19/2008

INTESTINAL OBSTRUCTION
DR S EBRAHIM
COMMENTATORS: DRS R GOGA & SKS NTLOKO
MODERATOR: MR S MASEME

INTRODUCTION1
Intestinal obstruction is a common and potentially dangerous surgical emergency associated with
high morbidity and mortality if managed inappropriately. The clinical features are vomiting,
constipation, abdominal distension and pain, with difference in magnitude according to the cause
and site of intestinal obstruction. Early diagnosis is the key to success as the mortality rate rises
with each passing hour from the onset of disease.
DEFINITION2,3
It is the cessation of normal progression of intestinal contents either due to a mechanical or nonmechanical cause.
Mechanical obstruction: physical barrier to the passage of stool
Simple obstruction: lumen occluded with intact blood supply
Strangulation obstruction: obstructed lumen, mesenteric
vascular occlusion
Closed loop obstruction: both limbs obstructed
Non- mechanical obstruction: functional failure of progressive transit
Ileus
Pseudo-obstruction
AETIOLOGY OF INTESTINAL OBSTRUCTION4,5
Mechanical obstruction

2
Luminal
Small Bowel
Obstruction

Large Bowel
Obstruction
Benign
Malignant

Neoplasia (6%)
Obsturators (bezoar,
gallstones, worms
foreign bodies)

Faecal impaction
Colorectal carcinoma
(90%)

Mural
Irradiation
Inflammation
Intussusception (3%)

Diverticular disease (12%)
Stricture
Radiation colitis
Pseudo-obstruction

Extramural
Adhesions (60%)
Hernias (15%)- external, internal,
incisional
Volvulus (3%)
Superior mesenteric artery
syndrome
Intra-abdominal abscess
Volvulus (17%)
Hernia
Adhesions
Extrinsic obstruction secondary to
metastatic carcinoma

PATHOPHYSIOLOGY 4-9
Pathophysiology is essential for understanding evaluation and management
Mechanical
1. Proximal dilatation of obstructed bowel
- bowel proximal to obstruction dilates (with fluid secretions and gas) and bowel
distal to obstruction collapses due to absorption. This results in:
- abdominal distension
- activity in visceral afferent fibres (from dilated segments), causing sweating, drop
in BP and severe vomiting.
2. Increased fluid and electrolyte loss
the proximal small bowel has a predominantly secretory role whereas the distal
small bowel has an absorptive role.
normally almost 95% of daily upper GIT secretions delivered to the proximal bowel
is reabsorbed by small bowel. The colon reabsorbs approximately 3% of this.
with small bowel obstruction, secretion is thus greater than reabsorption resulting
in a net fluid and electrolyte loss from intravascular system
fluid loss is augmented by:
- vomiting
- congestion and oedema of the mucosa resulting in fluid loss intraluminally and
intraperitoneally
electrolyte loss (H+, K+, Chloride) is greater with proximal SBO than distal SBO
in order to maintain plasma volume, excretion of Na+ and water is reduced 
resulting in oliguria. Interstitial space fluid is deployed
to the intravascular space.
 signs of dehydration
3. Increased gas in the lumen is as a result of:
swallowed air (70%)  due to poorly absorbable nitrogen
bacterial fermentation : CO2, H2S, NH3
neutralization of HCO3-  CO2
4. Motility changes
initially increased proximal peristalsis to overcome the obstruction  increased
bowel sounds
eventual fatigue of intestinal smooth muscle cells results in cessation of

3
peristalsis  cessation of bowel sounds
5. Bacterial overgrowth
favoured by stasis of secretions
types of bacteria : anaerobic, aerobic
ischaemic bowel is readily permeable to bacteria and toxins prior to
perforation. Importantly, simple intestinal obstruction (of large and small bowel) in
the absence of necrotic bowel does cause bacterial translocation in man.
There is a significant correlation of bacterial translocation and
postoperative sepsis. In a study by O’ Boyle et al, 41% of patients, who had
evidence of bacterial translocation, developed postoperative sepsis compared to
14% in whom no organism was cultured. This study also showed that the strongest
predictor of bacterial translocation was distal intestinal obstruction. Factors
promoting bacterial translocation include: 1) bacterial overgrowth, 2) increased
intestinal permeability, 3) decreased immune status; all of which occur in obstructed
bowel.
6. Ischaemia and necrosis
With increasing unrelieved intraluminal pressure, venous hypertension ensues. Arterial
occlusion occurs when systolic pressure = venous pressure, resulting in bowel ischaemia
and necrosis. Further, increases in pressure, results in perforation.
7. Large bowel obstruction
Competency of ileocaecal valve is a crucial factor:
- if incompetent (20-30% of patients with LBO),
- reflux of colonic contents into the ileum occurs.
- ultimately resulting in faeculent vomiting
- if competent, “Closed loop” obstruction forms between the
lesion and valve. Progressive distention of this closed loop occurs as ileum empties
into it. Intraluminal pressure reaches very high levels  gangrene  perforation.
The law of Laplace: “The larger the vessel radius, the larger the wall tension required to
withstand a given internal fluid pressure.” The largest radius in this case being the caecum,
reaching maximal tension sooner than the rest of the obstructed segment, thus perforating. Beware
of impending ischaemic necrosis and perforation of the caecum when diameter is approximately
15cm. Decompression must be initiated immediately.
Gut dilation

Fluid back-up, vomiting
“A vicious cycle”
Increase in
gut secretion

Pathophysiology of adhesions
Normal peritoneal healing:

obstipation. distention Proximal obstruction:  vomiting before constipation Distal obstruction:  distention and obstipation before vomiting Strangulation : evolution of character of pain (colicky to continuous)fever vs. silk). ischaemia may result from: excessive manipulation. rather than resolution of the fibrinous exudates. What is the most likely aetiology? History Symptoms: - Abdominal pain. use of cautery Foreign body reaction: excessive formation of fibrin coagulation. Is it partial or complete? Important distinction as it determines operative operative management. 4. Is there a mechanical obstruction? 2. vomiting. sutures (chromic. Intraperitoneal blood: plays a role in adhesion formation. Factors promoting adhesion formation: . Subsequently vascularisation and cellular in growth occurs and adhesions are created. SBO)? 3. which then become infiltrated by proliferating fibroblasts. crushing. Commonly include: corn starch powder and talc (gloves). Inflammatory conditions: Crohn’s disease Radiation enteritis Ischaemia seems to be the underlying factor in preventing adequate fibrinolysis. blood does not always lead to adhesions unless in the presence of ischaemia Infection: release of proteolytic enzymes  tissue damage. CLINICAL PRESENTATION3 The following questions need to be answered at the end of clinical evaluation: 1. ligating. suturing. nausea. What is the level of obstruction (colonic vs. non- . gauze. Disruption of the existing equilibrium between fibrin deposition and fibrinolysis leads to persistence of the fibrinous strands. Free however. Is it simple or strangulated? 5. The new mesothelium is derived from metaplasia of subperitoneal perivascular connective tissue cells that resemble primitive mesenchymal cells.Inadequate fibrinolysis as a result of: Inadequate blood supply with peritoneal injury leads to organization.4 Peritoneal injury  microvasculature beneath mesothelium get disrupted  extravasation of serum and cellular elements  within 3 hours : proteinaceous fluid coagulates producing fibrinous bands between abutting surfaces  12 hours later : polymorphonuclear cells are entangled in fibrin strands which are subsequently replaced with a macrophage infiltrate  by 48 hours after peritoneal injury : wound surface covered with layer of macrophages  Within 72 hours of insult : the fibrinolytic system is triggered to lyse these fibrinous strands  within 5 days of insult : re-epithelialization of the peritoneal injury occurs. constipation. cauterizing or stripping off peritoneum. ischaemia  adhesion formation. although role not clear.

