o For example: Intestinal malrotation and midgut volvulus

Far Eastern University – Nicanor Reyes Medical Foundation -considered in adults with acute or chronic symptoms of SBO
Basic Surgery B – Intestinal Obstruction (especially among those with no prior abdominal surgery)
Roman P. Oblena, Jr, MD

-Definition of Terms -Examples

-Epidemiology -Management
-Pathophysiology -Prevention
-Clinical Presentation -Complications
-Diagnosis

DEFINITION OF TERMS

Mechanical SBO / Small Bowel Obstruction

-most frequent surgical disorder of the small intestine
§ Rare Etiology of SBO
Obstructing lesion according to its anatomical relationship to the o Superior Mesenteric Artery Syndrome: compression of the 3rd
intestinal wall: portion of the duodenum by SMA. This should be considered in
§ Intraluminal – foreign bodies, gallstones, meconium young asthenic individuals who have chronic symptoms
§ Intramural – tumor, Crohn’s disease-associated inflammatory strictures suggestive of proximal SBO.
§ Extrinsic – adhesions, hernias, carcinomatosis
PATHOPHYSIOLOGY
Onset of obstruction
§ gas and fluid accumulate within the intestinal lumen proximal to the
site of obstruction.
§ The intestinal activity increases to overcome the obstruction,
Intraluminal Intramural Extrinsic
accounting for the colicky pain and the diarrhea

EPIDEMIOLOGY
§ Cancer-related SBO are commonly due to extrinsic compression or
invasion by advanced malignancies arising from other organs; few are
due to primary small bowel tumors.
§ Intra-abdominal adhesions related prior to abdominal surgery account
for 70% of SBO. (*up to 75% of cases from Schwartz’s)
§ Less prevalent etiologies: (varies according to the patient population
and practice setting)
o Hernia – Inguinal (direct & indirect-mass with scrotal
enlargement), Lateral, Femoral, Incisional, Umbilical and
Epigastric Hernia
o Malignant bowel obstruction
o Crohn’s disease – chronic idiopathic intramural inflammatory
disease with skip lesions that may affect any part of GIT
Most of the gas that accumulates originates from swallowed air, although
some is produced within the intestine. The fluid consists of swallowed
liquids and gastrointestinal secretions (obstruction stimulates intestinal
epithelial water secretion)
Bowel distention
§ With ongoing gas and fluid accumulation, the bowel distends
and intraluminal and intramural pressures rise.
§ The intestinal motility is eventually reduced with fewer contractions.
With obstruction, the luminal flora of the small bowel, which is usually
sterile, changes and a variety of organisms have been cultured from the
contents. Translocation of these bacteria to regional lymph nodes has
been demonstrated, although the significance of this process is not well
understood.

Impaired intestinal microvascular perfusion

§ Increased intramural pressure leads to decreased bowel perfusion.
§ Continued increase in pressure and obstruction leads to intestinal
ischemia, and, ultimately, necrosis.

Strangulated Bowel Obstruction

§ Happens when intramural pressure becomes high enough
§ Intestinal microvascular perfusion is impaired, leading to intestinal
ischemia and infarction
§ Tissue necrosis with possible perforation +/- bacterial invasion

Partial Small Bowel Obstruction

§ only a portion of the intestinal lumen is occluded, allowing passage of
some gas and fluid.
§ The progression of pathophysiologic events described previously
tends to occur more slowly than with complete small bowel obstruction,
and development of strangulation is less likely.

Complete Bowel Obstruction

§ There is a complete occlusion in the intestinal lumen that typically
presents with acute abdominal pain, hence a surgical emergency.
§ On physical examination, there is obstipation and absence of bowel
§ Congenital causes of SBO movements.
o Evident during childhood
o May be diagnosed during adulthood presenting with abdominal
symptoms

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Closed Loop Bowel Obstruction
§ A particularly dangerous form of bowel obstruction in which a
segment of intestine is obstructed both proximally and distally (e.g.,
with volvulus).
§ In such cases, the accumulating gas and fluid cannot escape either
proximally or distally from the obstructed segment, leading to a rapid
rise in luminal pressure and a rapid progression to strangulation.
HISTORY
§ Prior abdominal operations (suggesting the presence of adhesions)
§ presence of abdominal disorders (e.g., intra-abdominal cancer or
malignancy or inflammatory bowel disease) that may provide insights
into the etiology of obstruction.
EXAMINATION
§ check for possible presence of hernias (particularly in the inguinal and
femoral regions)
§ diagnosis of small bowel obstruction is usually confirmed with
radiographic examination.

RADIOGRAPHIC EXAMINATION (Abdominal series)

§ Abdominal radiograph in supine position
§ Abdominal radiograph in upright position
§ Chest radiograph in upright position.

