LARGE BOWEL OBSTRUCTION

- DR. SHASHANKA R
- DR. AASTHA ARORA
LEARNING OBJECTIVE

• Embryology, anatomy and physiology of large bowel

• Pathophysiology of dynamic and adynamic intestinal obstruction

• Cardinal features on history and examination

• Causes of large bowel obstruction

• Indications for surgery and other treatment options

EMBRYOLOGY
ANATOMY
ARTERIAL
SUPPLY
INTESTINAL OBSTRUCTION
DYNAMIC

Peristalsis working against a mechanical

obstruction.

ADYNAMIC

Peristalsis is inadequate or absent.

CAUSES OF INTESTINAL
OBSTRUCTION
CAUSES OF INTESTITINAL
OBSTRUCTION
PATHOPHYSIOLOGY

• Dilatation of the proximal loop

• Collapsed distal loop

• Distension due to gas and fluids

• Closed loop obstruction

• Strangulation
CLOSED LOOP OBSTRUCTION

Carcinomatous stricture of the hepatic flexure

Closed loop obstruction with distension with with competent ileo-caecal valve
impending perforation
ENTERIC STRICTURES

• Most common site – small bowel

• Most common cause – Tuberculosis > Crohn’s

• Other causes – Malignancy

• Treatment – resection and anastomosis

BOLUS OBSTRUCTION

• Trichobezoars

• Phytobezoars

• Stercolith

• Worms

Worms Trichobezoars
ADHESIONS
• CAUSES –

1. Acute inflammation

2. Foreign body

3. Infections

4. Radiation enteritis
ADHESIONS
CLINICAL FEATURES

PAIN VOMITING

INTESTINAL
OBSTRUCTION

ABSOLUTE DISTENSION
CONSTIPATION
CLINICAL FEATURES

• Dehydration

• Electrolyte imbalance

• Pyrexia

• Hypothermia
SIGNS

• Hypotension

• Tachycardia

• Tenderness

• Rigidity

• Examination of the genitalia

• Bowel sounds
CLINICAL FEATURES

Signs of strangulation in an incisional hernia Visible peristalsis seen in a case of

obstructed inguinal hernia
INVESTIGATIONS

• Imaging

• Blood investigations – Serum Electrolytes

 IMAGING

• First investigation –
ERECT XRAY
ABDOMEN

• If no signs of
strangulation – CECT

Gas filled small bowel loops Multiple air fluid levels – stepladder pattern
‘SUN SHOULD NOT BOTH RISE AND SET’ on a case of
unrelieved intestinal obstruction.
 NEW CONCEPT – Conservative
management upto 72 hours if no signs of
ischaemia.
TREATMENT

• NASOGASTRIC DECOMPRESSION

• Keep the patient NIL BY MOUTH

• Fluid resuscitation

• Correct electrolyte imbalance

• Abdominal girth monitoring

• Definitive treatment
DEFINITIVE TREATMENT

• IBD – Steroids

• Paracolic abscess – drained percutaneously

• Faecal impaction – stool softener and laxative with manual

disimpaction.
SURGICAL TREATMENT

Undiagnosed cases – midline laparotomy incision

Locate the site and pathology

Operative decompression

Definitive surgery

Assess the viability of the bowel

Resection and anastomosis

NON VIABLE BOWEL
DEFINITIVE SURGERY

• Adhesions – adhesiolysis

• Neoplastic obstruction -

1. Safest – PAUL MIKULICZ PROCEDURE or

HARTMANN PROCEDURE

2. Bridge therapy – Stenting till the definitive

surgery is performed
PAUL MIKULICZ PROCEDURE
ADHESIONS

Wall injury resulting from band compression oversewn with an absorbable seromuscular suture.
ADYNAMIC OBSTRUCTION
• TYPES :

1. Postoperative ileus

2. Infection

3. Reflex ileus

4. Metabolic
ADYNAMIC OBSTRUCTION
• Clinical features :

1. No passage of flatus even after 72h of surgery

2. Distension

3. Vomiting

4. Absence of bowel sounds

ADYNAMIC OBSTRUCTION
• Investigations – Erect abdomen Xray, Serum Electrolytes, RFT

• Treatment –

1. Nasogastric suction

2. Restriction of oral intake

3. Maintain electrolyte imbalance

4. Abdominal girth monitoring

5. If >7 days – relaparotomy

REFERENCES

• Bailey and Loves Short Practice of Surgery – 28th edition

• Sabiston textbook of Surgery – 21st edition

THANK YOU