Erect CXR Accuracy Sensitivity Specificity Mechanical obstruction 75% 77% 50% Part.Abdomen: tender  peritonitic masses examine all hernial orifices .Per rectum: occult blood.Hydration status : tachycardia. hypochloraemia) Serum amylase. obturator hernia. (especially lower abdominal or pelvic). fluid in rectovesical pouch or POD . hypokalaemia. febrile Abdomen: .dehydration White cell count: elevation indicates strangulation 2) Biochemical: Urea and electrolytes: rising urea indicates simple dehydration or acute renal failure. CPK. Radiographs: AXR (Erect and supine). Examination General: . dryness of mucosa . masses. /complete Partial: 83% Complete: 86% Strangulation Generally not helpful in diagnosing strangulation Perforation Erect CXR: sub diaphragmatic air Level of obstruction: 60% Cause of obstruction: 7% Advantages Readily available Cost effective initial investigation No contrast required Disadvantages .10 Laboratory tests 1) Haematological: Full blood count: increased haematocrit. low BP.Inspect for scars .5 Past surgical history: Previous operations. With severe GI losses: decreased potassium and sodium levels elevated potassium. Phosphate: generally unhelpful 3) Imaging strategies Profile of imaging techniques Imaging tool 1.sign of strangulated bowel Arterial blood gas: metabolic acidosis: strangulated bowel perforation. severe GI losses metabolic alkalosis : very proximal obstruction (assoc.Auscultate bowel sounds: increased proximal to obstruction absent : prolonged obstruction (fatigue) strangulation or paralytic ileus.Toxicity : acidotic.Clinical correlation with plain films often miss diagnosis in up to 30% of cases . INVESTIGATIVE STUDIES3.Nutritional status : wasting .Per stoma (if applicable): for obstruction at level of fascia .

Abnormally dilated loops of bowel (>3cm) and air-fluid levels . pneumatoses intestinalis or free peritoneal air (in perforation) Large bowel obstruction .evidence of strangulation (not specific) : mucosal thumb printing.low grade partial versus high grade partial/complete obstruction: 1) Differential air-fluid level. to detect early reversible ischaemia./complete Strangulation Diagnosing Perforation Level of obstruction: Cause of obstruction : Advantages Disadvantages 2.gas throughout the entire length of colon (ileus or partial mechanical obstruction) .detect resectability and metastases Requires contrast with all its potential complications . 2) Pneumobilia.presence of air-fluid levels and dilated loops in the same place on erect and supine films : suggestive of closed loop obstruction (adhesion. Sensitivity increased to 96% on using helical scanning. It still fails to diagnose early reversible intestinal ischaemia. However.Massive distention of the colon. thickened small bowel loops. particularly when clinical and radiographic findings are inconclusive In CT study of large bowel obstruction due to Carcinoma: .6 . pseudo-obstruction) Biliary or renal calculi Air in the biliary tree (gallstone ileus): Riglers Triad: 1) Evidence of intestinal obstruction.paucity of distal colonic gas (in rectum) or abrupt cut-off of colonic gas with proximal colonic distention and airfluid levels (suggestive of complete or near complete colonic obstruction) . Although one study with helical CT scanning claims. 2) width of airfluid levels > 25mm . internal hernia) . 3) Ectopic stone.Poor ability to identify cause of obstruction Small bowel obstruction: . 93% 87% CT scanning is useful in making an early diagnosis of strangulated obstruction and in delineating the myriad other causes of acute abdominal pain. Can reliable diagnose perforation by means of free intraperitoneal air as well as impending perforation. Parameters Imaging tool Mechanical obstruction Part. CT scans Accuracy 94% Sensitivity 93% Specificity 100% 92% 71% CT scanning has a sensitivity of 83% and specificity of 93% in diagnosing intestinal ischaemia. further prospective studies are needed. caecum or sigmoid (volvulus.

effective 4.Extent of tumour .pneumatoses intestinalis .“target” sign . Contrast studies Accuracy Sensitivity 93% Specificity 96% This is its main indication.transition zone of proximally dilated bowel and distal collapsed bowel . more accurate in diagnosing obstruction as well as its level and cause.mucosal oedema bowel wall thickening . Used as an adjunct to CT if not helpful in .7 Cannot reliable detect early reversible strangulation Parameters In simple SBO .mesenteric venous congestion . can be performed in pregnant women 3. cost.portal venous gas In colonic obstruction due to carcinoma: .whirl sign – seen in volvulus .“smooth” beaking In strangulated obstruction : .presence of intrabdominal metastases Imaging tool Mechanical obstruction Level of obstruction: Cause of obstruction: Advantages Disadvantages Imaging tool Mechanical obstruction Partial vs . additional use of Doppler studies may provide information on presence of strangulation. bed side technique 2.serrated beaking . 5.ascites . operator dependent 4.mesenteric haziness . 3. 1.reduced bowel wall enhancement (most sensitive) .resectability of the tumour . Ultrasound Accuracy 84% Sensitivity 83% Specificity 100% 70% 23% 1.small bowel faeces sign .

Used to differentiate partial from complete bowel obstruction .presence of contrast in caecum after 6-12 hours of ingestion suggests partial bowel obstruction that will most probably resolve with non-operative management 2. Strategies for adhesion prevention: Proposed mechanism Reduction in peritoneal Damage Strategy Laparoscopic surgery Adherence to meticulous technique . Adhesive small bowel obstruction Epidemiology: - Peritoneal adhesions can be defined as abnormal fibrous bands between organs or tissues or both.operative adhesions develops in 6-8% of all patients undergoing laparotomy. however most are acquired as a result of peritoneal injury. MRI  the most sensitive and specific investigation to date. in the abdominal cavity that are normally separated. Adhesions may be acquired or congenital. Small bowel obstruction due to post. its high cost and unavailability preclude its routine usage.operative adhesions. Water soluble contrast. Does not however reduce the need for surgical intervention 3. 93-100% of patients who undergo transperitoneal surgery will develop post. Potentially therapeutic value of water soluble contrast in shortening hospital stay by hastening the response to nonoperative management. dilutes on its way down to caecum 3. Adhesive small bowel obstruction followed initial laparotomy in as few as two weeks to as long as thirty years.11 The management principles of commoner causes are described below. Delay with contrast studies 5. Even superior to Contrast enhanced helical scanning.8 complete differentiating complete from partial obstruction With Enteroclysis: Level of obstruction Cause of obstruction Advantages Disadvantages 89% 86% 1. MECHANICAL BOWEL OBSTRUCTION3. the most common cause of which is abdomino. Risk of perforation and barium peritonitis 2. Application : Enteroclysis / CT enteroclysis has increased sensitivity and specificity in differentiating complete from partial bowel obstruction as well as level and cause of obstruction 1.pelvic surgery. But. probably by the hyperosmolar nature of the contrast.

