ABDOMINAL PAIN,VOMITING &

CONSTIPATION
Shermin Shakil
CASE #1
• A 54 year old man is admitted to the hospital with
complaints of crampy abdominal pain & bilious
vomiting that has lasted for 3 days. He has not had a
bowel movement or passed flatus for the last 2
days. A few years ago, he had an appendectomy for a
perforated appendicitis with no Post. Op. complications.
Physical exam reveals a pulse of 100/min, blood
pressure of 110/60mmHg, temp. 37.5C. His abdomen is
distended with hyperactive and tympanic bowel
sounds. There is no abdominal tenderness to
palpation. His haemoglobin is 15.4, WBC 10,000
• Most likely diagnosis?

Acute Intestinal Obstruction

Etiology
• List the differential diagnosis
• Intestinal obstruction
• What is the most likely diagnosis in this case?
Acute intestinal obstruction
• What is the likely cause?
Adhesions
• How would your answer to question 2 be altered if the
patient had no previous history of surgery?
• Intestinal obstruction secondary to Malignancy

• Which abdominal signs if present would be ominous

indications that the patient needed urgent operative
treatment?

• Localized tenderness with increasing abdominal rigidity

• Absent bowel sounds
• What is the patient’s predicted fluid and
electrolyte status?
• With vomiting—loss of H+, Na+, Cl- and water

ALKALOSIS &VOLUME CONTRACTION

Kidney retains Na+ and H+ and loss of K+

Obstruction due to Adhesions
• The lifetime risk of requiring an admission to
hospital for adhesional small bowel obstruction
subsequent to abdominal surgery is around 4 per
cent and the risk of requiring a laparotomy
around 2 per cent
• Early postoperative period, the onset of such a
mechanical obstruction may be difficult to
differentiate from paralytic ileus.
Causes of adhesions:
TREATMENT
• Initially, management is based upon - Nasogastric
decompression and I.V fluid resuscitation
• continued up till maximum of 72 hours. When
laparotomy is done, multiple adhesions may be found
but only one could be causative. When there is absolute
certainty that only that particular adhesion is the cause
of obstruction, this should be divided and the remaining
adhesions be left
• If the obstruction is caused by multiple adhesions, the
adhesions should be freed by sharp dissection from the
duedeno-jejunal junction to the ceacum
CASE#2
• A 54 year old woman presents to the ER with a 48
hr history of colicky abdominal pain, vomiting
and abdominal distention. On examination, pulse
120/min, BP 100/75 mm Hg, temperature 38’C.
Abdominal examination reveals generalized
tenderness with a firm , tender, 3x4 cm swelling
in the right groin. The skin above the swelling has
a purplish discolouration and there’s no cough
impulse. Bowel sounds are absent. WBC count is
24000/mm3
• Diagnosis?
• Strangulated Hernia- Surgical emergency

• Shock suggests underlying ischemia, especially if

its resistant to fluid resuscitation
• Generalised tenderness and the presence of
rigidity indicate the need for early laparotomy
• In impending or established strangulation, pain
is never completely absent.
• When strangulation occurs in an external hernia,
the lump is tense, tender and irreducible and
there is no expansile cough impulse. Skin
changes with erythema or purplish
discolouration are associated with underlying
ischaemia
STRANGULATION
• Life threatening consequences
• Blood supply compromised ischemia
• CAUSES:
Direct pressure on bowel wall
• Hernial orifices
• Adhesions/bands

