INTESTINAL OBSTRUCTION Bernard M. Jaffe, MD Professor of Surgery, Emeritus

INTESTINAL OBSTRUCTION Common Clinical Problem Carries 3-5% Mortality Rate/Episode Some Patients Have Multiple Bouts Can Involve Small or Large Bowel Requires Both Operative and Non- Operative Care

SYMPTOMS Specifics Depends on Site of Obstruction Crampy Abdominal Pain Abdominal Fullness Nausea, Vomiting Thirst, Weakness, Dehydration

PHYSICAL FINDINGS Abdominal Distention Bowel Sounds Early- Hyperactive Rushes High Pitched Late- Hypoactive to Absent Tachycardia, Dry Skin

DIFFERENTIAL- ILEUS Functional Obstruction Electrolyte Abnormalities- ↓Na, ↓K, ↓Mg Meds- Opiates, Anti-Cholinergics, Anti- Psychotics Intra-Abdominal Infection/Inflammation Systemic Sepsis Post-Laparotomy

INITIAL MANAGEMENT Done During Evaluation/ Diagnosis Intravenous Fluid Resuscitation Ringer’s Lactate Electrolytes Close to Those Lost Nasogastric Tube Decompression Foley Catheter Placement

DIAGNOSIS Upright Abdominal X-Ray Air Fluid Levels Obstruction- Step Ladder Pattern Ileus- All at Same Level ? Air in Colon- Incomplete Obstruction ? Thumb Printing- Ischemic Bowel

CT SCAN Not Always Necessary Can Localize Site- Transition Point (Change from Distended to Flat Bowel) Sometimes Diagnose Cause Distinguish Complete from Incomplete Obstruction Markedly Overused

CAUSES Adhesions (60-70%) Neoplasms (20%) Hernias (10%)- External, Internal Others- Intussusception Volvulus Intra-Abdominal Abcess/Infection Gallstone Ileus Stricture, Extrinsic Compression

GALLSTONE ILEUS Fistula Between Biliary Tract (Gallbladder) and Intestine Stone Passes into Intestine Travels to Narrowest Point –Distal Ileum X-Ray Diagnosis- Air in Biliary Tract Stone Visible in RLQ

CARCINOID Malignancy Ileum > Jejunum 30% are Multiple Metastasizes Nodes, Liver Syndrome- Flushing Diarrhea Bronchoconstriction Right Sided Cardiac Valvular Lesions

OTHER NEOPLASMS Adenocarcinoma Lymphoma Leiomyosarcoma Other Sarcomas

COMPLICATIONS Gangrene- Intraluminal Tension>Venous Pressure Venous Flow Stops Venous → Arterial Gangrene Perforation Short Gut Syndrome Following Resection

EMERGENCY OPERATION Closed Loop Obstruction Complete Obstruction Impending Gangrene All Increase Risk of Intestinal Gangrene

IMPENDING GANGRENE Very Difficult to Diagnose- Variable, Non-Specific Abdominal Tenderness Rebound Tenderness, Guarding Fever, Tachycardia Acidosis Elevated White Blood Cell Count

NON-EMERGENCY OPERATIONS Failure to Respond to Conservative Management Partial Obstruction Multiply Recurrent Bouts of Obstruction

ACUTE POST-OP OBSTRUCTION Difficult to Diagnose Behaves Like Ileus Enteroclysis is Most Successful Modality Non-Operative Management Post-Op Days 1-7

TREATMENT of ADHESIONS Adhesiolysis at Site of Obstruction ? Lysis of All Adhesions Resect Gangrenous Bowel/Re- Anastamose Run Bowel of Site of Injury Perforation

JEJUNUM Proximal 40% of Intestine Larger Circumference, Thicker Wall Prominent Plicae Circulares End-Arterial Blood Supply Fewer Vascular Arcades (1-2) Less Lymphatic Material

LAPAROSCOPY Mild Abdominal Distention Proximal Obstruction Partial Obstruction Anticipated Single Band Obstruction

GALLSTONE ILEUS TREATMENT Enterotomy with Removal of Stone Try to Identify Site of Fistula Cholecystectomy with Fistula Closure ONLY IF RUQ Not Too Inflamed or Indurated

OPERATIVE COMPLICATIONS Perforation- Missed Injury Bovie Burn Delay in Opening Up Nutrition- Enteral, Parenteral Wound Failure- Dehiscence, Hernia. Infection- Superficial Wound Intraperitoneal Recurrent Obstruction