INTESTINAL OBSTRUCTION

MSU Medical Students. Batch 2. Group 2.

CONTENTS
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Definition Introduction Etiologies Categories Pathophysiologiy Clinical Manifestation Investigations Treatment Complication

Definition
‡ Intestinal obstruction is a partial or complete blockage of the bowel caused by whether mechanical or functional obstruction of the intestines that results in the failure of the intestinal contents to pass through.

Introduction
‡ Mechanical obstruction is divided into: a) Obstruction of the small bowel (including the duodenum) and b) Obstruction of the large bowel. ‡ Obstruction may be partial or complete. a) About 85% of partial small-bowel obstructions resolve with non-operative treatment, whereas b) About 85% of complete small-bowel obstructions require operation.

Etiologies
‡ Overall, the most common causes of mechanical obstruction are adhesions, hernias, and tumors. ‡ Other general causes are diverticulitis, foreign bodies (including gallstones), volvulus (twisting of bowel on its mesentery), intussusception (telescoping of one segment of bowel into another and fecal impaction. ‡ Specific segments of the intestine are affected differently.

Aetiologies
LOCATION Colon CAUSES

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Adult

Tumors (usually in left colon) Diverticulitis (usually sigmoid) Volvulus (sigmoid or cecum) Fecal impaction Hirschprung's disease

Duodenum

‡ Cancer of duodenum ‡ Cancer of head of pancreas ‡ Ulcer disease ‡ ‡ ‡ ‡
Atresia Volvulus Bands Annular pancreas

Neonates

LOCATION Jejunum and Ileum Adult

CAUSES

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Hernias Adhesions (common) Tumors Foreign body Meckel's diverticulum Crohn's disease (uncommon) Ascaris infestation Midgut volvulus Intussusception by tumor (rare) Meconium ileus Volvulus of malrotated gut Atresia Intussusceptiom

Neonates

Categories
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Complete or Partial Mechanical versus Functional Small versus Large intestine Acute, Sub-Acute, Chronic

Mechanical vs. Functional
A. Mechanical 1. Extraluminal: adhesions (bands of scar tissue), hernias, volvulus (twisted bowel), tumours. 2. Intramural: tumors, IBD (e.g Crohn s), strictures, paralytic, intussusception (telescoping bowel) 3. Intraluminal (partial or complete): foreign bodies, fecal impaction, gallstones, bezoars, worms

Mechanical vs. Functional
B. Functional Paralytic Ileus ‡ Failure of peristalsis to move intestinal contents: adynamic ileus (paralytic ileus, ileus) due to neurologic or muscular impairment ‡ Accounts for most bowel obstructions ‡ Causes include a. Post gastrointestinal surgery b. Tissue anoxia or peritoneal irritation from hemorrhage, peritonitis, or perforation c. Hypokalemia d. Medications: narcotics, anticholinergic drugs, antidiarrheal medications e. Spinal cord injuries, uremia, alterations in electrolytes

Pathophysiology
1) In simple MECHANICAL obstruction, blockage occurs without vascular compromise. 2) Ingested fluid and food, digestive secretions, and gas accumulate above the obstruction. 3) The proximal bowel distends, and the distal segment collapses. 4) The normal secretory and absorptive functions of the mucosa are depressed, and the bowel wall becomes edematous and congested. 5) Severe intestinal distention is self-perpetuating and progressive, intensifying the peristaltic and secretory derangements and increasing the risks of dehydration and progression to strangulating obstruction.

6) Strangulating obstruction is obstruction with compromised blood flow; it occurs in nearly 25% of patients with small-bowel obstruction. 7) It is usually associated with hernia, volvulus, and intussusception. 8) Strangulating obstruction can progress to infarction and gangrene in as little as 6 h. 9) Venous obstruction occurs first, followed by arterial occlusion, resulting in rapid ischemia of the bowel wall. 10) The ischemic bowel becomes edematous and infarcts, leading to gangrene and perforation. 11) In large-bowel obstruction, strangulation is rare (except with volvulus).