systemic toxicity Disadvantages of non-operative management .Complications like strangulation that goes undetected despite regular abdominal examinations. perforation.Adhesions remain unlysed. .Any features of strangulation.9 Prevention of fibrin formation Achieving excellent haemostasis Minimizing tissue handling Reducing infection risk Avoiding dryness of tissues by irrigation Limited use of cautery and sutures Avoiding peritoneal closure Use of starch free gloves 32% Dextran 70 Providone Heparin Adenosine Inhibit inflammatory reaction Corticosteroids Nonsteroidal anti-inflammatories Pentoxifylline Calcium channel blockers Vitamin E Promotion of fibrinolysis Streptokinase Urokinase Recombinant tPA Separation of damaged surfaces 32% Dextran 70 Amniotic membrane Silicone Modified oxidized regenerated cellulose (Interceed) Expanded polytetrafluoroethylene (Preclude) Hyaluronan-based membranes (Seprafilm) Poly(lactide-co-glycolide) (PLGA) Polylactic acid film (SurgiWrap) tPA= tissue plasminogen activator.abdominal malignancy Contraindications: .Complete bowel obstruction . There is a 30% failure rate in diagnosing strangulation using clinical and radiographic means only. thus increasing chances of future obstruction . Non-operative management Indications: - Partial adhesive bowel obstruction Inflammatory bowel disease Recurrent bowel obstruction Early postoperative adhesive bowel obstruction Patients with intestinal obstruction due to widespread intra . Principles of management: Non-operative versus operative treatment: Not always distinct.

It did not significantly reduce the number of episodes that need operative intervention eventually. most partial adhesive SBOs (90%) respond to non.e. decreased bowel distension and lower rates of bowel ischemia. The study concluded that though the patients who had received Gastrografin® had had a shorter hospital stay than those who did not. with Ringer’s Lactate and rehydration. strangulation. Operative intervention was required if Gastrografin® failed to reach the caecum within 12 to 18 hours of being administered orally. Non-operative management more than 48 hours is associated with increased morbidity. Furthermore the risk of re-hospitalisation is greater if non-operative management is successful. it did not reduce the number of episodes that required operative management significantly. Octreotide administration results in: net increased intestinal water and electrolyte absorption. a significant number of patients required surgery.Prevents aspiration during induction of anaesthesia . Several authors have suggested that Gastrografin® has a therapeutic effect in adhesive small bowel obstruction. 12. Those in whom the contrast medium reached the colon in 22 hours were considered to have partial intestinal obstruction and were fed orally.13 after which. In one study. administration of oral Gastrografin ® was used to differentiate partial from complete intestinal obstruction.May provide definitive management .Allows the administration of contrast . Need a clearly defined time limit at which non-operative management is deemed to be unsuccessful A time limit of 48 hours has been advocated.14 Operative management - Indications Features of peritonism. Pharmacological therapy:  Adequate analgesia with opioids  IV antibiotics for non-operative prophylaxis (controversial) Favoured since the bacterial translocation does occur in simple bowel obstruction and it is these bacteria that cause systemic toxicity  Use of Somatostatin analogues (Octreotide) allows the bowel to rest by reducing the volume of intestinal secretions thereby decreasing pain and simplifying fluid management..Relief of nausea.10 - The risk of recurrence is greater and interval to re-obstruction is shorter with non-operative management Components of non-operative management: - - Fluid resuscitation. systemic toxicity . NG decompression : Can use the NG tube or if available a multipurpose tube: Advantages : . It led to a shorter hospital stay and good tolerance to an early oral diet. vomiting and pain and abdominal distension .Multipurpose tubes are softer and easier to use which can be used for therapeutic procedures like enteroclysis. immediate operation is indicated (this is controversial!) Fortunately. Beyond this period (i. thus allowing a change in the management of adhesive intestinal obstruction. if the radiographic contrast did not reach the caecum within this period).operative management and resolve by 48 hours.

as it will result in septic shock. When encountering a volvulus.) Allow an initial 12-24 hours for fluid resuscitation and correction of electrolytes 2. and from Strangulated intestinal obstruction = 10-37% The risk of resection rises dramatically in patients whose surgery is postponed > 24 hours. mortality from surgery for Simple intestinal obstruction = < 5%. resect and anastomose or bring out a mucous fistula.11 Reasons Closed loop obstruction. Principles of operative management 1. Role of laparoscopy15.) Prophylactic preoperative antibiotics at least ½ hour before skin incision. 3. decreased wound sepsis. Bowel perforation Infarcted bowel or perforation Cannot find cause.) Laparotomy Guidelines: Laparotomy incision should be long enough to allow a comfortable exploration of entire abdominal cavity Consider different sheath incision for entry into abdominal cavity Handle distended bowel very carefully Follow collapsed bowel to locate the site of obstruction Controversial: Simply lyse problematic adhesions only. do not detort. and those causing acute distortion of bowel vs.adhesive - 80% will require surgery 20-40% chance of perforation with complete obstruction Clinical signs cannot be relied upon to diagnose early strangulation CT is incapable of detecting early reversible strangulation. Local teaching favours complete adhesiolysis. early return of bowel function and decreased hospital stay Success rate of laparoscopic lysis of adhesions remains between 46% and 87%.16 Growing experience has rendered it both feasible and safe in selected patients Advantages: Advantages of a minimally invasive procedure: Decreased wound infection. complete adhesiolysis. Simple intestinal obstruction – non-adhesive causes Simple intestinal obstruction: complete . Malignancy Controversy: Does Laparoscopy prevent adhesions?17 . - - Disadvantages: Conversion rates are high 40-50% 16 and are necessitated in: dense and multiple adhesions.

Keep NPO on NG decompression . CT useful investigation in 1st 10 days post op diiferentiates ileus from mechanical identifies cause Management Most will resolve with non-operative management. On the other hand. External placation largely of historical interest and not practiced Intraluminal stenting: Modified Baker tubes (1978 by Munroe and Jones) Insertion via a gastrostomy or jejunostomy after complete adhesiolysis. stoma obstruction): requires urgent operation Adhesions (90%): manage non-operatively Diagnosis: Rule out ileus look for possible causes and treat. This matter needs further prospective randomized controlled trials.preferred due to:  Low risk of strangulation with multiple recurrences  Technically demanding Surgery . Early post-operative obstruction3 Early postoperative mechanical obstruction is not uncommon and occurs in 10% of patients: Could be due to technical complications (phlegmon. Removed in ward under sedation (10 days later) .TPN if necessary (>5 days) - - If Operation necessary: Complete adhesiolysis Adherence to adhesion prevention strategies Bowel fixation procedures18-20 Rationale: Bowel fixation methods attempt to lay down bowel in gently formed curves to allow adhesion reformation to occur in a nonobstructive manner.12 - - Some advocate laparoscopy reduces post-operative adhesions because: Lack of use of retractors.Non-operative . less blind dissection and tissue damage. maintenance of a closed abdomen. lack of use of gauze packs. abscess. as ischaemia is unlikely and adhesions are soft and flimsy NG decompression advised up to 14 days TPN indicated if NPO > 5 days Continous monitoring for strangulation is still advised although improbable. Diamond et al described in a multicentre study a high16 (97%) incidence of adhesion formation following laparoscopic adhesiolysis. Management of Recurrent adhesions3 Epidemiology: 30% recurrence rate of small bowel obstruction due to obstruction post adhesiolysis and subsequent episodes of adhesive small bowel obstruction potentiate further episodes Management: . reduction in peritoneal dryness and lack of introduction of foreign bodies.

