Intestinal Obstruction

Ahmed Badrek-Amoudi FRCS

The common Scenario




A 50 year old gentleman presents
with abdominal pain, distension and
absolute constipation. With
repeated episodes of vomiting.
His vital sign were stable, abdomen
distended with diffuse tenderness
but minimal peritonism. Bowel
Sounds are hyperactive.

The plain abdominal xray was taken
on admission.
What are your objectives?
You should be able to address the following questions
1. Is this bowel obstruction or ileus?
2. Is this a small or large bowel obstruction?
3. Is this proximal or distal obstruction?
4. What is the cause of this obstruction?
5. Is this a complex or simple obstruction?
6. How should I start investigating my patient?
7. What is the role of other supportive investigations?
8. What is my immediate/ intermediate treatment plan?
9. What are the indications for surgery?
10. What are the medico-legal and ethical issues that I
should address?
Introduction and Definitions




Accounts for 5% of all acute surgical admissions
Patients are often extremely ill requiring prompt
assessment, resuscitation and intensive monitoring
Obstruction A mechanical blockage arising from a
structural abnormality that presents a
physical barrier to the progression of gut
contents.
Ileus is a paralytic or functional variety of
obstruction
Obstruction is: Partial or complete
Simple or strangulated
physiology I - Patho
8L of isotonic fluid received by the small intestines
(saliva, stomach, duodenum, pancreas and hepatobiliary )
7L absorbed
2L enter the large intestine and 200 ml excreted in the
faeces
Air in the bowel results from swallowed air ( O
2
& N
2
) and
bacterial fermentation in the colon ( H
2
, Methane & CO
2
),
600 ml of flatus is released
Enteric bacteria consist of coliforms, anaerobes and
strep.faecalis.
Normal intestinal mucosa has a significant immune role
Distension results from gas and/ or fluid and can exert
hydrostatic pressure.
In case of BO Bacterial overgrowth can be rapid
If mucosal barrier is breached it may result in translocation of
bacteria and toxins resulting in bactaeremia, septaecemia and
toxaemia.
Patho-physiology II
Obstruction results in:
1. Initial overcoming of the obstruction by increased
paristalsis
2. Increased intraluminal pressure by fluid and gas
3. Vomiting
4. sequestration of fluid into the lumen from the surrounding
circulation
5. Lymphatic and venous congestion resulting in oedematous
tissues
6. Factors 3,4,5 result in hypovolaemia and electrolyte
imbalance
7. Further: localised anoxia, mucosal depletion necrosis and
perforation and peritonitis.
8. Bacterial over growth with translocation of bacteria and its
toxins causing bacteraemia and septicaemia.
Decompress with NGT
Replace lost fluid
Correct electrolyte abnormalities
Recognise strangulation and perforation
Systemic antibiotics.
Causes- Small Bowel
Extraluminal Mural Luminal
Postoperative
adhesions

Congenital
adhesions

Hernia

Volvulus
Neoplasims
lipoma
polyps
leiyomayoma
hematoma
lymphoma
carcimoid
carinoma
secondary Tumors
Crohns
TB
Stricture
Intussusception
Congenital
F. Body
Bezoars
Gall stone
Food Particles
A. lumbricoides
Small Bowel Adhesions
Accounts for 60-70% of All SBO
Results from peritoneal injury, platelet activation and fibrin
formation.
Associated with starch covered gloves, intraperitoneal sepsis,
haemorrhage and wash with irritant solutions iodine and other
foreign bodies.
As early as 4 weeks post laparotomy. The majority of patients
present between 1-5 years
Colorectal Surgery 25%
Gynaecological 20%
Appendectomy 14%
70% of patients had a single band
Patients with complex bands are more likely to be readmitted
Readmission in surgically treated patients is 35%
Hernia
Accounts for 20% of SBO
Commonest 1. Femoral hernia
2. ID inguinal
3. Umbilical
4. Others: incisional and internal H.
The site of obstruction is the neck of hernia
The compromised viscus is with in the sac.
Ischaemia occurs initially by venous occlusion,
followed by oedema and arterialc ompromise.
Attempt to distinguish the difference between:
Incaceration
Sliding
Obstruction
Strangulation is noted by:
Persistent pain
Discolouration
Tenderness
Constitutional symptoms
Other causes
IBD
Gall stone Ileus Intussusception
Large Bowel Obstruction









Aetiology:
1. Carcinoma: The commonest cause, 18% of colonic ca. present
with obstruction
2. Benign stricture: Due to Diverticular disease, Ischemia,
Inflammatory bowel disease.
3. Volvulus: 1. Sigmoid Volvulus: Results from long redundant,
faecaly loaded colon with a narrow pedicle
2. Caecal Volvulus
4. Hernia.
5. Congenital : Hirschusbrung, anal stenosis and agenesis
Distinguishing ileus from mechanical obstruction is challenging

According to Leplacs law: maximum pressure is at the its
maximum diameter. Cecum is at the greatest risk of perforation

Perforation results in the release of formed feaces with heavy
bacterial contamination
Sigmoid Volvulus
Colonic Obstruction
Radiological Evaluation
Normal Scout
Always request: Supine, Erect and CXR
Gas pattern:
Gastric,
Colonic and 1-2 small bowel
Fluid Levels:
Gastric
1-2 small bowel
Check gasses in 4 areas:
1. Caecal
2. Hepatobiliary
3. Free gas under diaphragm
4. Rectum
Look for calcification
Look for soft tissue masses, psoas shadow
Look for fecal pattern
The Difference between small
and large bowel obstruction
Small Bowel Large bowel
Central ( diameter 5 cm max)
Vulvulae coniventae
Ileum: may appear tubeless
Peripheral ( diameter 8 cm max)
Presence of haustration
Role of CT
Used with iv contrast, oral and
rectal contrast (triple contrast).
Able to demonstrate
abnormality in the bowel wall,
mesentery, mesenteric vessels
and peritoneum.