12) Perforation may occur in an ischemic segment (typically small bowel) or when marked dilation occurs. 13) The risk is high if the cecum is dilated to a diameter 13 cm. 14) Perforation of a tumor or a diverticulum may also occur at the obstruction site.

Pathophysiology
‡ COLICKY PAIN due to excessive contraction ‡ PROXIMAL DISTENSION due to accumulation of fluid, gas ‡ Impaired absorption of fluid and electrolyte DEHYDRATION ‡ SEPSIS - bacterial overgrowth due to stasis ‡ Impairment of venous & arterial flow STRANGULATION, INFARCTION, PERFORATION

Clinical Features
‡ Colicky low abdominal pain ‡ Vomiting ‡ Abdominal distension ‡ Absolute constipation ‡ Others - dehydration, fever, tachycardia, oliguria, hypotension, peritonism

Manifestations Small Bowel Obstruction a. Vary depend on level of obstruction and speed of development b. Cramping or colicky abdominal pain, intermittent, intensifying c. Vomiting 1. Proximal intestinal distention stimulates vomiting center 2. Distal obstruction vomiting may become feculent d. Bowel sounds 1. Early in course of mechanical obstruction: borborygmi and high-pitched tinkling, may have visible peristaltic waves 2. Later silent; with paralytic ileus, diminished or absent bowel sounds throughout e. Signs of dehydration

Manifestation Large Bowel Obstruction a. Only accounts for 15% of obstructions b.Causes include cancer of bowel, volvulus, diverticular disease, inflammatory disorders, fecal impaction c. Manifestations: deep, cramping pain; severe, continuous pain signals bowel ischemia and possible perforation; localized tenderness or palpable mass may be noted

Investigation
‡ FBC ‡ Electrolytes and Urea ‡ Plain supine AXR - dilated SB, central, valvulae coniventes, air fluid level ‡ Contrast X-rays barium/gastrograffin followthrough/enema ‡ CT scan with oral contrast

Treatment 1 - Resuscitation
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NBM Fluid replacement - IV fluid IV antibiotic Correction of electrolyte imbalance Nasogastric suction Monitoring - vital signs, fluid balance Adequate analgesia

Treatment 2 - Surgery
Indications ‡ Non-resolving or failure of conservative treatment ‡ Perforation / peritonitis ‡ Underlying disease e.g hernia, crohns, tumour 

Avoid in obstruction due to adhesions  High mortality in poorly resuscitated patients

Treatment 3
‡ Resuscitation ‡ Surgery a. Laparotomy b. Hemicolectomy- Right / extended right / left c. Sigmoid colectomy d. Anterior resection e. Abdominoperineal resection f. Hartmann s procedure g. Colostomy ‡ Staged laparotomy 1, 2 or 3-stage procedures

Complications a. Hypovolemia and hypovolemic shock can result in multiple organ dysfunction (acute renal failure, impaired ventilation, death) b.Strangulated bowel can result in gangrene, perforation, peritonitis, possible septic shock c. Delay in surgical intervention leads to higher mortality rate

SBO

SBO

SBO

Intussusception

Volvulus

Large-bowel obstruction. This chest radiograph demonstrates free air under the diaphragm, indicating bowel perforation.

Abdominal (KUB) film of a patient with obstipation. Dilation of the colon is associated with large-bowel obstruction.

Large-bowel obstruction. Gastrografin study in a patient with obstipation reveals colonic obstruction at the rectosigmoid level.

Large-bowel obstruction. Contrast study demonstrates colonic obstruction at the level of the splenic flexure, in this case due to carcinoma.

Large-bowel obstruction. Abdominal (KUB) radiograph depicting massive dilation of the colon due to a cecal volvulus.

Large-bowel obstruction. Contrast study of patient with cecal volvulus. The column of contrast ends in a "bird's beak" at the level of the volvulus.

Large-bowel obstruction. Massive dilation of the colon due to a sigmoid volvulus.

References
1. Merck Manual Professional 2. eMedicine (http://emedicine.medscape.com) 3. MedlinePlus (http://medlineplus.gov)

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