To this Jones replies that one needs to weigh the burden of repeated hospital admission to recurrence and the complications of intraluminal stenting which are not common All trials are retrospective and have various flaws. local experience with this procedure has been a favourable one and is advocated in recurrent bowel obstruction. but has been associated with complications such as enterocutanous fistulae and pelvic abscesses DeFreid et al have vehemently slammed intraluminal stenting as unsuitable as a prophylactic measure against recurrence due to their complications even though they have demonstrated obstruction free survival at 54 months of 87%. gradual development of a fibrotic stricture 2. If the contrast has not reached the caecum it is highly likely that the patient will not settle with continued conservative management and consideration should be given to surgery.adhesion strategies for primary prevention of adhesions after elective major abdominal surgery. Patients presenting with symptoms and signs consistent with ASBO should undergo plain abdominal X-rays. Further work is required to develop anti.21 Inflammatory bowel disease3 - - Crohn’s disease may present in three ways: 1. Its use has been appreciated in maintaining a consistent obstruction free duration (approximately 4 years) . and there is no clinical suspicion of strangulation. If operative intervention necessary then: Strictureplasty or resection may be required Strictureplasty: indicated Selected duodenal strictures Single discreet ileocolonic anastomotic stricture previous extensive bowel resection: . if there is no remaining clinical concern.adhesion product in operative cases but caution is advised if a bowel resection is required. In summary. However. a water soluble contrast agent should be administered via nasogastric tube. If this confirms the diagnosis. If diagnostic doubt remains after clinical assessment and plain X-ray a CT scan may be helpful. Consideration should be given to the use of an anti. as a perforation Commonly the fibrostenotic type prevails and is generally managed by: Tube decompression TPN if bowel rest prolonged Pharmacological treatment: Anti-inflammatories Can progress to high dose steroid therapy strictures may improve as inflammation resolves. In addition reliable techniques for early detection of intestinal strangulation are not yet available and further work is required to develop these. adhesive SBO (ASBO) remains a common clinical problem. the patient should be fed and discharged as soon as clinical resolution has occurred. Thus prospective randomized controlled trials are necessary to evaluate this procedure. If this shows that the contrast has reached the caecum then. The patient should be rehydrated and a plain Xray repeated at a time convenient to the clinical team within 24 h of admission. If surgery is required and the surgeon is skilled with laparoscopy this can be considered but a low threshold for conversion to an open approach should be maintained.13 - - - - Potential complication on removal : intussuception. inflammation with luminal occlusion 3.

and progresses to gangrene and perforation of the intussusceptum. Strangulation ensues if unrelieved. and consider the possibility of a benign cause and the implications of the site of the primary tumour before deciding for or against surgery. Surgery must be justified on the basis of more benefit than burden to the patient. The mucosa is the most sensitive to strangulation and sloughs off leading to occult blood in stools and later the “red current jelly” Adult intussusception occurs rarely and in most cases is associated with an intraluminal lesion. sigmoidorectal Investigations: abdominal radiography. bowel obstruction is rarely an emergency and strangulation is uncommon. Consent to surgery should include discussion of the surgical risks. intussusception is the most common cause of intestinal strangulation next to strangulated hernia Common causes: tumours. The possibility of a stoma should be discussed.22 . or do not want a further operation. undertake appropriate radiological investigations. check the findings of previous surgery. like any other medical intervention. The significance of malignant embolisation and intraluminal spread by initial reduction is not yet settled. In many regions of Africa. Due to the risk of necrotic segments and malignancy. attempts at manual reduction are justified. ileocaecal. Clinical presentation often vague with features of intermittent. In instances where resection would necessitate a permanent stoma. incomplete intestinal obstruction (small and large bowel) Varieties : jejunojejunal. More than 90% of colonic carcinoma distal to the splenic flexure In cancer patients. The invaginating portion is the intussceptum and the receiving portion of the intestine is the intussuscipiens. ileocoloc. Idiopathic Intussusception has been diagnosed in AIDS patients. in which it is believed to be induced by lymphoid hyperplasia which is associated with the immunodeficiency state. Acute colonic obstruction due to carcinoma3 Epidemiology: Incidence of colorectal cancer obstruction = 8-40% It forms > 90% of large bowel obstruction. There is time to monitor the clinical situation. CT Management: The controversy is the problem of reduction of the intussusception prior to resection.14 - patient at risk of short bowel syndrome single or multiple short fibrotic Strictures in the setting of diffuse jejunoileitis Intussusception3 - - Intussusception is due to an imbalance in the longitudinal forces along the bowel which causes the proximal segment of bowel to invaginate into the distal segment of bowel. ileoileal. resection without prior reduction is the recommended approach for most cases. Supportive and palliative care treatments are available for patients who are unfit for surgery or inoperable. inflammatory masses and Meckel’s diverticuli. colo-colic. complications and alternatives.

widespread metastases. 6. (Discussed later) 1. Resection with primary anastomoses 2. Preoperative colonic decompression and elective resection and Primary anasotomosis Controversies Pre-operative colonic stenting for decompression. pleural effusion) Poor general performance status Poor nutritional status (e. followed by an elective procedure versus emergency surgery? If irresectable: Palliation: Improve quality of life. the quickest and safest procedure that can alleviate the obstruction or favourably impact on symptoms should be considered. Preoperative3 1. low lymphocyte count) Advanced age in association with cachexia Previous radiotherapy of the abdomen or pelvis * Each is a “stand-alone”contraindication Management Principles: 23 With regard to operative management.g. caeco-sigmoidostomy . CT scan: to accurately stage patient and determine respectability.abdominal masses Massive ascites which rapidly recur after drainage Relative Extra-abdominal metastases producing symptoms which are difficult to control (e. Surgical options: Defunctioning colostomy Internal Bypass: e. Antibiotic prophylaxis covering gram negatives and anaerobes 5. DVT prophylaxis 4.g. On table: Lloyd Davies positioning for access to the pelvis.g. Intra-operative: If resectable. 2.15 Contraindications to surgery22 Absolute* A recent laparotomy which demonstrated that further corrective surgery was not possible Previous abdominal surgery which showed diffuse metastatic cancer Involvement of proximal stomach Intra-abdominal carcinomatosis demonstrated radiologically with a contrast study revealing a severe motility problem Diffuse palpable intra. marked hypoalbuminaemia. 2. marked weight loss/ cachexia. Optimal resuscitation with correction of electrolyte disturbances and haematological profile. 1. Pre-operative stoma marking 7. Staged procedure: Hartmann’s procedure Three stage procedure (obsolete) 3. NG decompression (if vomiting) 3. the options include: 1. dyspnoea) Nonsymptomatic extensive extra-abdominal malignant disease (e.g.

