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

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

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

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

5. 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

6. Intestinal obstruction: Causes

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

9. Adynamic obstruction-causes
Paralytic ileus
Mesenteric vascular occlusion
Pseudo obstruction

10. 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,

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

12. 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

13. Closed loop obstruction
Strangulation
Distention
Necrosis
perforation

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

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

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

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

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

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

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

24. Abdomen tenderness Localized – ischemia
Peritonitis – infarction or, perforation

25. 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

26. 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

27. Supine

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

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

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

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

34. Supportive
NG tube drainage
Na , water replacement
Antibiotics

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

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

37. 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

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

39. 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

41. 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

43. 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

46. Differential diagnosis
Acute enterocolitis
Henoch Schoenlein perpura
Rectal prolapse

47. 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

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

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

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

55. Thanks