Bowel obstruction

Abdulqader Taha Almuallim, MBBS

General Surgery Resudent
Case3:

37-year-old man presents with 1-day history of abdominal pain, nausea, and
vomiting. The patient reports that the pain was colicky in nature at the onset
but has become dull and persistent over the past few hours. He stated that the
symptoms started shortly after dinner. He wakes up 4 time vomiting large
amount of bilious material. Since the start of the complaint he did not passed
flatus or stool. PSHx revealed laparotomy for perforated duodenal ulcer 5-
years ago.
Case3:

O/E:
V/S: P: 105, T:38.5, BP: 130/84, RR: 28.
Abdomen is severely distended with mild tenderness throughout, without
peritonitis, exaggerated bowel sounds, and PR showed empty rectum.
WBC: 16, the rest of labs are within normal ranges.
Abdominal X-Ray.
What is the next step?
Case3:
What is the next step?
 INTESTINAL
OBSTRUCTION
Intestinal obstruction

• Can be:
• Dynamic:
• Intraluminal: Fecal impaction, Foreign body, Gallstone.
• Intramural: Stricture, Malignancy, Intussusception,
Volvulus.
• Extramural: Bands, adhesions, Hernia.
• Adynamic:
• Paralytic ileus, pseudo-obstruction.
Presentation

• Cardinal features of bowel obstruction:

• Abdominal pain.
• Distension.
• Vomiting.
• Absolute constipation.
• In Large bowel obstruction:
• The early symptoms is abdominal distension.
• Vomiting and dehydration are late.
Other manifestation

• Dehydration.
• Hypokalemia.
• Pyrexia.
• Abdominal tenderness.
• High pitched bowel sounds.
• Scanty or absent bowel sounds.
Clinical features of strangulation.

• Constant sever pain.

• Tenderness with rigidity and peritonism.
• Shock.
• If hernia: Irreducible, Change in skin color. No cough impulse.
Small VS Large bowel obstruction.

• Small: • Large:
• Adhesion, neoplasm, • Tumor and Volvulus.
hernia, crohn’s. • AXR: Dilatation ( >6cm in
• AXR: Dilatation Lt. colon, >8cm in
(>3cm) with collapsed transverse colon, >10cm
large bowel, central, in Rt. colon), no air in
rectum, peripheral,
air-fluid level, Plaicae haustration, and can
cercularis and can not follow.
follow.
Small VS Large bowel obstruction.
Management

ØAcute intestinal obstruction:

• NGT.
• Fluid and electrolyte replacement.
• Relief of obstruction.
• Surgical management.
Management

ØAdhesive intestinal obstruction:

• Conservative management:
• NGT
• Fluid and electrolyte replacement.
• Relief of obstruction.
• Surgical management.
Management

ØIndication of early surgical management:

• Rapidly progressing pain or distention.
• Peritonitis, Fever, Decrease urine OP, Leukocytosis and
acidosis.
• Failure to resolve after 48 hours.
• Obstructed external hernia.
• Suspicion of intestinal strangulation.
• Obstruction in virgin abdomen.
volvulus
Management

ØTreatment of cecal volvulus.

• Surgery.
ØTreatment of sigmoid volvulus.
• Decompression by sigmoidoscopy.
• Elective sigmoid colectomy.
MCQs

A 36-year-old woman who has had open appendectomy 6 years back surgery presents
with intermittent abdominal distension and pain of 1 week’s duration and persistent
vomiting for the past 1 day. Her physical examination does not reveal any hernias and is
consistent with that of distal small bowel obstruction. She is afebrile. Her WBC count is
4000/mm2. Which of the following is the most appropriate next step?
a) Attempt nonoperative treatment for 48 hours.
b) Perform upper gastrointestinal tract endoscopy.
c) Proceed with an immediate exploration laparotomy.
d) Obtain a serum carcinoembryonic antigen (CEA).
e) Perform a CT scan.
MCQs

A 36-year-old woman who has had open appendectomy 6 years back surgery presents
with intermittent abdominal distension and pain of 1 week’s duration and persistent
vomiting for the past 1 day. Her physical examination does not reveal any hernias and is
consistent with that of distal small bowel obstruction. She is afebrile. Her WBC count is
4000/mm2. Which of the following is the most appropriate next step?
a) Attempt nonoperative treatment for 48 hours.
b) Perform upper gastrointestinal tract endoscopy.
c) Proceed with an immediate exploration laparotomy.
d) Obtain a serum carcinoembryonic antigen (CEA).
e) Perform a CT scan.
Abdulqader T. Almuallim
Mobile: 0505505595
Email: atmuallim@gmail.com
Twitter: @ATMuallim

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