UNIVERSITY OF GONDAR

SCHOOL OF MEDICINE AND OTHER HEALTH

SCIENCE
SCHOOL OF PHARMACY
DEPARTMENT OF CLINICAL PHARMACY
SEMINAR ON INTESTINE OBSTRUCTION

PEPARED AND PRESENTED BY: EPHRATA TESFASELASSIE

AND EMAN HUSSIEN
 INTRODUCTION

Definition
• The term intestinal obstruction refers to any form of
impedance to the normal passage of the bowel
contents through the small intestine or large intestine.
• It can occur any where in the course of the intestine
from duodenum to anus.
 Epidemiology

• Intestinal obstruction accounts for 20% of all

acute surgical admissions.
• If untreated , strangulated obstructions cause
death in 100% of patients. But the mortality
rate decreases to 8% with prompt diagnosis
and treatment.
 Clinical features

• The clinical features of intestinal obstruction

vary according to-
 the location of the obstruction

 the age of the obstruction

 the underlying pathology

 the presence or absence of intestinal ischemia

 Cont…

However, the 4 cardinal symptoms of IO are:

1.Abdominal pain
2.Abdominal distention
3.Vomiting
4.Constipation
 Abdominal pain
• Site :- central(SBO)

peripheral or lower abdomen(LBO)

• Onset :- sudden
• Character :- colicky & intermittent(lasts 2-4min)

steady ( strangulation)
• Radiation :- none
• Relieving factor :- relieved by pressure
 Nausea & vomiting
• Due to reverse peristalsis
• Stomach matter bilious feculent
• Feculent( smells like feces ) vomiting is pathgnomic for
Terminal ileum obstruction
• Blood tingled vomitus may indicate hemorrhage and
gangrene
• The higher the obstruction the more frequent the
vomiting
 Abdominal Distention

• Central:- distal SBO(illeum)

• Peripheral:- LBO
• Localized to one or two quadrants

: volvulus(sigmoid)
 Constipation

• SBO It may take 1 or 2 days to empty the bowel

distal to the obstruction. Because it was already
there.
• LBO Early
• Obstipation:- failure to pass both feces and flatus
 Pathophysiology
• Early in the course of intestinal obstruction ; motility and
contractility increase in an effort to propel luminal contents past
the obstructing point which is responsible for the colicky
abdominal pain.
• The increase in peristalsis that occurs early in the course of bowel
obstruction is present both above and below the point of
obstruction thus accounting for finding of diarrhea that may
accompany partial or complete bowel obstruction in the early
period.
 Cont…
• Later in the course of obstruction, the intestine becomes
fatigued and dilates with contractions becoming less frequent,
less intense and dilates which is a protective phenomenon to
prevent vascular damage secondary to increased pressure.
• As the bowel dilates, water and electrolytes accumulate both
in the lumen and in the abdominal wall itself which accounts
for fluid loss, causing dehydration and hypervolemia.
 Classification

 Depending on the nature of obstruction

I. Dynamic
II. Adynamic
 Depending on blood supply
I. simple
II. Strangulated
III. Closed loop
 Depending on severity of obstruction
I. Acute
II. Chronic
III. Acute on chronic
IV. subacute
 Cont…
causes of dynamic obstruction
a. Intraluminal -gallstone
-food bolus obstruction
-round worm mass
-foreign body

b. Intramural -stricture
-carcinoma
-stenosis
-crohn’s disease

c. Extramural -adhesion
-hernia
-volvulus
-intussusception
 Cont…
Causes of Adynamic obstruction
a. Paralytic ileus – post operative
-infection
-reflux ileus
-metabolic
b. Mesenteric vascular occlusion

c. Pseudo obstruction – idiopathic

- metabolic
-severe trauma
- shock
- retroperitoneal irritation
- drugs
 Cont…
• Other classifications-
1) Small bowel / large bowel obstruction
2) Partial / complete obstruction
 Cont…
Small bowel obstruction
• The leading causes of small bowel obstruction in the
industrialized countries are:
 post operative adhesion (60%)
 Malignancy
 Crohn’s disease
 Hernia
 Intussusception
 Volvulus
 Foreign body
 Cont…
Large bowel obstruction

• The three most common causes of mechanical obstruction are -

-colon carcinoma
- sigmoid volvulus
- diverticular disease
• Less common causes –
-inflammatory bowel disease
-adhesion
-intussusception
-fecal impaction
 Cont…
• Pseudo obstruction( Ogilvie’s syndrome); no
mechanical obstruction. Causes-
-mostly idiopathic
-hypokalemia
-DM
-severe trauma
 Asses for gangrene or impending gangrene

• Dehydration (oliguria)
• Pyrexia, constant pain
• Respiratory embarrassment
• Peritonitis
PHYSICAL EXAMINATION
• General Appearance
– Acutely sick looking
( in pain and
vomiting)
 Cont..
• Vital signs
• BP:- hypotension
• PR:-tachycardia
• RR:- tachypnea
• T:- febrile
• Anthropometry
– undernourished
 Cont..
• H.E.E.N.T
• Icteric sclera
• Sunken eyes
• Dry tongue and buccal mucosa
• Signs of anemia
• Respiratory system
• Basal crepitation & decreased air entry
• CVS
• Ejection systolic murmur
 Abdominal Examination
• Inspection
– Distention • Percussion
– Not moving with • hyper tympanic
respiration • Shifting dullness
– scar surgical • Fluid thrill
– Hernia sites
– Visible peristalsis
• Auscultation
– Hyperactive and high • Palpation
pitched (borborygmi) – Palpable loops
– Hypoactive – Tenderness
– Palpable mass
 Abdominal Examination
Uneven distention due to
Sigmoid volvulus step ladder peristalysis
 Digital Rectal Examination
• Presence or absence of fecal matter
• Empty:- SBO or complete LBO
• Mass suggests colorectal carcinoma
• Blood on examining finger may suggest
malignancy or strangulation
Investigations
 Cont..
• Imaging
– Plain abdominal X-ray
• At erect and supine position