Radiographic Triad of SBO:

§ Dilated small bowel loops (>3 cm in diameter)
§ Air-fluid levels seen on upright films
§ Paucity of air in the colon

SUPINE UPRIGHT

CLINICAL PRESENTATION
Cardinal Features: order and degree of manifestation depends on the level
of obstruction
1. Abdominal Pain
-First feature; severe and sudden onset
-If constant and/or localized, suggests impending bowel compromise from
§ The sensitivity of abdominal radiographs in the detection of small
ischemia and or perforation
bowel obstruction ranges from 70% to 80%.
2. Abdominal Distention § Specificity is low because ileus and colonic obstruction can be
-Greater degree in more distal obstruction and longer episode associated with findings that mimic those observed with small bowel
3. Vomiting obstruction.
Onset: -proximal obstruction(short interval between onset of pain & § False-negative findings on radiographs can result when the site of
vomiting); colonic obstruction (late or absent) obstruction is in the proximal small bowel and when the bowel lumen
Nature: gastric outlet obstruction (undigested stomach contents without is filled with fluid but no gas, thereby preventing visualization of air-fluid
bile);distal obstruction(bilious becoming more feculent as obstruction levels or bowel distention.
moves distally)
4. Absolute Constipation COMPUTED TOMOGRAPHY
-Failure to pass stool or flatus; occurs earlier in distal obstruction §Ideally done with contrast (for the lab exam, make sure to include BUN
-passage of flatus and stool 6-12 hours (partial obstruction) 5130 and creatinine à kidney function)
Other Clinical Findings: Intestinal 's§Provides global evaluation of the abdomen (reveal the etiology of the
tosi
§ Bowel Sounds pneuma obstruction)
o Initially hyperactive o Important in the acute setting when intestinal obstruction
o Minimal in late stages represents only one of many diagnoses in patients presenting with
§ Laboratory findings eg. CBC, electrolytes (Na, K, Cl) acute abdominal conditions
o Reflect intravascular volume depletion (hemoconcentration and §Sensitivity (80% to 90%) and Specificity (70% to 90%)
electrolyte abnormalities) §Limitations: Low sensitivity (<50%) in the detection of low-grade or
o Mild leukocytosis partial SBO
§ Features of Strangulated Obstruction: (red flags for early §The findings of small bowel obstruction include:
intervention) o a discrete transition zone with dilation of bowel proximally
§ Abdominal pain disproportionate to the degree of abdominal o decompression of bowel distally
findings, suggestive of intestinal ischemia o intraluminal contrast that does not pass beyond the transition
§ Tachycardia,vfever

ry
zone, and
§ Localized abdominal tenderness o colon containing little gas or fluid
§ marked leukocytosis and acidosis §may provide evidence of closed loop obstruction and strangulation
§ Usually performed after administration of oral water- soluble contrast
§ DIAGNOSIS
or diluted barium
a) Distinguish mechanical obstruction from ileus § Both prognostic and therapeutic (appearance w/in 24 hours is
b) Determine the etiology of the obstruction predictive of nonsurgical resolution of bowel obstruction)
c) Discriminate partial from complete obstruction
d) Discriminate simple from strangulating obstruction

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Closed-Loop Obstruction
§ U-shaped or C-shaped dilated bowel loop (with a radial distribution of
mesenteric vessels converging toward a torsion point)
Strangulation
§ Thickening of the bowel wall
§ Pneumatosis intestinalis (Air in the bowel wall)
§ Portal venous gas
§ Mesenteric haziness
§ Poor uptake of intravenous contrast into the wall
Small bowel obstruction.
Image shows grossly dilated loops
of small bowel, with
decompressed terminal ileum (I)
and ascending colon (C),
suggesting a complete distal small
bowel obstruction.
Intestinal pneumatosis(arrow).
The cause of this radiological
finding was intestinal ischemia.
Patient was taken emergently to
the operating room and underwent
resection of an infarcted segment
of small bowel.
Chronic partial small bowel
obstruction. This patient
presented with a several months
history of chronic abdominal pain
and intermittent vomiting.
Findings:
-dilated loops of proximal small
bowel on the left side (wide arrow)
-decompressed loops of small
bowel on the right side (narrow
arrow).
EXAMPLES
ADHESION
Adhesive bands obstructing at two
points
Findings:
-Orlando Wilde
-Ruby-Leigh Carey
-Manrai Oneil
-Maleeha Bautista
-Clement Dodson
TUMOR
May cause intraluminal, intramural
or extraluminal obstruction by
physical blockage of bowel lumen
(mechanical obstruction)
GI NEOPLASM
Colorectal CA-most common
malignancy of the GIT
Polyps- any projection from the
surface of the intestinal mucosa
regardless of its histologic nature
Coronal view
Dotted blue line: enhancing mass at the junction between descending
colon and sigmoid colon
Yellow (*): proximal LBO with the cecum distended
INTUSSUSCEPTION
-More common in children
-can occur anywhere
-Ileocolic: most common location
-Ileoileocolic: 2nd most common
-Ileoileal & colocolic: uncommon
UTZ (Ultrasound)
-Target sign aka Doughnut sign
-Pseudokidney sign
CT
-modality of choice
-layers of the bowel are duplicated
forming concentric rings
HERNIA
Presentation:
- Severe abdominal pain, with
persistent pain during the interim
periods of paroxysmal pain;
gradually increased shock
- Evident peritoneal irritation and
increased body temp, pulse rate
and WBC
- Asymmetrical bloating, palpable
and tender intestinal loops with
rebound tenderness
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 Elective surgery
VOLVULUS
o If symptoms do not improve within 48 hours after initiation of
- Describes the torsion of bowel around nonoperative therapy
its mesentery
- Results in narrowing of the lumen at Water-soluble oral contrast
the point of rotation and compromise of o Diagnostic, prognostic and therapeutic
the vessels
- Gastric volvulus Operative procedures (according to etiology)
- Midgut volvulus
o Adhesions are lysed
- Cecal volvulus: occur in female in
o Tumors are resected
their 4th & 5th decade of life; ischemia is
o Hernias are reduced and repaired
common
- Sigmoid volvulus: most common
CT Scan Note: regardless of the etiology, affected intestine should be
-generally, demonstrate the whirl sign examined and non-viable bowel should be resected