Interrupted mesenteric blood flow

• Volvulus
• Intussusception

Increased intraluminal pressure

• Closed loop obstruction
• CLOSED LOOP OBSTRUCTION
• when the bowel is obstructed at both the proximal and
distal points
• The distention is principally confined to the closed loop
• Classically seen in a malignant stricture of the colon
• Treatment:
• Nasogastric decompression and IV fluid
resuscitation
• Urgent surgery to prevent bowel ischemia.
• Consent for bowel resection
• Do not attempt to manually reduce the hernia—
closed loop obstruction
CASE#3
• A 10 months old male infant was brought to OPD by his
parents. The parents told that the baby has episodes of
crying and drawing of the legs. The attacks last for few
minutes and occur repeatedly. They told that during the
attacks the child becomes pale and between episodes he
may be listless. Initially the passage of stool was normal
but now the baby evacuates blood and mucus “Red
CURRANT JELLY STOOL” Few days back the baby had
respiratory infection.
• On examination a sausage shaped mass with concavity
towards the umbilicus was found on palpation and there
was a feeling of emptiness in the right iliac fossa (dance’s
sign)
• DIAGNOSIS-
INTUSSCEPTION
INTUSSUSCEPTION
• Invagination of one portion of the gut (proximal)into the
adjacent segment(distal)
• Composed of three parts:
• Intussusceptum (entering tube)
• Returning or middle tube
• Intussucipiens(sheath/outer tube)
• Most common in children (ileocolic)
▫ May follow an upper respiratory tract infection
• Adult cases are secondary to intestinal pathology, e.g.
polyp, Meckel’s diverticulum
• Lead to ischemic segment
INVESTIGATIONS

Abdominal US-Target
sign Contrast enema-
claw sign
• CT scan—most sensitive radiologic method to
confirm
TREATMENT
• either a barium or water-soluble contrast enema, which
both confirms the diagnosis of intussusception, and in
most cases successfully reduces it
• surgical reduction is required if enema fails
• Pre-operatively, fluids and electrolytes are given and
nasogastric decompression is done
• In a surgical reduction, the surgeon opens the
abdomen(transverse right sided incision) and manually
squeezes the part that has telescoped. If the surgeon
cannot successfully reduce it, or the bowel is damaged,
they resect the affected section
Case# 4
• A 50 year old male resident of Mardan presents
with sudden onset of abdominal distention and
pain for the past 6 hrs. He has not passed feces
and there was one episode of vomiting on his
way to the hospital. There is no surgical history.
On examination, pulse is 90, BP is normal, and
he is afebrile. The abdomen is markedly
distended & tender. Bowel sounds are inaudible.
• Diagnosis
• Volvulus
VOLVULUS
• Twisting of a portion of bowel about its
mesentry.

obstruction to lumen
vascular occlusion in mesentry
• Volvulus Neonatorium
• Sigmoid Volvulus
• Caecal Volvulus
SIGMOID VOLVULUS
• Rotation occurs in the anticlockwise direction

• Predisposing factors:
▫ Overloaded pelvic colon
▫ Long pelvic mesocolon
▫ Narrow attachment of pelvic mesocolon
▫ Band of adhesions
 PRESENTATION

INDOLENT
FULMINANT
Insidious
Sudden onset,
onset, slow
severe pain , early
progressive
vomiting, rapidly
course,less
deteriorating
pain, late
clinical condition
vomiting
CECAL VOLVULUS
• More common in females in fourth and fifth decades and
usually present with classic features of obstruction.
• Ischemia is common
• At first obstruction is partial with passage of flatus &
faeces.
• In 25% of cases, examination– palpable tympanic
swelling in midline or left side of abdomen
OMEGA SIGN
BEAK SIGN
TREATMENT
• SIGMOID VOLVULUS:
• Flexible/rigid sigmoidoscopy and insertion of a
flatus tube---deflation of gut. Tube should be
secured in place with tape for 24hrs and repeat
X-ray to ensure that decompression has
occurred.
• deflation will resolve the acute problem,
provided that the ischemic bowel is excluded.
• In elderly with co morbidities and recurrent
episodes of volvulus---resection or two point
fixation with combined
endoscopic/percutaneous tube insertion.
• If bowel is viable—sigmoid colon is fixed to the
posterior abdominal wall.
• Cecal volvulus
• Ischemic volvulus—resection
• Viable—reduced. Further management—fixation
of cecum to the right iliac fossa
(caecopexy)and/or a caecostomy.
Case #5
• A 50 year old obese female presents to the opd
with complains of intermittent colicky
abdominal pain , abdominal distention, nausea
and vomiting. She is giving history of episodic
pain in right hypochondrium for last 1 year. On
examination, pulse is 100 bpm. There is mild
tenderness, abdominal distention and absent
bowel sounds.
• Diagnosis
• Gallstone ileus
Gall stone ileus
• Gallstone ileus is an uncommon complication of
gallstone disease, occurring in about 0.5% of cases.[4]
• It accounts for only about 1-4% of causes of intestinal
obstruction
• Investigations :
• XRAY abdomen—small bowel obstruction, penumobilia ,
radiolucent gall stones ( rigler’s triad)
• CT Scan
Rigler’s triad:
The characteristic radiological sign of gallstone ileus is Rigler’s triad,
comprising: small bowel obstruction, pneumobilia and an atypical mineral
shadow on radiographs of the abdomen.

