INTESTINAL

OBSTRUCTION
ADHESIONS
 Aetiology
 Iatrogenic (Post operative) :
Individual susceptibility
May be induced by talc (powder from
gloves), cotton or linen (surgical
mops, suture material)
 Inflammatory / Infections :
Following appendicitis and PID
Following peritonitis (specially biliary)
Plastic type of peritoneal tuberculosis
 Ischaemia :
Arterial or venous occlussion
Occurs at sites of anastomoses
Ischaemia due to mobilisation of peritoneum

 Irradiation :
Radiation enteritis

 Drugs :
Practolol
 Types
 Fibrinous :
Early
Easy to do adhesiolysis / flimsy
May reduce over time

 Fibrous :
Occurs later
Difficult to do adhesiolysis / dense
No tendency to improve over time
Occurs due to associated ischaemia and
vascular ingrowth and replacement
with mature fibrous tissue
 Treatment - Medical

 Monitor the vital signs :

TPR / BP / IO / Abdominal girth chart
 Nil Per Oral
 Nasogastric tube (Ryle’s tube) insertion and
dependent drainage. Intermittent (fourth
hourly) aspiration
 IV fluid supplement : Ringer’s lactate or
Normal saline
 Antibiotics if strangulation suspected
 Reassess periodically
 Treatment – Surgical

 Indications :

When conservative treatment for 3 to 5

days does not result in resolution
When strangulation is suspected / cannot
be ruled out
 Treatment – Surgical
Emergency exploratory
laparotomy

Adhesiolysis / Enterolysis
Resect the strangulated bowel and do
end to end anastomosis

• Handle the bowel carefully (less abrasion)

• Do not produce ischaemia of peritoneum
• Do not mobilize and suture peritoneum
• Do thorough peritoneal lavage with saline
• Instillation of inhibitors - controversial
Treatment for recurrent intestinal
obstruction due to adhesions

Repeat Adhesiolysis / Enterolysis

Noble’s plication
Charles –Phillips transmesentric plication
Intestinal intubation
BANDS
 Aetiology

 Congenital :
Ladds bands
Obliterated vitellointestinal duct
Mesodiverticular band
 Inflammatory :
A string band following bacterial peritonitis

 Greater omentum adherent to the parietes

Gall Stone
ileus
 Definiti
on
• Gall stone obstructing the
lumen of bowel, usually the
small intestine
Pathogenesis

• Gall stone erodes the wall

of the gall balder and
enters the duodenum
• Impaction 60 cm proximal
to ileo- cecal junction
 Clinical
Features
• Elderly female
• Severe colicky pain
• Recurrent attacks –ball
valve obstruction
• Vomiting
• Distension
• Usually no constipation
Investigati
ons
• Routine
• Plain x-ray abdomen
– Air fluid level with Air in the
biliary tree- pneumobilia
(diagnostic)
– Gall stone may or may not be
seen
• CT
scan
• CT
scan
 Treatme
nt
• General measures
• Laparotomy
– Explore by palpating bowel
– Crush the stone without
opening bowel
– Enterotomy and removal
Do not explore gall bladder
 Intussuscept
Definition: ion
Invagination of one portion of the gut
within the other and it is usually proximal
into the distal bowel;
Rarely retrograde.

- Telescoping
Etiology:
Primary - Idiopathic
• Seen in children; no lead point
• Peak incidence 3 - 9 months
• Hyperplasia of Payer’s patches in the
terminal ileum
- Secondary to weaning
- URTI due to adenovirus or
rotavirus Adults – Secondary
• Meckel’s diverticulum, HS Purpura
• Polyp (Peutz – Jegher syndrome)
• Submucous lipoma , submucous
haemorrhage
• Malignancy of the colon
Types:
• Simple - Ileocolic, ileoileal,
colocolic
• Retrograde - Jejunogastric
• Compound - Ileoileocolic
• Multiple

• Chronic intussusception
• Recurrent intussusception
Parts of the
intussusception:
• Intussusceptum:Proximal bowel which
enters inside
– inner tube
• Intussuscipiens:Distal bowel which
receives the intestine – outer tube
• Apex: Starting point or the part which
advances
• Neck:Narrowest portion
 INTUSSUSCIPIENS NECK

LEAD POINT APEX INTUSSUSCEPTUM

Pathology:
• As the intussusception progresses the
mesentery is dragged through the neck
• Mucosal ulcers and hemorrhages
• Venous engorgement with oedema of the wall
• Blood and mucous from the wall and will be
discharged per rectally – red currant jelly
• Arteries get occluded and gangrene sets in
• Perforation and peritonitis
• Strangulating obstruction
(compound obstruction )
• Gangrene sets in at the neck
• Inner layer blood supply get
impaired
Clinical features
• Male child between 3 -9 months of age
commonly affected
• Colicky pain abdomen - onset is sudden
and the child screams with drawing up of
the legs
• Attack lasts for few minutes, recur every 15
minutes and becomes progressively severe.
• Vomiting may or may not be there
• Facial pallor
• Red current jelly stools
• Dehydration, tachycardia
On examination
Abdomen
• Visible peristalsis
• Lump may be felt under the right or left coastal
margin
• Sausage shaped lump with the concavity towards
the umbilicus; mass may disappear
•Sign - de – Dance, Right iliac fossa
is empty Per rectal
• Blood stained mucous
• Apex of the intussusception may be felt
• Intussusception may protrude from the anus
Investigations
• Haemogram
• Plain X ray abdomen
• Barium enema -
Diagnostic and
therapeutic Pincer
shaped filling defect
( Claw sign / meniscus sign /
coiled spring appearance)
CT SCAN –YIN YANG SIGN
• Ultra sound
– Concentric
rings of high
and low
echogenicity
(Target Sign)
Treatment:
• Nil per orally
• IV fluids
• Ryle’s tube aspiration
• Electrolytes, Antibiotics

Hydrostatic
reduction
Contraindicated
in
Presence of
obstruction
Peritonitis
• Hydrostatic
reduction -
– Selected cases
– Barium enema
– Infants
– 50% success
• Hydrostatic
reduction -
– Enema can at
height
– Push barium
rapidly
– Confirm with x-ray
Surgical treatment
• Laparotomy and reduction of intussusception
• Reduction is done by squeezing the distal part
proximally (
Do not pull)
• Last part of the intussusception is the most
difficult part to reduce
• Free the adhesions between neck & distal bowel
• Appedicectomy is done
• If the intestine is gangrenous then resection and
end to end anastomosis is done
THANK YOU