16 2.2% Caecal volvulus 21. Sites: Sigmoid volvulus 76. One study.2% 3. and involvement of vascular supply results in strangulation Described in all parts of the bowel with a mobile mesentery 2. Definition: Torsion of bowel around a narrow mesenteric pedicle. Aetiology: - high fibre intake laxative abuse institutionalization pregnancy motility disorders of the gut Chaga’s disease 4.3% mortality from operative colostomy closure. Local experience is needed to evaluate this procedure. or otherwise severely injured bowel c) Prevent recurrence with minimum morbidity 5. necrotic. the stent is already in place for palliation If resectable. Pre-operative colonic decompression with self expanding metallic stents (SEMS) is attractive since: Does not require an anaesthetic Achieves decompression and reverses pathophysiological changes of the proximal bowel wall without a colostomy. the colostomy has its own morbidity and reversal of colostomy does not occur in 2/3 of patients. Its drawbacks. Management goals: a) Resolve the obstruction b) Remove perforated. Sigmoid volvulus . Allows time for optimizing comorbidities Allows time to investigate to stage the patient and plan the appropriate elective procedure If results of investigation reveals irresectable lesion. Overall decrease in hospital stay and cost to the hospital and patient.9% Splenic flexure 0. Continue medical symptomatic treatment Pre-operative stenting for decompression.7% Transverse colon 1. Stenting: non-operative decompression 3. followed by an elective single stage procedure versus emergency surgery? 24-28 The mortality ratio of emergency surgery versus elective surgery for colorectal obstruction is almost 2 fold. thus creating a favourable condition for anastomosis healing. Requires skilled fluoroscopist to stent Potential complications: Perforation Stent migration Recent literature suggests a strong move toward preoperative stent decompression as a bridge to elective surgery. Closed loop obstruction occurs. showed a morbidity of 49. Colonic Volvulus 29-31 1.1 % and 4. then a single stage primary resection and anastomosis can be achieved. When compared to a colostomy.

peritoneal irritation. Leukocytosis. the sigmoid colon develops a clockwise twist of > 200° that creates: proximal obstruction closed loop of involved segment The site of torsion is frequently encountered approximately 15 cm above the anal verge and within reach of the rigid sigmoidoscope 7-10% of patients will develop colonic infarction or perforation at presentation Features of large bowel obstruction Look for features of systemic toxicity: Fever. usually occurring years after high fibre intake or laxative use.17 a) Demographics: Patient profile: Debilitated patients. Effective in reducing volvulus in up to 70%-90% of patients Recurrence: 18-90% Advantage: Bowel preparation prior to definitive surgery Allows optimization of medical conditions Disadvantage: Reducing gangrenous bowel and perforation (1-3%) NOTE: The mucosal membrane must be visualized for ischaemic changes and blood stained effluent. Difficult to differentiate simple obstruction from early strangulated obstruction clinically d) e) Investigations: AXR: highly suggestive features include: Omega sign (bend inner tube) Bird’s beak appearance Barium Enema: highly accurate at confirming diagnosis Typical beak appearance Management: Fluid resuscitation / Reasonable urine output Antibiotics Non-operative decompression followed by elective surgery on the same admission Rigid proctosigmoidoscopy is performed Rectal tube passed to stent the colon as scope removed. Patient needs to be monitored for the onset of septic shock in the event of detorting gangrenous bowel. . bloodstained rectal discharge. institutionalized Non-ambulatory History of Chronic illness Previous abdominal surgery Laxative use Dementia High fibre Diet Age: 60-70 years with female preponderance <30 years in the African male population b) Mechanism: - c) Clinically Lengthening of the sigmoid mesentery is an acquired phenomenon. Usually have abnormal bowel motility During the development of volvulus.

Coffee bean appearance in 90% cases 2) Barium enema: shows a similar picture 3) CT scan: whirl sign 4) Colonoscopy: high failure rate and unpopular Has been discovered incidently at laparotomy for acute abdomen Caecal infarction in 17-21% patients at presentation . incising the long sigmoid mesocolon longitudinally. Investigations: 1) AXR . Subtotal colectomy advised in patients with megacolon Non-resectional 1. Caecal volvulus A congenital mobile caecum occurs in 11% of population. perforation.18 - Therapeutic value of Barium enema: detorsion in 5% of cases Colonoscopy/ flexible sigmoidoscopy for more proximal torsions - Operative Indications: Elective surgery: 7-10 days following non-operative decompression Emergency: Presence of ischaemia. peritonitis Failed attempt at non-operative decompression . raising the flaps and suturing it transversely resulting in a broader base High recurrence rates of up to 22% are against its routine use. incidence of caecal volvulus : 21% Types: 1) Axial clockwise twist (85%) rotates terminal ileum to right of caecum.Viable bowel: Resection: Resection of redundant sigmoid (curative) (mortality 4-12%) Primary anastomoses of unprepared bowel acceptable.) Mesosigmoidoplasty Involves.) Surgical detorsion +/. 2) Caecal bascule (15%) mobile caecum folded on itself without twisting. female preponderance Presents clinically with distal bowel obstruction. . 6. pointing appendix to diaphragm Not a true volvulus mean age : 50-60 years. Other non-resectional methods: 3) percutaneous endo-scopic colopexy 4) laparoscopic fixation 5) extraperitonealisation of the sigmoid colon and mesenteropexy. have still to be evaluated in randomized controlled trials.colopexy (high recurrence of up to 22%) 2. provided not gangrenous.Non-viable bowel / Severe ischaemic injury / perforation: RESECTION: Sigmoid colectomy and stoma: Hartmann procedure Or ileostomy and mucous fistula mortality: 18-75%.

Not advised. AIDS) Aim: Improvement in quality of life.19 - Contributes to 17% mortality Management: Most require urgent surgical treatment Non-operative treatment not successful Viable caecum Options include: 1) Detorsion +. Transverse colon and splenic flexure Rare Management is surgical Viable colon: Detorsion +/.32-35 Treatment options: No algorithm or single treatment modality but rather defined . Choice will depend on patient factors and anaesthetic tolerance.colopexy OR Resection with primary anastomosis Non-viable colon: Resection with colostomy Diverticular disease (3%)3 10-15% of patients with complicated diverticular disease develop LBO by one of 2 mechanisms: a) Acute diverticulitis with pericolic abscess Causes local spasm / extrinsic compression Management : IV antibiotics Bowel rest Percutaneous drainage if amenable Resection and primary anastomosis b) Repeated attacks of diverticultis Difficult to distinguish from Cancer Management: As if managing carcinoma THE ROLE OF THE SURGEON IN THE TREATMENT OF TERMINALLY ILL PATIENTS (MALIGNANT BOWEL OBSTRUCTION. Prolonged survival is of secondary benefit 9. 7.23.caecopexy: recurrence 13% either way 2) Right hemicolectomy: Definitive treatment mortality: 5-25% (wide Variation) 3) Caecostomy: high rate of complications and mortality.22. Non-viable caecum/perforation Resection of caecum necessary associated with 15% morbidity 22-45% mortality Detorsion carries an almost certain risk of septic shock Diversion with ileostomy and mucus fistula should strongly be considered in this group due to the severe risks of an anastomosis.