presence of two of these radiological signs has been considered pathognomic

of gallstone ileus and is encountered in 40–50 per cent of the cases
Management
• Initial management involves fluid resuscitation
and nasogastric suctioning.
• Surgery is definitive, with removal of the stone
(enterolithotomy) and repair of the
choledochoenteric fistula, accompanied by a
cholecystectomy.
Case#6
• A 66 year-old man develops moderate diffuse
abdominal discomfort and bloating 5 days after a
cholecystectomy. He also complains of some
nausea and denies passing any flatus or faeces
since the operation. On examination, the
abdomen was tender and tympanic, with absent
bowel sounds.
• Diagnosis
• Paralytic ileus
PARALYTIC ILEUS

disruption of the normal propulsive ability of

the gastrointestinal tract (adynamic obstruction)
obstruction caused by the failure of peristalsis,
rather than by mechanical obstruction
After abdominal surgery, a normal physiological ileus occurs and it
resolves spontaneously within 2-3 days

The terms postoperative adynamic ileus or paralytic ileus are

defined as ileus of the gut persisting for more than 3 days
following surgery

Ileus occurs from hypomotility of the gastrointestinal tract in the

absence of a mechanical bowel obstruction

This suggests that the muscle of the bowel wall is transiently

impaired and fails to transport intestinal contents

This lack of coordinated propulsive action leads to the

accumulation of both gas and fluids within the bowel
CAUSES
 Abdominal Surgery – most common
 Drugs (e.g, opioids, antacids, anticholinergics,
amitriptyline, chlorpromazine)
 Metabolic disturbances e.g, hypokalemia
 Myocardial infarction
 Lower lobe Pneumonias
 Trauma (e.g, fractured ribs, fractured spine)
 Head injury and neurosurgical procedures
 Intra-abdominal inflammation and peritonitis
 Retroperitoneal or intraabdominal hematomas
 Spinal or Pelvic fractures
HISTORY
Patients with ileus typically present with vague,
mild abdominal pain and bloating

 nausea, vomiting, and anorexia

 Abdominal cramping is usually not present

 Patients may or may not continue to pass flatus

and stool

History of prior operation

EXAMINATION
distended and tympanic abdomen, depending
on the degree of bowel distension

 may be tender

A distinguishing feature is absent or

hypoactive bowel sounds unlike the high-
pitched sound of obstruction

 The silent abdomen of ileus reveals no

discernible peristalsis or tinkling
TREATMENT
• Nasogastric suction and restriction of oral intake
until bowel sounds and passage of flatus return.
• Electrolyte & fluid balance
• Cause should be treated.
• The distention relieved by decompression.
• No use of peristaltic stimulants
• Laparotomy—longer the bowel inactivity persists
particularly if it persists for more than 7 days or if
bowel activity recommences following surgery and
then stops again.
CASE # 7 A 76 year old
man with a 40 pack-
year history of
smoking presents with
abdominal distension,
nausea and vomiting,
and cramping
abdominal pain. He
reports passing no
flatus or faeces for 5-6
days. Site of
obstruction?
CLASSIFICATION