• SBO
 * air-fluid level (central and multiple)
 *distended loop( >3cm)
 *paucity of air in the large bowel
 * valvulae conivintes

LBO
* Air- fluid level( peripheral and few)
* distended loop(>06 cms for large bowel
&>09 cms for cecum)
* Haustrations
*paucity of air in the rectum( to tell partial
from complete)
Valvulae connivente vs haustriae
Cont’d
• CT SCAN
• Triple contrast( IV, oral and rectal)
• It can define
– the level of obstruction
– The cause: volvulus, hernia, luminal and mural causes
– The degree of ischaemia( pneumatosis)
– Free fluid and gas
• Draw back
– Less sensitive in partial obstruction
CT scan of patient showing collapsed terminal ileum(I) and
ascending colon(C) and massively distended small bowel
suggesting a complete distal small bowel obstruction
Ultra sound - detect fluid and gas level
- togetherwith Doppler waves it can measure:
*direction of blood flow
*tissue perfusion
*the color of blood using colored image
MRI
- gas & fluid level
- no ionizing radiation & contrast is used
 b/c of its cost & less availability, it is not practically used
Angiography- used to detect arterial & venous thrombosis
which are 1⁰ causes for strangulation.

Intestinal biopsy - to see histologic configuration

E.g. hirschsprung’s disease
• Radiological contrast dye injection
- to assess level of obstruction
- two common methods:
small bowel series
enteroclysis
Small bowel series
-contrast dyes
-injected through- swallowing, nasogastric tube, nasoenteric
tube
- if there is obstruction contrast stops at the level of obstruction
Enteroclysis
• Enteroclysis, involves the oral insertion of a tube into the
duodenum to instill air and barium directly into the small
intestine and to follow the movement fluoroscopically
CBC
Hgb malignancies
WBC sepsis and infections
Electrolyte analysis - check for all electrolytes if they are in physiologic
concentration.
- hypokalemia
- acidosis / alkalosis
Blood group
Coagulation test
Organ function test
 MANAGEMENT OF
INTESTINAL OBSTRUCTION
 2 Types
Supportive management and
Definitive management
1. Supportive Management
 Keep NPO/nothing per oral
 Secure Intravenous/IV line
 Resuscitation, electrolyte replacement
 NGT/Nasogastric tube decompression
 Catheterization
 Broad spectrum antibiotics
 2.Definitive Management

 Surgical treatment - The operative procedure performed

varies according to the etiology of obstruction.
Indications for early surgical intervention
■ Obstructed external hernia
■ Clinical features suspicious of intestinal strangulation
■ Obstruction in a ‘virgin’ abdomen
Reason to delay surgery
 Hoping spontaneous resolution of medical conditions that are not
life threatening within 72 hrs , especially in adhesions.

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 Bowel preparation

 To decrease post op infection

 To decease bacterial load in the colon &rectum
 Laxatives
• caster oil (soap & water)before 3 days of surgery
• Enema before a day of surgery
 Antibiotic prophylaxis
 neomycin & Erythromycin

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 Management of SBO

 Adhesion – do laparatomy to free attached edges by short

dissection & the bare area should be covered with omental
graft to prevent recurrence.
N.B. adheolysis of the causative only.

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How to prevent adhesions secondary to surgery?
 Good surgical skill
 Washing peritoneal cavity with saline
 Minimize contact with gauze
 Covering anastomosis & suturing raw peritoneal surfaces
 Intussusception – Clinical modification & non op reduction
by air or barium enema.
 Contraindications – perforation, peritonitis & shock

 surgery – gentle compression of the distal part toward its origin

 Tumor - resection & anastomosis

 Hernia - reduction & repair
 Volvulus - if strangulated, resection and stoma
formation(HARTMAN’S PROCEDURES) & If not deflation &
resection after stabilizing the patient.

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 Management Of LBO
(resection, anastomosis & stomies)

 Removable lesions in cecum , ascending colon ,hepatic flexure

or proximal transverse Colon
 right hemi colectomy
 For Irremovable lesions
 proximal stoma(colostomy or ileostomy) or ileotransverse
bypass
 For obstructive lesions at splenic flexure
 right extended hemi colectomy with ileodesc. Colon anastomosis
 For obstructive lesions of Lt colon or recto sigmoid junction
 Immediate resection
 Ileostomy
– End & loop

 Colostomy

 Anastomosis – end to end , end to side & side to side.

 Mx. Of caecal volvulus

Reduce volvulus at op.

Fixation of cecum at right iliac fossa
(cecopexy) &/or cecostomy
Right hemicolectomy - for
ischemic/gangrenous cecum
 Mx. Of sigmoid volvulus
 Deflation
 If succeed ,continue with resuscitation & elective
procedures
 if failed ,proceed with early laparatomy to untwist
the loop & per anum decompression
 Mx. of Adynamic obstruction
 NG suction & electrolyte balance with oral intake restriction
 Remove primary cause
 Exceptions for early surgery
 Partial SBO
 Early post-op obstruction
 IO due to crohn’s disease
 Carcinomatosis

03/07/2024 seminar on IO
THANK YOU