Both the incidence and severity of abdominal tuberculosis are . HIV AND INTESTINAL OBSTRUCTION36-39 Tuberculosis can involve any part of the gastrointestinal tract and is the sixth most frequent site of extrapulmonary involvement.Required equipment and expertise . Affords non-operative decompression Disadvantages: . decreasing splanchnic blood flow . 5. TB.20 Outcomes: 1. Internal bypass mucous fistulae and colostomy Sometimes benign adhesions could be causing the obstruction which can be lysed thus affording relief Ascites is a poor prognostic indicator for surgery and is associated with high morbidity. haloperidol Rectal: prochlorperazine.Complications : Stent migration (0-40%) Perforation (0-15%) Re. hydroxyzine 3. . Endoscopic treatments Percutaneous endoscopic gastrostomy: . thereby reducing vomiting . co-analgesics to treat obstruction. More than 3 litres have peri.occlusion (0-33%) vomiting. promethazine. Permit to return home or hospice facility Multidisciplinary approach: Pharmacological treatments 1. Antiemetics: IM / IV / oral: metoclopramide (C/I: complete obstruction) Subcut: odansetron.Delays oedema.Endoluminal stents: colorectal stents.3-0.operative mortality of 41%. Opioids: morphine 2. Psychosocial support: essential for patients and caregivers.Doses: 0.Increasing water and electrolyte absorption.Offers better quality of life in alleviating pain and obstruction and nausea and patients cannot eat. Corticosteroids: decreases peri. synthetic somatostatin . Alleviate pain 4. 6. Nutrition: venting gastrostomy can allow patients to stay at home.tumoural oedema and activate its central and peripheral antiemetic effects. But Surgical: only in carefully selected patients as morbidity and mortality from surgery 42% and 532% respectively The shortest and least risky procedure is advocated. Antisecretory: Octreotide: Very effective.Poor candidates: patients with ascites .decreases GIT secretions and prolongs small bowel transit. Allow patient to eat 3. low fibre diet.related pain. .6 mg/ day subcut. Ensure patient does not have to tolerate continual obstruction and nausea and vomiting 2.Response is frequent and dramatic (70%-100%) . Hydration: parenteral fluids 4.

Management is with conventional antitubercular therapy for at least 6-9 months. omental thickening. Transverse ulcers. must be treated surgically. Thus. thickening and stricturing of the bowel wall. or where there is no sign of resolution of obstruction in 48 hours.21 expected to increase with increasing incidence of HIV infection. Lymphoma of small bowel. dry type with adhesions. serum ascites albumin gradient less than 1. If ascites is present.1 g/dl. This is particularly important where the aetiology is tuberculous. enlarged and matted mesenteric lymph nodes. Ileocaecal and small bowel tuberculosis presents with a palpable mass in the right lower quadrant and/or complications of obstruction. computed tomographic scan and colonoscopy. Approximately one fifth of patients require surgical intervention. avoiding extensive resection. perforation or malabsorption especially in the presence of stricture. TB is associated with significant mortality (5–10%) and morbidity (anastomotic leak and fistula). patients with acute and sub-acute intestinal obstruction. either for confirming the diagnosis or as the first line approach to the management of uncomplicated abdominal tuberculosis. and fibrotic type with omental thickening and loculated ascites. restriction of oral intake and aggressive intravenous fluid replacement to correct fluid and electrolyte deficits. predominantly lymphocytic cells. Chest X-rays show evidence of concomitant pulmonary lesions in less than 25 per cent of cases. Peritoneal tuberculosis occurs in three forms: wet type with ascites. In this respect. it is evacuated and the abdomen closed without leaving drains. Minimal surgical intervention is recommended. However. no difference exists between management of HIV-negative and –positive patients. and peritoneal tubercles characterize the gross pathology. in the absence of external hernias or post. Useful modalities for investigating a suspected case include small bowel barium meal. mesenteric lymphadenopathy and intussusception. thought to be related to an . Tuberculosis bacteria reach the gastrointestinal tract via haematogenous spread. ingestion of infected sputum. Kaposi Sarcoma of small and large bowel. though sufficient to alleviate the obstruction. The recommended surgical procedures today are conservative and a period of preoperative drug therapy is controversial. intestinal obstruction per se warrants a conservative approach of nasogastric drainage. When colicky abdominal pain becomes constant and severe. ultrasonography. In a few cases.operative adhesions. Diseased segments of bowel with adequate free margin are removed. Surgery is no longer recommended. In HIV-positive patients the following specific causes of intestinal obstruction may be found: Tuberculous adhesions/mass/intestinal stricture. Complete bowel decompression prior to resection and anastomosis is recommended. With respect to HIV and bowel obstruction. then a laparotomy is indicated. abdominal TB may be considered in young adults presenting with acute bowel obstruction. or when signs of peritonitis supervene. barium enema. or direct spread from infected contiguous lymph nodes and fallopian tubes. The prognosis in patients with abdominal TB has improved markedly as a result of advances in diagnostic methods. Ascitic fluid examination reveals straw coloured fluid with high protein. Great care should be taken when unravelling adherent loops of bowel because a postoperative enterocutaneous fistula is often fatal. However. Laparoscopy is a very useful investigation in doubtful cases. Representative tissue should be sent for histological examination. and recurrence is a problem. fibrosis. the signs of intestinal obstruction may be mimicked by a paralytic ileus. Surgery is also needed in patients with a free perforation or perforation associated with abscess formation. better anti-tubercular drugs and safer surgical procedures. The most common site of involvement of the gastrointestinal tuberculosis is the ileocaecal region. who do not respond to conservative measures. and adenosine deaminase levels above 36 U/l.

Mechanoreceptors located within the wall of the large intestine.OBSTRUCTION3. connective tissue diseases (e.obstruction (ACPO. ACPO occurs most often in hospitalized or institutionalized patients with serious underlying medical and surgical conditions. via efferent sympathetic nerves targeting the myenteric plexus or colonic smooth muscle. Clinical presentation: The exact incidence of ACPO is unknown. COLONIC PSEUDO.40-42 Definition: Colonic pseudo. pharmacological. signs and radiographic appearance of large bowel obstruction without a mechanical cause. An imbalance in autonomic innervation. the precise mechanisms underlying ACPO remain poorly understood.g. Fever. Passage of flatus or stool is reported in up to 40% of patients. is the inhibition of colonic motility (colo-colonic reflex). amyloidosis. CMV). Abdominal distention usually develops over 3–7 days but can occur as rapidly as 24h. Because the vagal supply to the large bowel terminates at the splenic flexure and the parasympathetic innervation of the left colon originates from the sacral plexus. neurological (e. in this circumstance.22 HIV neuropathy. On examination. activate a reflex pathway whose final effect. respiratory. as a result of increased sympathetic drive. produced by a variety of factors. it has been proposed that transient parasympathetic impairment at the sacral plexus may cause atony of the distal large bowel and result in functional obstruction. It most often affects those in late middle age (mean age of 60 years). orthopaedic surgery. may play an important role in the pathophysiology of ACPO. post traumatic. As in pseudo-obstruction (Ogilvie’s syndrome).g. and chronic types. when stimulated by distention. The parasympathetic nervous system increases contractility. DM). . hyperactivity of inhibitory neurones to the large bowel. Slight male predominance (60%). However. marked abdominal tenderness and leucocytosis are more common in patients with ischaemia or perforation but also occur in those who have not developed these complications. leads to excessive parasympathetic suppression or sympathetic stimulation. Patients with ischaemic or perforated bowel have similar symptoms but are more likely to be febrile. whereas the sympathetic nerves decrease motility in the colon. correction of fluid and electrolyte derangement should be followed by a conservative approach. the abdomen is tympanitic and bowel sounds are typically present. obstetric and gynecological procedures etc. The clinical features of ACPO include abdominal distention. EBV.g.Ogilvie’s Syndrome). infections (e. the use of guanethidine and/or neostigmine can relieve the ileus completely. scleroderma). Causes: Metabolic. abdominal pain (80%) and nausea and/or vomiting (60%). Pathophysiology: The pathogenesis of ACPO is not completely understood although it likely results from an alteration in the autonomic regulation of colonic motor function. Alternatively. Acute colonic pseudo. despite improved knowledge of the pathophysiology of colonic motility. cardiac.obstruction is a term used to characterize a clinical syndrome with symptoms.

