1. Intestinal Obstruction

2. Introduction
Intestinal obstruction is said to have occurred when the peristaltic movements of the intestines stop and the passage of food through the lumen stops.

3. Pathophysiology
Bowel distends – altered motility – below the obstruction has normal motility – absorption until it is empty- later contracts and becomes immobile.
Proximal to the obstruction peristalsis increases to overcome obstruction – later paralysed - intestine distends
Causes of gas : aerobic and anaerobic organisms  gas production – O2 and CO2 absorbed – nitrogen and hydrogen sulphide remains in the gut

4. Causes of Fluid : digestive juices – absorption of fluid stops – dehydration and electrolyte loss – decreased intake – lack of absorption - vomiting - sequestration of fluid in bowel lumen.
Stangulation : - blood supply gets cut off in a few cases. – hernial orifices adhesions , bands – interruption of mesenteric flow like volvulus, intussusception, - rising intraluinal pressure ( closed loop obstruction) – mesenteric vascular obstruction.

5. Classification of Intestinal Obstruction
Dynamic
Adynamic

6. Dynamic Obstruction
Peristalsis is working against a mechanical obstruction
Extramural : intraperitoneal bands and adhesions, hernias, volvulus, intussusception
Intramural : malignant or inflammatory strictures
Intraluminal : impacted faeces, foreign bodies, bezoar, gall stones
Trichobezoar
intussusception
Volvulus
adhesion
band
maligstricture

7. Adynamic Obstruction Two forms Peristalsis absent (Paralytic ileus)
Peristalsis present; but in a nonpropulsive form (mesenteric vascular occlusion or pseudo-obstruction)
In both types a mechanical element is absent

8. Dynamic obstruction Abdominal pain of colicky type
Abdominal distension
Vomiting
Absolute constipation

9. strangulation
Stangulation – viability at risk – due to external compression(henial ofifices/adhesions/bands)

10. Clinical Types high Small bowel obstruction Large bowel obstruction
low
Large bowel obstruction

11. In high small bowel obstruction
vomiting occurs early
Profuse
Rapid dehydration
Distension is minimal
Little evidence of fluid levels on X-Ray

12. In low small bowel obstruction
Pain is predominant
Central distension
Vomiting is delayed
Multiple central fluid levels in X-Ray

13. In large bowel obstruction
Distension is early
Pronounced distension
Pain is mild
Vomiting and dehydration are late

14. In high small bowel obstructions In low small bowel obstructions
In large bowel obstruction
Vomiting occurs early, profuse
Vomiting is delayed
Vomiting is late
Rapid dehydration
Pain is predominant
dehydration is late
Pain is mild
Distension is minimal
Central distension
Distension is early and pronounced
Little evidence of fluid levels on X-ray
Multiple central fluid levels in X-ray
Distension is early Pronounced distension Pain is mild Vomiting and dehydration are late

15. Nature of Presentation
Acute obstruction –usually small bowel – sudden onset of severe colicky central abdominal pain, distension with early vomiting and constipation
Chronic obstruction – usually large bowel – lower abdominal colic and absolute constipation distension
Acute on chronic obstruction – long history of pain
Incomplete obstruction

16. Acute Intestinal Obstruction
Clinical Features
Pain – colicky - severe pain  strangulation- pain does not occur in paralytic ileus. Severe pain indicative of strangulation
Vomiting – the more distal the obstruction the later it appears
Distension – the more distal the more is the distension
Constipation – neither faeces nor flatus is passed – this does not apply in Richter’s hernia, gall stone obstruction, mesenteric vascular obstruction, obstruction associated with pelvic abscess, faecal impaction, neoplasm
Late manifestations are : dehydration
Oliguria
Hypovolaemic shock

17. Pyrexia
Septicaemia
Respiratory embarassment
Peritonism
In all cases of intestinal obstruction all the hernial orifices must be examined

18. Clinical Features Pain colicky, abdominal tenderness
Abdominal distension
Absolute constipation
Discharge of blood in the stools
Dehydration , hypotension, shock
Fever
Dehydration
Oliguria
Septicaemia
Respiratory embarassment
Peritonism
Constipation - not applicable in Richter’s hernia, gall obturation, mesenteric vascular occlusion, obstruction associated with a pelvic abscess, partial obstruction (faecal impaction /colonic neoplasm)

19. Strangulation : shock, pain is never completely absent, symptoms commence suddenly and recur regularly, rigidity and rebound tenderness
Generalized tenderness and the presence of rigidity are indicative of the need for early laparotomy.
In hernia the lump is tense, tender, irreducible, there is no expansile cough impulse and it has recently increased in size.

20. Abdominal distension

21. Abdominal distension in intestinal obstruction

22. Congen i t a l
Megaco L on

23. Small and large bowek obstruction

24. Small bowel obstruction

25. Small bowel obstruction with multiple fluid levels

26. Small bowel obstruction upright view

27. Hirschprung’s disease

28. Congenital megacolon

29. In ischaemic colitis

30. Intussusception

31. Mechanical ileus

37. Gas shadow supine view

38. Gas-shadowing

39. Adynamic ileus

40. Investigations Supine abdominal film
Small bowel : straight segments, central, lie transversely no gas in colon
Jejunum : valvulae conniventes concertina or ladder effect
Ileum : featureless
Caecum : a rounded gas shadow in RIF
Large bowel : except caecum the rest show haustrations
Volvulus of the sigmoid – grossly dilated loop of colon, with or without visible haustrae which arises from the pelvis and extends obliquely across fthe spine to the upper abdomen

42. Six

47. Six

51. six

52. Treatment Three main measures: Gastrointestinal drainage
Fluid and electrolytic replacement
Relief of obstruction, usually surgical
Antibiotics

53. Intestinal volvulus – with gangrenous loop

55. Volvulus of the intestine

56. Hirschprung’s disease

57. Congenital megacolon – resected specimen

58. Hirscprung’s disease

61. intestine
worms

63. Surgeon’s fingers
Surgeon’s fingers
The adhesive band is seen at the centre of the circle. Under which an instrument has been passed to make the band prominent. The bands develop between one loop of intestine and the abdominal wall.
Six

64. Tricho bezoar
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