction Translocation and systemic exposure to microbes/ toxins Morbidity/ mortality- age, extent, Peripheral vascular failure

Closed loop obstruction Strangulation Distention Necrosis perforation

Acute Intestinal Obstruction-CP Location, age of obstruction, pathology, ischemia Pain Vomiting Distension Constipation Dehydration, Hypokalemia, fever, abdomen tenderness

Pain – severe, colicky, umbilical, lower abdomen Increases with peristalsis, later reduces Severe pain - strangulation

Vomiting High obstruction- violent Low obstruction- slow onset nausea/vomit Gradually digestive food changes to feculent material

Distension Greater if distal obstruction Visible peristalsis Peristalsis delayed in colonic obstruction Absent in Mesenteric vascular obstruction

Constipation Absolute Relative Absent in – Richter’s hernia, gallstone, MVO, Pelvic abscess, partial obstruction

Dehydration Vomiting, fluid sequestration Dry skin, poor venous filling, sunken eyes, oliguria Raised blood urea, Hb, - secondary polycythemia

Hypokalemia K, amylase, LDH – strangulation, raised TLC or, leucopenia Fever – indicates – ischemia, perforation, inflammation Hypothermia – septic shock

Abdomen tenderness Localized – ischemia Peritonitis – infarction or, perforation

Strangulation Diagnosis is clinical Features of obstruction Persistent pain, Shock, local tenderness Non-responsive to conservative Mx Hernia strangulation – tender, irreducible, absent cough impulse, recent increase in size

Radiology Supine/ erect plain abdomen films Small gut- central, transverse, no gas-colon Jejunum- valvulae connivantes Ileum- featureless Cecum- round gas in RIF Large gut- haustral folds

Supine

Sigmoid volvulus Dilated, no haustral pattern Small gut- air and fluid levels More the fluid levels, more distal the lesion

Inv: Plain x ray- impacted foreign body Fluid levels – non obstructing conditions – inflammatory bowel disease, acute pancreatitis, abdominal sepsis

Treatment 3 measures Intestinal drainage Fluid and electrolyte replacement Relief of obstruction

Surgical Mx Mx of segment at the site of obstruction The distended proximal bowel Underlying cause of obstruction

Supportive NG tube drainage Na , water replacement Antibiotics

Large gut Ca or diverticular disease Contrast study – pseudo-obstruction Caecal perforation- caecostomy, ileostomy

Adhesions/bands Commonest Fibrin – adhesions-fibrinous, fibrous Appendectomy , gynaecological op. Bands- congenital, bacterial peritonitis, greater omentum causing band Mx- conservative – 72 hrs –lap adhesiolysis

Special obstructions Int. hernia – foramen of Winslow, hole in the mesentery, hole in transverse colon, defects in broad ligament, cong diaphragmatic hernia, paraduodenal fossae, intraperitoneal fossae Mx- release the ring, reduction of hernia

Enteric strictures TB, Crohn’s, Ca, lymphomas, stricturoplasty Bolus obstruction – food, gall stone, trichobezoars, phytobezoars, stercoliths, worms

Ac Intussusception Proximal gut enters distal gut Adults – lead point, polyp, submucosal lipoma, tumor, Colo-colic – adults Pathology- inner tube, outer tube, returning of middle tube Strangulating obstruction- ileoileal, ileocaecal, ileocolic

Clinical picture Severe attacks of pain – lasts few minutes Later - red currant jelly stool Exam –between episodes-50-60% sausage shaped lump – empty RIF –Sign de Dance P/R – blood stained finger Later vomit, distension

Radiology Plain film – absent caecal gas Ba enema- claw sign CT scan Mx- Hydrostatic reduction with enema Operative reduction Recurrent – 5%- anchorage of ileum to ascending colon

Differential diagnosis Acute enterocolitis Henoch Schoenlein perpura Rectal prolapse

Volvulus Axial rotation of bowel at its mesentery Congenital or secondary Small intestine, caecum, sigmoid-common Small gut- spontaneous, vegetable consumption – untwist Caecal – clockwise- females- lap . Untwist, resection if gangrene

Sigmoid Anticlockwise Bands, overloaded colon, large mesocolon, narrow pelvic mesocolic attachment

Treatment Flexible sigmoidoscopy/ rigid Laparotomy- untwisting Viable – fixing to retroperitoneum Resection – Paul Mickulikz- gangrene Sigmoid colectomy/ Hartmann’s procedure later re-anastomosis

Compound volvulus Rare, ile-osigmoid knotting Gangrene Laparotomy - Decompression, resection and anastomosis

Thanks