reproduced by Hutchinson in 1992. Water soluble contrast enema: to rule out mechanical obstruction Colonoscopy: TO rule out mechanical bowel obstruction Ancillary tests Manometry: differentiates between neuropathy and myopathy Radio-isotope studies: evaluates emptying Biopsies . ANCA Radiological AXR: distended bowel which may show lack of haustrations. glucose tolerance test Test for infective causes Endocrine: TFT Collagen vascular diseases: ANF. .23 Investigations: Haematological FBC.full thickness to assess the presence of neural or muscle cells Management Conservative in general including 1) Bowel rest 2) NG decompression 3) IV fluids and correction of metabolic parameters 4) Other measures treatment of infections changing position of patient in bed discontinuation of drugs that inhibit GIT motility Repeat enemas rectal tubes and rigid sigmoidoscopy 96% success rate duration of treatment : approx 3-7 days Can be continued as long as: no signs of peritonism no increases in abdominal distention Mortality in conservatively treated patients: 14% a) Pharmacological management Frequent liquid meals Use of motility stimulants – usage of erythromycin. Similar results with using neostigmine alone. Cisapride – enhances Ach release in the myenteric plexus Erythromicin – motilin agonist Use of adrenergic blocker and subsequent cholinesterase Inhibitor: Guanethine – adrenergic blocker Neostigmine – cholinesterase inhibitor st 1 introduced by Catchpole 1969. cisapride. Can occur at hepatic or rectosigmoid area.5 mg IV over 1 min). 73% improvement with acute colonic pseudo-obstruction following admin of guanethidine (20mg IV) followed by neostigmine (2. metoclopramide : not very useful. U+E blood glucose. “cut off sign” – commonly at splenic flexure.

Placing indwelling decompression tubes 2. particularly. - b) Surgical management Indications: .Failure of pharmacological Mx and colonoscopy .obstruction 2. Success rates: 77-86% low morbidity rates = 0. bradycardia. Usage of polyethylene glycol electrolyte solutions (PEG). Recurrence rates 15-65% Recurrence can be improved by 1. colonoscopic decompression is the treatment of choice.2-2% Disadvantages: 1. Surgery is reserved for those with peritonitis or impending perforation b) Colonoscopic decompression Indications: 1. Technically difficult and demanding procedure compared to elective diagnostic colonoscopy 2. Patient should thus be in a high care set up with Cardiac monitoring Atropine available to reverse effects Ability to intubate Slow infusion rather than IV bolus decreases risk of S/E - - Contra-indications: Baseline HR < 60. Unprepared bowel 3. hypotension and brochospasm.24 Precautions need to be taken due to parasympathomimetic S/E of neostigmine. Careful minimal insufflation to prevent perforation 4.Impending perforation (gross caecal dilatation) . perforation . which leads to prompt colon decompression in most patients after a single infusion. sepsis. In patients failing or with contraindications to neostigmine. Systolic BP < 90 mmHg Active bronchospasm requiring meds Haven’t ruled out mechanical obstruction The best studied treatment to date is IV neostigmine. Failed neostigmine or contraindicated.Signs of perforation and ischaemia caecal necrosis : resect with ileostomy and mucous fistula Perforation : Excise area and exteriorize as acolostomy Tube caecostomy: Indicated in acute dilatation without perforation or ischemia Advantage: successful decompression can be obtained with fewer complications Mortality: 30% If caecal perforation: mortality up to 50% .Options: Urgent laparotomy: . Failure of conservative management in acute pseudo. Studies show that the administration of PEG post decompression had a sustained response rate and prevents recurrence.Features of ischaemia.

Risk factors: Teenage female (retrograde menses). subacute intestinal obstruction with poorly defined abdominal mass. use of practolol. . Within this structure.Usually present with acute.25 RARE CAUSES OF BOWEL OBSTRUCTION Abdominal Cocoon (Sclerosing encapsulating peritonitis): 43-45 A rare acquired condition in which there is encapsulation of the small bowel by a fibrous membrane. Only about 50 reported cases worldwide. the small bowel loops are coiled up in either a concertina-like or serpentine fashion and are interconnected by fine adhesions. TB. SLE. in dwelling abdominal catheters (LeVeen shunts). sarcoidosis. chronic ambulatory peritoneal dialysis.

. Search the entire GIT for synchronous bezoars and remove them. Abdominal radiographs are only suggestive of an obstructive pattern. pneumobilia and any other co-existing pathology contributing to the impaction of the gallstone. most commonly the distal ileum.Either milk it through the ileocaecal valve into the caecum.removal of stone via an enterotomy or sometimes. Treatment Surgery . pneumobilia and ectopic gallstones may be occasionally detected by plain radiograph or ultrasound. Presenting features may be that of acute small bowel obstruction that may be complete or incomplete.47 Usually four types: 1 Phytobezoars: composed of vegetable matter and undigestable Fibres (cellulose. Patients with trichobezoars need psychiatric management. Patients with previous gastric surgery need to be advised of avoiding citrus fruits and persimmons.excision of the sac and adhesiolysis. followed by jejunum and stomach. CT and ultrasound may be of help but are non-specific. The gallstone enters the gastrointestinal tract through a fistula between a gangrenous gallbladder and duodenum or other parts of the GIT. Can manifest as the The Rapunzel syndrome: This syndrome is characterized by intestinal obstruction secondary to a bezoar possessing a tail which extends to or beyond the ileo-cecal valve. however. Interval cholecystectomy can be performed once inflammation has settled and repair of fistulous communication. Occasionally stone may come into the intestine through a fistulous communication between the bile duct and the gastrointestinal tract. or perform an enterotomy to remove the bezoar. It accounts for up to 25% of all cases of small bowel obstruction over 65 years of age. can be identified at CT: clustered small bowel loops encased by membrane-like sac. Important to look for the parent bezoar in the stomach which is present in most cases and either remove by gastrotomy or endoscopically. tannins) Uncommon: 0. 3 Pharmacobezoars : cholestyramine. Computed tomography invariably demonstrates a fistulous communication. Bezoars 46. kayexalate resin. Treatment: Surgery . Treatment: Immediate Surgery. intraluminal gallstone in the small bowel. Gall stone ileus3 Gallstone ileus is a mechanical obstruction caused by impaction of gallstone(s) in any part of the gastrointestinal tract. hemicellulose. 2 Trichobezoars concretion of hair fibres. antacids 4 Lactobezoars : milk curd 2° to infant formula Diagnosis: due to high degree of suspicion and suggestive history.5 cm in diameter. Intestinal obstruction is usually caused when the gallstones are greater than 2. Radiological findings comprising of Rigler’s classic triad of small bowel obstruction. the stone can be milked into the caecum without enterotomy.4-4% More than half of the cases of phytobezoars had previous history of previous gastric surgery. Usually in Psychiatry patients.26 Diagnosis: usually diagnosed at laparotomy.