DYNAMIC- ADYNAMIC-No
Peristalsis is mechanical
working against a obstruction
mechanical Peristalsis absent or
obstruction inadequate

Paralytic
ileus
Pseudo-
obstruction
DYNAMIC

• Stricture
Fecal impaction • Malignancy
Foreign bodies • Intussusception
bezoars • volvulus
Gallstones
INTRALUMINAL
INTRAMURAL
EXTRAMURAL

• Bands/
adhesions
• hernia
According to the speed of onset of
obstruction
 Acute (usually in small bowel) – Rapid and severe

 Chronic (usually in large bowel) – Insidious

Mostly due to CA

 acute on chronic  spread from large bowel to involve

the small bowel as the obstruction becomes complete –
sudden in onset
A/C TO THE NATURE
• Simple obstruction  occlusion of the lumen without
any damage to the blood supply

• Strangulated obstruction  Blood supply of the

involved segment is compromised (e.g. in Strangulated
hernias, Volvulus, Intussusception)
- If left untreated it may result in:
infarction,
gangrene or
perforation of the intestinal wall
A/C TO AGE GROUPS
 Neonates: congenital atresia and stenosis, imperforate
anus, volvulus nenatorum, Hirschsprungs disease and
meconium ileus
 Infants: intussusception, Hirschsprungs disease,
strangulated hernia and Meckels diverticulum
 Young adults and middle age: Adhesions and bands,
strangulated hernia , Crohns disease
 Elderly: strangulated hernia, bowel carcinoma,
diverticulitis and impacted faeces

* Strangulation of a hernia is an important cause from infancy to old age

PATHOPHYSIOLOGY
EXAMINATION
• Patient rolling in bed
• Dry skin & tongue, sunken eyes , oilguria (dehydration-
due to vomiting)
• Pulse ↑
• Temperature is usually normal. Rise in temperature plus
rapid pulse suggests  strangulation
INSPECTION PALPATION AUSCULATATION
• Scar marks • Bowel sounds usually
• Generalized accentuated and twinkling
• Hernia
abdominal pain sounds
• Peristalsis
• mass • DRE-Low lying
obstruction
Cardinal clinical features of acute
obstruction
• Abdominal pain
• Distension
• Vomiting
• Absolute constipation
• In high small bowel obstruction, vomiting occurs early,
is profuse and causes rapid dehydration. Distension is
minimal with little evidence of dilated small bowel
loops on abdominal radiography
• In low small bowel obstruction, pain is predominant
with central distension. Vomiting is delayed. Multiple
dilated small bowel loops are seen on radiography
• In large bowel obstruction, distension and pronounced.
Pain is less severe and vomiting and dehydration are
later features. The colon proximal to the obstruction is
distended on abdominal radiography. The small bowel
will be dilated if the ileocaecal valve is incompetent
• Other features include:
• Dehydration
• Pyrexia
• High pitched bowel sounds
• Hypokalemia
• Abdominal tenderness
 Plain abdominal X-rays (two views should be taken- erect
& supine) :
 Show distended bowel loops with air fluid levels
 In small bowel obstruction  Distended bowel loop with Air fluid level in the
center of the abdomen & there is complete striation produced by mucosal folds
(valvulae conniventae)
 In large bowel obstruction  Distended bowel loop seen in the periphery &
haustrations of the taenia coli help us in identifying large bowel

 Barium follow through - usually not done in acute cases

 Water soluble contrast enema  mostly used
 CT scan  localises obstructing mass and tells us the cause
 Colonoscopy or sigmoidoscopy
Principles of Management
• Three main measures:
• Gastrointestinal drainage via a nasogastric tube
• Fluid and electrolyte replacement
• Relief of obstruction
• Surgical treatment is necessary for most cases of
intestinal obstruction but should be delayed
until resuscitation is complete (24- 72hrs),
provided there is no sign of strangulation
or evidence of closed-loop obstruction
Indications for surgical intervention
• Obstructed external hernia
• Clinical features suspicious of intestinal
strangulation
• Obstruction in a ‘virgin’ abdomen