GASTRIC OULET OBSTRUCTION

Assessment for viability: (visual inspection or Doppler technique)
o Color
Presentation:
o Peristalsis
- Non bilious vomiting
o Marginal arterial pulsations
- Profound hypokalemic
hvpochloremic, metabolic alkalosis
Decision point in a hemodynamically stable patient
- Dehydration
§ Short lengths
- Pain or discomfort
o Should be resected
- Prominent weight loss
o Primary anastomosis of the remaining intestine should be
performed
Grossly distended stomach, containing a
§ Larger proportion involved
large volume of debris. Thickening and
o concerted effort to preserve intestinal tissue should be made
enhancement of the antrum/pylorus of
o bowel of uncertain viability should be left intact;
the stomach, suggestive of a tumor.
o reexplore in 24-48 hours)
Clinical Findings: Succussion splash may be audible on auscultation
over the epigastrium
Diagnosis: confirmed by endoscopy
Initial treatment: Nasogastric suction, IV hydration, Electrolyte repletion
and Acid suppression
Most patients with obstructing ulcer disease require intervention
o Balloon dilation or operation

MANAGEMENT
Fluid resuscitation
o Using isotonic fluid given intravenously

Indwelling bladder catheter

o To monitor urine output

Central venous or pulmonary-artery catheter monitoring

o Not generally indicated unless the patient has underlying
cardiac disease and severe dehydration

Broad-spectrum antibiotics
o Not indicated unless there is concern for bowel ischemia and
surgery is planned
o Cephalosporin (3rd gen); Metronidazole for anaerobes

Nasogastric tube replacement

o For continuous evacuation of air and fluid in the stomach
(decreases nausea, distention, and the risk of vomiting and
aspiration)

Expeditious surgery LAPAROSCOPIC SURGERY

o Mainstay of treatment for partial bowel obstruction
o Minimizes the risk for bowel strangulation
o GOAL: operate before the onset of irreversible ischemia
Conservative therapy
o NGT decompression & fluid resuscitation - commonly recom-
mended in the initial management of non-ischemic partial SBO
§ Associated with significantly lower rates of overall complications, surgical
site infections, and a shorter length of hospital stay
§ Early cases of proximal small bowel obstruction that are likely due to a
single adhesive band are best suited for this approach
§ Risk: Iatrogenic bowel injury

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 ADVANTAGES DISADVANTAGES
Lower rates of complications Risk of iatrogenic bowel injury COMPLICATIONS

Less surgical site infection Greater surgical time § Perforation of intestine/s

§ Peritonitis
Shorter length of hospital stay § Sepsis – in cases of delayed diagnosis and management
(4 vs 10 days) § Abscess – intraabdominal
§ Dehydration – including electrolyte disturbances
OUTCOMES § Organ failure – in rare cases
§ Death
§ Long-term prognosis - related to etiology of obstruction
§ Many patients treated conservatively for adhesive SBO do not
require future readmissions References:
§ Standard hospital-wide policy can help improve care of patient with -Doc Oblena’s lecture, February 2022
bowel obstruction, reducing their time to surgery and shortening their -Schwartz’s Principles of Surgery. 11th ed
length of hospital stay -J! trans

PREVENTION

§ Cornerstone of adhesion prevention

o Good surgical technique
o Careful handling of tissue PREVENTION
o Minimal use and exposure of peritoneum to foreign bodies

§ Use of laparoscopic surgery, when possible

o Open surgery - associated with a fourfold increase in risk of
small bowel obstruction within 5 years of the index procedure

§ Adhesion prevention therapy

o Use of hyaluronan-based agents (e.g. Sperafilm)
o Reduces the incidence of postoperative bowel adhesions