internal hernias have no age or sex predilection.retroanastomotic (5%)  In general. arrangement or crowding of small-bowel loops within the hernial sac. almost equal to those caused by adhesions in one study. Over the past decade. Without a heightened awareness and understanding of these hernias.  In the broad category of internal hernias are several main types. external and internal.paraduodenal (53%) .  These symptoms may be altered or relieved by changes in patient position  Because of the propensity of these hernias to spontaneously reduce. . and abnormal apertures arising from anomalies of internal rotation and peritoneal attachment.  The orifice can be either acquired.  In the past.  General radiographic features with barium studies include: . In this subset of patients. and . their incidence has been increasing because of the more frequent performance of liver transplantations and gastric bypass surgery for bariatric treatment. have been reported to have an overall mortality exceeding 50% if strangulation is present.  External hernias refer to prolapse of intestinal loops through a defect in the wall of the abdomen or pelvis  Internal hernias are defined by the protrusion of a viscus through a normal or abnormal peritoneal or mesenteric aperture within the confines of the peritoneal cavity. based on location: .49 Internal hernias have an overall incidence of less than 1%.  However.27 INTERNAL HERNIAS48. including both normal apertures. which.8% of all smallbowel obstructions. General Imaging Findings on Radiography and CT:  Imaging studies often play an important role in the diagnosis of internal hernias because they are often difficult to identify clinically. internal hernias account for just over half of all cases of small-bowel obstruction. if left untreated. traumatic.  Symptom severity relates to the duration and reducibility of the hernia and the presence or absence of incarceration and strangulation. patients are best imaged when they are symptomatic. or Post-inflammatory defect.trans-mesenteric and transmesocolic (8%) . such as a postsurgical.foramen of Winslow (8%) . and multi-planar reformatting capabilities. they constitute up to 5.apparent encapsulation of distended bowel loops with an abnormal location.pericecal(13%) . and recurrent intestinal obstruction. internal hernias can be asymptomatic.  or cause significant discomfort ranging from constant vague epigastric pain to intermittent colicky periumbilical pain  Additional symptoms include nausea. these hernias were most frequently assessed with small-bowel oral contrast studies. General Clinical Findings:  Clinically. Definition:  Hernias are of two main types. vomiting (especially after a large meal). CT has become the first-line imaging technique in these patients because of its availability.inter-sigmoid (6%). or congenital. they can often be misdiagnosed. such as the foramen of Winslow. with subsequent significant morbidity and mortality. speed.

Any factor that sharply narrows the aortomesenteric angle causes the compression of the third part of duodenum. coursing between the SMA and aorta. voluminous vomiting and eructation. In these cases there is a high incidence of small bowel ischaemia and infarction and resection of the strangulated small bowel segment may be necessary. The diagnosis can be difficult and usually is made by exclusion. Iatrogenic internal hernias can be successfully managed by laparoscopy and laparoscopic repair of congenital internal hernias has been described. Management of internal hernias: The management of internal hernias requires reduction of the hernia and repair of the defect by either a laparoscopic or open approach. fullness. with ad-ditional features of apparent fixation and reversed peristalsis during fluoroscopic evaluation On CT. and the third part of the duodenum crosses caudally to the origin of the SMA. E= transmesenteric and F= retroanastomotic Superior Mesenteric Artery Syndrome: An Unusual Cause of Intestinal Obstruction50 Superior mesenteric artery (SMA) syndrome is an uncommon cause of proximal intestinal obstruction. resulting in the SMA syndrome. There are some important etiologic factors which may precipitate the narrowing of the aortomesenteric angle and lead to chronically mechanical obstruction such as: slight body build.28 - evidence of obstruction with segmental dilatation and stasis. The SMA usually forms an angle of 45 ° with the abdominal aorta. D= pericaecal. the use of body cast in the treatment of scoliosis or vertebral fractures. C= intersigmoid. spinal disease. particularly . Illustration of various types of internal herniasA= paraduodenal. The most characteristic symptoms are postprandial epigastric pain. severe injuries. rapid linear growth without compensatory weight gain. and stretching of these vessels commonly found and providing an important clue to the underlying diagnosis. with engorgement. exaggerated lumbar lordosis and abdominal wall laxity. deformity or trauma. additional findings include mesenteric vessel abnormalities. frequently occurring in patients who have had an important weight loss. malabsorption. dietary disorders such as anorexia nervosa. such as head trauma leading to prolonged bed rest. B= foramen of Winslow. These symptoms are due to the compression of the third portion of the duodenum against the posterior structures by a narrow-angled SMA and surgical management is necessary. depletion of the mesenteric fat caused by rapid severe weight loss due to catabolic states such as cancer and burns. crowding. twisting.

pronounced dilatation and stasis of the duodenum.29 in adolescents.delay of 4 to 6 hours in transit through the gastro-duodenal region . The wisdom of the adage “never let the sun set or rise on a small bowel obstruction” remains a most practical guideline whenever any uncertainty exists. Surgery is indicated if there is a long history of vomiting. barring development of pancreatitis or an obstruction of the duct of Wirsung. The outcome of the disease is excellent if it is diagnosed early and if the patient receives appropriate therapy. gastrojejunostomy. with or without gastric dilatation . An annular pancreas can be asymptomatic or can cause external compression on the second portion of the duodenum. Procedures used are: duodenojejunostomy from the second portion of the duodenum to the jejunum (the best choice). “It is less dangerous to leap from the Clifton Suspension Bridge (250-275 feet above the Avon River) than to suffer from acute intestinal obstruction and decline operation”. The initial treatment of the SMA syndrome is generally conservative. “Frederic Treves” of the London Hospital. Roux en Y duodenojejunostomy and anterior transposition of the third part of duodenum. in patients with a short history and a relatively minor degree of duodenal stasis shown radiologically. CONCLUSION52 The modern day surgical management of small bowel obstruction continues to focus appropriately on avoiding operative delay whenever surgery is indicated. REFERENCES 1. The clinical diagnosis can be confirmed by radiologic studies in 95% of cases. in his monograph of 1899 said. Annular pancreas51 This rare condition involves a lesion that consists of a thin flat ring of histologically normal pancreatic tissue that surrounds the descending duodenum in an anomalous position.antiperistaltic flow of barium proximal to the obstruction producing to-and-fro movement . SMA syndrome occurs in females more often than in males.By the use of selective SMA arteriography against a barium-filled duodenum it is possible to demonstrate extrinsic compression and to measure the aortomesenteric angle and the distance from the aorta. vascular compression of duodenum in association with peptic ulcer disease and traumatic mesenteric arteriovenous fistula following abdominal aortic aneurysm repair. 2007. Khanzada.relief of obstruction when the patient is placed in a position (prone or knee-chest)that diminishes the drag of the small-bowel mesentery. the anatomy and the relationships of the superior mesenteric vessels and excluding other pathology . progressive weight loss. It is almost invariably associated with an intrinsic cause of duodenal obstruction (duodenal atresia). . 5(2): 59-61.CT is also useful in demonstrating both the duodenal distention. with multinutritional support and postural therapy. Annular pancreas results from abnormal rotation of the ventral pancreatic bud and usually functions normally. which creates a partial or complete obstruction. Tariq Wahab et al.abrupt vertical and oblique compression of the mucosal folds . . Gomal Journal of Medical Sciences. Etiological spectrum of dynamic intestinal obstruction.dilatation of the first and second portions of the duodenum. There are some unusual causes such as familial SMA syndrome. The following radiologic criteria have been established for the diagnosis of SMA: .

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