It can define
the level of obstruction
The degree of obstruction
The cause: volvulus,
hernia, luminal and mural
causes
The degree of ischaemia
Free fluid and gas

Ensure: patient vitally stable
with no renal failure and no
previous alergy to iodine
Role of barium gastrografin
studies



As: follow through, enema
Limited use in the acute
setting
Gastrografin is used in
acute abdomen but is
diluted
Useful in recurrent and
chronic obstruction
May able to define the level
and mural causes.
Can be used to distinguish
adynamic and mechanical
obstruction
Barium should not be used in
a patient with peritonitis
How to initially investigate
your patient
Lab:
CBC (leukocytosis, anaemia, hematocrit, platelets)
Clotting profile
Arterial blood gasses
U& Crt, Na, K, Amylase, LFT and glucose, LDH
Group and save (x-match if needed)
Optional (ESR, CRP, Hepatitis profile
Radilogical:
Plain xrays
USS ( free fluid, masses, mucosal folds, pattern of paristalsis,
Doppler of mesenteric vasulature, solid organs)
Other advanced studies (CT, MRI, Contrast studiessenior
decision)
ECG and other investigations for co-morbid factors
Understanding the
clinical findings
Clinical Findings
. History 1














Persistent pain may be a sign of strangulation
Relative and absolute constipation
The Universal Features
Colicky abdominal pain, vomiting, constipation (absolute), abdominal
distension.
Complete HX ( PMH, PSH, ROS, Medication, FH, SH)
Colonic
? Preexisting change
in bowel habit
Colicky in the lower
abdomin
Vomiting is late
Distension prominent
Cecum ? distended

Distal small bowel
Pain: central and
colicky
Vomitus is feculunt
Distension is severe
Visible peristalsis
May continue to pass
flatus and feacus
before absolute
constipation
High
Pain is rapid

Vomiting copious and
contains bile jejunal
content

Abdominal distension
is limited or localized

Rapid dehydration
Clinical Findings
. Examination 2
Others

Systemic examination
If deemed necessary.
CNS
Vascular
Gynaecological
muscuoloskeltal
Abdominal

Abdominal
distension and its
pattern
Hernial orifices
Visible peristalsis
Cecal distension
Tenderness,
guarding and
rebound
Organomegaly
Bowel sounds
High pitched
Absent
Rectal examination
General

Vital signs:
P, BP, RR, T, Sat
dehydration
Anaemia, jaundice,
LN
Assessment of
vomitus if possible
Full lung and heart
examination

Initial Management in the ER
Resuscitate:
Air way (O
2
60-100%)
Insert 2 lines if necessary
IVF : Crytloids at least 120 ml/h. (determined by estimated fluid
loss and cardiac function). Add K
+
at 1mmmol/kg
Draw blood for lab investigations
Inform a senior member in the team.
NPO.
Decompress with Naso-gastric tube and secure in position
Insert a urinary catheter (hourly urinary measurements) and
start a fluid input / output chart
Intravenous antibiotics (no clear evidence)
If concerns exist about fluid overloading a central line should be
inserted
Follow-up lab results and correction of electrolyte imbalance
The patient should be nursed in intermediate care
Rectal tubes should only be used in Sigmoid volvulus.
Indications for Surgery
Immediate intervention:
Evidence of strangulation (hernia.etc)
Signs of peritonitis resulting from perforation or ischemia

In the next 24-48 hours
Clear indication of no resolution of obstruction ( Clinical,
radiological).
Diagnosis is unclear in a virgin abdomen

Intermediate stage
The cause has been diagnosed and the patient is stabalised

Legal issues and consent
Ileus
Associated with the following conditions:
Postoperative and bowel resection
Intraperitoneal infection or inflammation
Ischemia
Extra-abdominal: Chest infection, Myocardia infarction
Endocrine: hypothyroidism, diabetes
Spinal and pelvic fractures
Retro-peritoneal haematoma
Metabolic abnormalities:
Hypokalaemia
Hyponatremia
Uraemia
Hypomagnesemia
Bed ridden
Drug induced: morphine, tricyclic antidepressants

Is this an ileus or
obstruction
Clinical features
Is there an under lying cause?
Is the abdomen distended but tenderness is not marked.
Is the bowel sounds diffusely hypoactive.

Radiological features:
Is the bowel diffusely distended
Is there gas in the rectum
Are further investigasions (CT or Gastrografin studies) helpful
in showing an obstruction.

Does the patient improve on conservative measures
Example of ileus