Flow:

When obstruction – we think

*High/low outlet obstruction

*complete/ partial

*Mechanical or functional (ileus or HIrschprung)

From history

- Delayed passage of meconium 3 days

So thinking of obstruction – where  do xray

=LOW
If high obstruction kay dli kaau ma claro ang distended abdomen kay high capacitance man. If low obstruction naa
distention

X-ray: When obstruction occurs, both fluid and gas collect in the intestine. They produce a characteristic
pattern called "air-fluid levels". The air rises above the fluid and there is a flat surface at the "air-fluid"
interface. Interaction between air and fluid causing the flattening of fluid line
Complete/partial

PE

- DRE: passage of gas and a lot of feces

- Will not consider intestinal atresia which is also common cause not onstruction in neonate
because that’s complete obstruction/ closed loop, strangulated obstrxn

Mechanical/functional

- Anatomical – intrinsic, extrinsic factor – we don’t know yet but so far no evidence from imaging
study
o Physical blockage to intestinal content: extrinsic – adhesion, hernia, volvulus, intrin -
tumor
- Functional – inefficient of either contraction or relaxatpion – ileus, hirschprung’s disease

Ileus Obstruction somewhere ie hirschprungs

Xray: diffusely dilated bowel throughout Dilation with air fluid level in the bowel
the intestinal tract proximal to the point of obstrxn and no
gas in the bowel distal to the obstruction

HX and PE  70-80% diagnostic already = low outlet  incomplete  functional = Hirschprungs?

- Do barium enema = 80-90% diagnostic

o Findings
- Have to do suctional biopsy = 100%

Note: to me lang:

gns of paralytic ileus are very similar to bowel obstruction. Nausea, abdominal pain, bloating
with vomiting, abdominal distention and obstipation being accompanying symptoms.
Classically paralytic ileus is suggested by hypoactive bowel sounds whereas small bowel
obstruction is described with rushes and bowel sounds consistent with peristalsis against
the obstruction.

However, if obstruction has led to ischemia and intra-abdominal sepsis, the patient may
have hypoactive bowel sounds. In a critically ill patient who is sedated and has impaired
mental status, it may be difficult to elicit complaints of nausea or pain. Anasarca can mask
abdominal distention. Obstipation and constipation may be overlooked as secondary to
medications.

Diagnostic approach
A high index of suspicion should be maintained in patients who develop high gastric tube
residuals or become intolerant of tube feeding. Patients with electrolyte abnormalities are at
a higher risk for paralytic ileus, as are multiple trauma, burn, and post operative patients, as
well as patients with any inflammatory response. Patients who are status post abdominal
surgical procedure can develop post operative bowel obstruction from adhesions.

The key is to distinguish ileus from obstruction as early as possible since small bowel
obstruction can lead to ischemia and perforation.

Diagnostic tests

Although plain abdominal films - flat, upright and decubitus films - are often initial tests
ordered outside the ICU, inside the ICU these films are often of poor quality for discerning
ileus from small bowel obstruction. Ileus usually has air throughout colon into rectum
compared to small bowel obstruction, which when complete does not show colonic air.
However these findings are not consistant when dealing with partial or early small bowel
obstruction. Air fluid levels are difficult to ascertain in the critically ill, as upright and
decubitus films are usually inadequate. (Figure 1 and Figure 2)