Intestinal

Obstruction
 Definition
Any condition interferes with normal propulsion
and passage of intestinal contents.

DYNAMIC ADYNAMIC
(MECHANICAL) (FUNCTIONAL)
Result from atony of the
Peristalsis is working intestine with loss of normal
peristalsis, in the absence of
against a mechanical a mechanical cause.
obstruction
 Mechanical obstruction
Intraluminal Intramural Extramural
• Impaction • Congenital atresia • Bands/ adhesion(40%)
• Foreign bodies • Stricture • Hernia (12%)
• Bezoars • Malignancy(15%) • Volvulus
• Gallstone • Intussusception
• Tumor-benign/malignant
Cause of Mechaniacal Intestinal
Obstruction
Mechanical obstruction
This mechanical obstruction can be partial ( lumen
narrowed but allow transit some content) or
complete ( lumen totally obstruction) this classify
to:
A. Simple obstruction (no vascular impairment)
B. Closed loop ( both ends are obstructed e.g volvulus)
C. Strangulation obstruction
Functional obstruction
Either paralysis or dysmotility of intestinal peristalsis.
Epidemiology
1% of all hospitalization
3% of emergency surgical admissions
Adhesion is the most common cause of intestinal obstruction
Mortality rate range between
◦ 3% for simple bowel obstruction to
◦ 30% when there is strangulation or perforation
 Intestinal obstruction
Pattern in Africa
Adhesions
Hernia
80% with gangrenous bowel segments Small Intest volvolus
Intussusception
3% 3% Sigmoid volvolus
10% Ascaris
Large bowel tumor

40%
14%

14%

16%

70 % of the patients were below the age of 15 years

 Etiology
Mechanical bowel obstruction

Small bowel obstruction: Large bowel obstruction :

◦ Adhesion 60% ◦ Cancer 60%.

◦ Hernia 20% ◦ Diverticular disease 15%.

◦ Neoplasm 5% ◦ Volvulus 15%.

◦ Volvulus 5%. ◦ Others: – fecal impaction .

◦ Others: - gall stone - foreign body -

intussusception.
SBO due to Ascaris lumbricoides.

11
Trichobezoar
Undigested hair balls due to persistent hair chewing and
sucking and may be associated with an underlying
psychiatric abnormality.

12
Corpus Alienum

13
Etiology
Functional bowel obstruction
1. Vascular occlusion ileus.
2. Adynamic or inhibition ileus :
◦ Post operative.
◦ Metabolic causes: DKA- hyponateremia-hypokalemia – hypomagnesaemia.
◦ Drugs: morphine –TCA-antacid-anticonvulsant.
◦ Intra-abdominal inflammation—sepsis—occult wound infection.
◦ Pneumonia—renal stone—retroperitoneal hematoma—fracture spine and ribs.

3. Spastic ileus. ( intestine remain contracted and no propulsive) causes

are:
◦ Uremia.
◦ Porphyria.
◦ Heavy metal poison.
Pathophysiology
Pathophysiology
Pathophysiology
(cont.)
Pathophysiology
Dehydration results from:
◦ Reduced oral intake,
◦ Defective intestinal absorption,
◦ Loses from vomiting & sequestration in bowel of lumen.
 Diagnosis
History and physical examination
Four cardinal symptoms
1. Pain
2. Vomiting
3. Distension
4. obstipation.

Examination :
o Vital signs.( PR-Temp-BP)
o Hydration status.
o Abdominal and rectal examinations
 Physical Examination
INSPECTION
◦ Abdominal distention, scars, visible peristalsis.
PALPATION
◦ Mass, tenderness, guarding
◦ Examination of hernial orifices
PERCUSSION
◦ Tympanic, dullness
AUSCULTATION
◦ Bowel sound are high pitch and increase in frequency
◦ Or silent.
 Difference between High & Low
intestinal obstruction
HIGH LOW
BEGINNING Acute Slow, insidious

GENERAL CONDITION Early compromission preserved

PAIN Crampy pain in paroxism Less intensity

VOMITING Early, profuse, biliary Late, feculent may be

absent
ABDOMINAL Moderate, upper Early, intense
DISTENTION quadrant
CONSTIPATION + +++
ELECTOLYTES Cl, K, Na rapid loss Late hydro electrolytic
imbalance
Diagnosis
Radiology
CXR :
◦ Detect extra-abdominal condition present with bowel obstruction e.g.
pneumonia.
◦ Presence of pneumoperitoneum indicates perforated viscus.
Diagnosis
Radiology
Abdominal X-RAY
◦ Small bowel considered dilated when diameter more
than 3 cm while proximal colon 9 cm and the sigmoid 5
cm.
◦ The cause of bowel obstruction can often determined
◦ Presence of pneumobilia suggest G.S ileus.
◦ Sigmoid and cecal volvulus produce pathognomnic images
 Radiology

Prone radiograph from a patient with

Fluid levels with gas above;
complete large bowel obstruction
‘stepladder pattern’. Ileal
shows distended large bowel in the
obstruction by adhesions; patient
periphery of abdomen with
erect.
haustration.
Treatment
For optimal treatment to be instituted, five
questions must be answered:
• Is the diagnosis intestinal obstruction?. Is the obstruction
is mechanical?
• What is the level of obstruction?.
• Is there evidence of bowel wall ischemia or perforation?.
• How severe is the associated systemic disorders?.
 Treatment
A. Resuscitation.
B. Conservative treatment
1. Incomplete obstruction.
2. Advanced malignancy.
C. Indications for surgery
1. Generalized or localized peritonitis.
2. Perforation.
3. Strangulated hernia.
4. Closed loop
5. Failure to improve on conservative treatment.
 Obstruction by Adhesions

• Peritoneal irritation local fibrin production

adhesions
• As early as 4 weeks post laparotomy. The majority
of patients present between 1-5 years
Colorectal Surgery 25%
Gynaecological 20%
Appendectomy 14%
• Prevention:
• good surgical technique, washing of the peritoneal
cavity with saline to remove clots, etc, minimizing
contact w/ gauze, covering anastomosis & raw
peritoneal surfaces
Treatment of adhesive obstruction
Conservatively provided there is no signs of strangulation; should rarely continue
conservative treatment for longer than 72 hours
At operation, divide only the causative adhesion and limit dissection.
Treatment of adhesive
obstruction
 Obstructed Hernia
Commonest
◦ Femoral hernia
◦ ID inguinal
◦ Umbilical
◦ Others: incisional
Ischaemia occurs initially by venous occlusion, followed by oedema and arterial
compromise.
Strangulation is noted by:
◦ Persistent pain
◦ Discolouration
◦ Tenderness
◦ Constitutional symptoms
◦ Loss of impulse with cough
 Volvulus
Features: palpable tympanic lump
(sausage shape) in the midline or
A twisting or axial rotation of a portion left side of abdomen.
of bowel about its mesentery. When Constipation, abdominal distension
complete it forms a closed loop (early & progressive)
obstruction
Relieved by decompression per anum.
Surgery is required to prevent or relieve
ischaemia
Volvulus
 Acute intussusception
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
Acute intussusception
Classically, a previously healthy
infant presents with colicky pain
and vomiting (milk then bile).
Between episodes the child
initially appears well.
Later, they may pass a ‘red currant
jelly’ stool.

Red currant
jelly stools
Intussusception
 Barium reduction of
intussusception
Head of intussusception Partial reduction Free flow of contrast into
is at hepatic flexure distal small bowel indicates
complete reduction
Thank You