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Avit Suchitra
BOWEL OBSTRUCTION OVERVIEW
CLASSIFICATION
COMMON CAUSES OF OBSTRUCTION
CLINICAL FEATURES
INVESTIGATION
TREATMENT
INTRODUCTION
Ileus:
is a paralytic or functional variety of obstruction
Obstruction is:
Partial or complete
Simple or strangulated
CLASSIFICATION
ADYNAMIC
(FUNCTIONAL)
Result fro
Result m atony of the
from
intestine withatony
lossof
ofthe
intestine with loss of
normal peristalsis, in the
absenceperistalsis,
normal of a mechanical
in the
cause.
absence of a mechanical
cause.
or it may
or it may be
be present
present
in a non-propulsive
in a non-propulsive
form (e.g. mesenteric
vascular
form (e.g.occlusion or
mesenteric
pseudo-obstruction)
vascular occlusion or
TYPES OF BOWEL OBSTRUCTION
TYPES AND CAUSES OF DYNAMIC
OBSTRUCTION
Descending
Ascending Colon
Colon
L..----- Jejunum
Cecum
ACUTE INTUSSUSEPTION
Occurs when one portion of the gut becomes invaginated within an
immediately adjacent segment.
Common in 1st year of life
Common after viral illness enlargement of Peyer’s patches
Ileocolic is the commonest variety in child.
Colocolic intussusception commonest in adult
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:
-Sigmoid Volvulus/ Caecal Volvulus
4. Hernia.
5. Congenital : HirschPrung, anal stenosis and agenesis
CLINICAL FEATURES
Large bowel obstruction
distension is early and pronounced.
Pain is mild and vomiting and dehydration are late.
The proximal colon and caecum are distended on abdominal radiography
CARDINAL FEATURES:
Colicky pain
Vomiting
Abd distention
Constipation
OTHER FEATURES:
Dehydration
Hypokalaemia
Pyrexia
Abd tenderness
PHYSICAL EXAMINATION
INSPECTION
Abdominal distention, scars, visible peristalsis.
PALPATION
Mass, tenderness, guarding
PERCUSSION
Tymphanic, dullness
AUSCULTATION
Bowel sound are high pitch and increase in frequency
INVESTIGATIONS:
Lab:
FBC (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)
RadiOlogical:
Plain ABDOMINAL xrays
USS ( free fluid, masses, mucosal folds, pattern of paristalsis, Doppler of mesenteric
vasulature, solid organs)
Other advanced studies (CT, MRI, Contrast studieS)
Figure 3. Lateral decubitus
view of the abdomen, showing
air-fluid levels consistent with
Fluid levels with gas above; Supine radiograph from a patient with intestinal obstruction (arrows).
‘stepladder pattern’. Ileal complete small bowel obstruction
obstruction by adhesions; shows distended small bowel loops in
patient erect. the central abdomen with prominent
valvulae conniventes (small white
arrow)
In small bowel In large bowel
Central 3cm thick Peripheral diameter 6cm
diameter Presence of haustration
Vulvulae coniventae
Ileum may occur
tubeless
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
• FIGURE: AXIAL COMPUTED TOMOGRAPHY SCAN SHOWING
DILATED, CONTRAST-FILLED LOOPS OF BOWEL ON THE
Ensure: patient vitally stable with no renal PATIENT’S LEFT (YELLOW ARROWS), WITH
DECOMPRESSED
failure and no previous alergy to iodine
DISTAL SMALL BOWEL ON THE PATIENT’S RIGHT (RED
ARROWS). THE CAUSE OF OBSTRUCTION, AN
INCARCERATED UMBILICAL HERNIA, CAN ALSO BE SEEN
(GREEN ARROW), WITH PROXIMALLY DILATED BOWEL
CONTRAST STUDIES
•At operation
•Full laparotomy should be performed
•Liver should be palpated for metastases
•Colon should be inspected for synchronous tumours
Generalised peritonitis
Localised peritonitis
Visceral perforation
Irreducible hernia
Palpable mass lesion
Failure to improve
Advanced malignancy
Incomplete obstruction
Advanced malignancy
SURGERY
Three-staged procedure
Defunctioning colostomy
Resection and anastomosis
Closure of colostomy
Two-staged procedure
Hartmann’s procedure: the
surgical resection of
the rectosigmoid colon with
closure of the rectal stump and
formation of an end colostomy. It
was used to treat colon
cancer or diverticulitis
Closure of colostomy
Complications associated with
intestinal obstruction repair
include excessive bleeding
infection
formation of abscesses (pockets of pus)
leakage of stool from an anastomosis
adhesion formation
paralytic ileus (temporary paralysis of the intestines)
reoccurrence of the obstruction.
PARALYTIC
ILEUS
A state in which there is a failure of transmission of peristaltic
waves 2° to neuromuscular failure ( in Auerbach’s and
Meissner’s plexuses)
Stasis leads to accumulation of fluid and gas within bowel
a/w distension, vomiting, absence of bowel sound and
absolute constipation
Varieties factors: postoperative, infection, reflex ileus and
metabolic
Radiological: gas filled loops of intestines with multiple fluid
levels
Management:
Essence of treatment prevention with use of
nasogastric suction and restriction of oral intake until
bowel sound and passage of flatus return
Maintain electrolyte balance
Specific treatment:
Removed primary cause
Decompressed GI distension
If prolong paralytic ileus , consider laparotomy exclude
hidden cause and facilitate bowel decompression
REFERENCE
http://emedicine.medscape.com/article/930576-overview#aw2aab6b2b4
http://www.patient.co.uk/doctor/intestinal-obstruction-and-ileus
https://www.youtube.com
https://en.wikipedia.org/wiki/Bowel_obstruction
http://www.webmd.com/digestive-disorders/tc/bowel-obstruction-topic-
overview
http://www.mayoclinic.org/diseases-conditions/intestinal-
obstruction/basics/symptoms/con-20027567