DEPARTMENT OF SURGERY

Case presentation
Intestinal obstruction

intern
deepak paudel
GMCTH
 68yr/M from Armala ,Ex Army by profession was admitted
through GMC ER on 27th of Asad 2073( @ 10:20 PM) with chief
complaints of:

• pain abdomen for 3 days

• Dyspepsia for 3 days
• Abdominal distention for 3 days
 HOPI
• Pain - in RIF
gradual on onset
burning sensation
continuous
started in the morning
non radiating
no known aggravating factor
relieved by shifting position
Pain is associated with

abdominal distention
water brash
nausea
burning micturation
H/O loss of appetite
• H/O passage of hard stool
• No H/O fever ,headache ,trauma
• No H/0 cough ,weight loss
• No H/0 vomiting.
 PAST HISTORY
• H/0 appendectomy 40 yrs ago
• From than ,he started to develop abdominal
pain of similar nature .
• According to him, he experiences similar
problem once in every year.
• Last time on Bhadra 2072 he was admitted to
GMCTH for abdominal pain ,admitted ,treated
conservatively and relieved.
 FAMILY HISTORY
• No such H/O in the family
• no H/O of HTN, DM, TB
 PERSONAL HISTORY
• Consumes alcohol occasionally.
• Non vegeterian
• Doesn’t smoke
• But has a habit of chewing tobacco.
 ALLERGIC HISTORY
• No known allergic history of any drug
• GENERAL EXAMINATION

Pt .was concious, well oriented to T,P,P lying comfortably in supine

position with cannula fitted in the left hand
- Vitals
R/R:-25/min
BP:- 110/70 mm of Hg in rt brachial Artery.
Pulse-84beats/min
Temp 98 F
• Pallor
• Icterus
• Lymphadenopathy nil
• Clubbing
• Cyanosis
• Oedema nil
• Dehydration
 GI EXAMINATION
Inspection
-umbilicus centrally placed and abdomen is
distended.
-visible scar in rt iliac fossa
-all quadrants move equally with respiration
-no visible pulsation and peristalsis
-hernial sites intact
-ext. genitilia-normal
Palpation
-Abdominal girth :90 cm(01) -86 cm(02) -72 cm (04/04)
-local temprature normal
-tenderness on lower abdominal region
-no palpable mass
-no organomegaly
-hernial sites intact and normal ext. genital
Percussion – resonant note
- tender RIF
-shifting dullness –ve

auscultation – normal bowel sound heard

-no vascular bruits heard
P/R exm- no mass, no blood, faeces present.
• Respiratory exmn-normal
• CVS exmn- normal
• CNS exmn –normal
 Provisional diagnosis
• Intestinal obstruction:
For abdominal pain
Constipation
Abdominal distention
 Differential Diagnosis
D/d For Against
Meckels Pain abdomen No antecedent
Diverticulitis h/o of lower GI
bleeding
Rt. Ureteric colic Abdominal Pain No history of
Aggravated on hematuria
movement no radiation to
loin
D/D For Against
Perforated peptic Severe pain in pain is not
ulcer RIF related to food
history of intake.
dyspepsia
Crohns diseases Pain abdomen No diarrhoea and
wt loss
 Investigation
• CBC:-WBC -10,000/mm3
• Na+ 141 ,k+ 4.0
• USG impression :
slightly prominent bowel loop.

• Plain abdominal X-ray

 Treatment
• Under liquid diet.
• IV fluids
• Analgesics:inj tramadol ,buscopan,
• Antibiotics :levoflox,inj xone
• Soap water enema.
Intestinal obstruction
 Definition:
• Intestinal Obstruction(IO) is a condition in
which there is a sudden stoppage of the
onward passage of intestinal contents-i.e. Gas,
digestive juices and food
Intestine
 CLASSIFICATION
According to:
Aetiopathology
Onset
Level
Nature
 DYNAMIC
ADYNAMIC
(MECHANICAL)
(FUNCTIONAL)

Result from atony of the

intestine with loss of normal
Peristalsis is working against peristalsis, in the absence of a
a mechanical obstruction mechanical cause.

or it may be present in a non-

propulsive form (e.g. mesenteric
vascular occlusion or pseudo-
obstruction)
 According to LEVEL

Small or Large bowel

High (Proximal) or Low (Distal) small bowel

High IO- near the ampulla- jejunum and
proximal ileum.

Low IO- distal to the ampulla- distal ileum

and colon.
 According to nature of Obstruction:

1. Simple Obstruction- the bowel lumen is occluded ,blood supply remains

intact. The source of obstruction is usually intra-abdominal. ( Eg. Intra-
abdominal adhesions, very rarely gallstones, ball of worms, bezoars).
2. Strangulation- the bowel lumen together with its blood supply is cut-off.
Eg. Strangulated inguinal hernias. Pure strangulation without bowel
luminal narrowing is usually due to mesenteric embolism/thrombosis.
3. Closed loop obstruction- The bowel is
obstructed both proximally and distally. Here
the blood supply may be impaired.
A classic example is seen in an obstruction of
the colon with a competent ileo-caecal valve.
NB: All the 3 types spoken about can occur at
the same time for example in a strangulated
inguinal hernia.
Closed loop obstruction
 According to onset:
-Chronic Obstruction-Usually seen in large
bowel obstruction. The symptoms may arise
from the cause and the subsequent obstruction.
-Acute on Chronic Obstruction- sudden
obstruction in a previously incomplete
obstruction.
Sub-acute Obstruction- There is a partial
obstruction.
Causes Dynamic obstructrion
BANDS
Ball of Ascaris worms
 Adynamic cause of Obstruction
• Paralytic ileus
• Electrolyte imbalance
• Spinal injury
• Diabetis mellitus
• Renal surgeries
• Mesenteric ischemia
Pathophysiology
 Clinical presentation
The clinical presentation varies according to;
- The location of the obstruction
- The age of the obstruction
- Underlying pathology
- Presence or absence of intestinal ischaemia.
 Clinical features
• Abdominal pain
• Vomiting
• Distension
• Constipation
• Dehydration
• Feature of toxemia and septicemia
• Feature of strangulation
• Temperature
• Bowel sound
• Per rectal examination
Small vs large bowel obstruction
 Investigation

• CBC
• Electrolyte Na/K
• Plan X-ray abdomen erect and supine
• CT scan
A. Investigations
(i) Supportive- FBC, BU+Cr. Other investigations may be
requested on the basis of clinical suspicion.
(ii)Diagnostic
-Plain abdominal x-rays
Erect and supine
-CXR
-Enema
-Endoscopic techniques
 Managmenet
I.V fluids and electrolytes rescusitation
N.G tube if repeated vomiting
Antibiotics
Exploratory laparatomy
Hernia  operation
Adhesions  Adhesiolysis
Obstruction  remove
Volvulus  derotate and or operate
Mesenteric ischemia  operate
Abscess or peritonitis  drain and treat
Intussusception  pneumatic or barium reduction or operate
 REFRENCES:
• SRB’s Manual of surgery, 4E
• Bailey & Love’s Short practice of surgery, 25th
Edition
• Principles of surgery
• Internet