intestinal obstruction

3. OUTLINE
INTRODUCTION
DEFINITION
CLASSIFICATION
AETIOLOGY
PATHOPHYSIOLOGY
CLINICAL PRESENTATION
MANAGEMENT
COMPLICATION
PROGNOSIS
HOMOEOPATHIC THERAPEUTICS

4. Intestinal obstruction is a partial or
complete blockage of the bowel that
prevents the contents of the intestine
from passing through.

5. Dynamic/ Adynamic
Small bowel obstruction [ high or low ]
Large bowel obstruction
Acute
Chronic
Acute on chronic
Subacute
Simple
Strangulated
Closed loop obstruction

6. DYNAMIC : where peristalsis is working
against a mechanical obstruction.
A DYNAMIC: it may occur in two forms
1st where peristalsis may be absent
(paralytic ileus,)occurring secondarily to
neuromuscular failure in the mesentery.
2nd where peristalsis may be present in
non-propulsive form.(pseudo-obstruction)
IN BOTH FORMS MECHANICAL
ELEMENT IS ABSENT.

7. ACUTE
CHRONIC
ACUTE ON CHRONIC
SUBACUTE

8. IT USUALLY OCCUR IN SMALL BOWEL
OBSTRUCTION WITH SUDDEN ONSET
OF SEVERE COLICKY CENTRAL
ABDOMINAL PAIN,DISTENTION AND
EARLY VOMITINGAND CONSTIPATION.

9. USUALLY SEEN IN LARGE BOWEL
OBSTRUCTION WITH LOWER
ABDOMINAL COLIC AND ABSOLUTE
CONSTIPATION,FOLLOWED BY
DISTENTION.

10. IT SATRTS IN LARGE BOWEL BUT
GRADUALLY INVOLVES THE
SMALL INTESTINE.
EARLY SYMPTOMS ARE PAIN AND
CONSTIPATION BUT WHEN SMALL
INTESTINE IS INVOLVED IT IS
CHARACTERIZED BY VOMITING
AND GENERAL DSTENTION.

11. SIMPLE MECHANICAL
STARANGULATED
CLOSED LOOP

12. IN WHICH THERE IS OBSTRUCTION BUT BLOOD SUPPLY TO
INTESTINE REMAINS INTACT.
IN THIS MESENTRIC BLOOD VESSEL
ARE OCCLUDED BESIDES THE USUAL
MECHANICAL OBSTRUCTION.
IT IS A DANGEROUS CONDITION AND
SHOULD BE OPERATED WITH OUT ANY
DELAY .
WHEN BOTH LIMBS (afferent& efferent
limbs) OF THE LOOPS ARE OBSTRUCTED
SO THAT THERE IS NEITHER
PROGRESSION NOR REGURGITATION.

14. INTRALUMINAL(OBSTRUCTION IN
THE LUMEN)
BEZOARS :which may be
trichobezoar(hair)or phytobezoar (fruit and
vegetables)
GALLSTONES
POLYPLOID TUMOR OF THE BOWEL
INTUSSUCEPTION
IMPACTION OF BARIUM AND WORMS
FOREIGN BODIES

15. GALLSTONES

16. INTUSSUCEPTION

17. (a)CONGENITAL:
1:ATERSIA AND STENOSIS
2: MEGA COLON {HIRSCHPRIUNG ‘S
DISEASE}
3: MICKEL’S DIVERTICULUM
4:IMPERFORATE ANUS
5:DIVERTICULI

18. Duodenal Artesia

19. • (b)TRAUMATIC
• (C)INFLAMATORY:
• 1:CROHN’S DISAESE
• 2:ULCERATIVE COLITIS (RARE)
• 3:DIVERTICULITIS (RARE)
• (d)NEOPLASIC:VARIOUS TUMORS
OF SMALL AND LARGE INTESTINE
ALSO CAUSE OBSTRUCTON.
•(e)MISCELLANEOUS:
•1:RADIATION THERAPY
•2:IATROGENIC STRICTURE

20. Intestinal tumor

21. (a) ADHESIVE BAND CONSTRICTIONOR
ANGULATION BY ADHESION.[LEADING
CAUSE OF SMALL INTESTINE OBSTRUCTION]
(b)EXTERNAL HERNIA [SECOND COMMON
CAUSE]
(c) VOLVULUS
(d) EXTRINSIC MASSES [eg (i)haematomas and
abscess may press the bowel and causes obstruction.
(ii)Neoplasm outside the bowel
(iii)Annular pancreas
(iv)Abnormal vessels (rare).]

22. ADHESIVE BANDS AND CONSTRICTION

23. PARALYTIC ILEUS:IT IS OF TWO
TYPES:
1ST ABDOMINAL CAUSES :IT
INCLUDES (i)INTESTINAL
DISTENTION
(ii)PERITONITS
(iii)RETROPERITONIAL LESIONS (e.g.
retroperitoneal hemorrhage)
2ND SYSTMIC CAUSES:ELECTROLYTE
IMBALANCE MAINLY HYPOKALEMIA
AMD TOXAEMIA .

24. 40%
15%
15%
12%
8%
5%
5%
percentage
adhesions
Inflamatory
carcinoma
obstructed hernia
faecal impaction
pseudo-obstruction
miscellaneous

25. Narcotics.
Antipsychotics.
Anticholinergics.
Ganglionic blockers.
Agents used to treat Parkinson’s
disease.

26. Diabetes.
Multiple sclerosis.
Scleroderma.
Lupus erythromatosis.
Hirshprung’s disease.

29.  In simple mechanical obstruction,
blockage occurs without vascular
compromise.
 Ingested fluid and food, digestive
secretions, and gas accumulate above
the obstruction. The proximal bowel
distends, and the distal segment
collapses.

30. •The distention proximal to an
obstruction is produced by two factors:
•GAS:Regaradless of the level of
obstruction, there is a significant
overgrowth of both aerobic and anaerobic
organisms, resulting in considerations
gas production.

31. •Following the reabsorbtions of oxygen
and carbon dioxide, the majority is
made up of nitrogen(90 %) and
hydrogen sulphide.
•FLUID : this is made up of the various
digestive juices.

32. •Following the obstruction, fluid
accumulates within the bowel wall and
any excess is secreted in to the lumen,
•Whilst absorption from the gut is
retarded.
•Dehydration and electrolyte l0ss are
therefore due to:
•-Reduced oral Intake;
•-Defective intestinal obstruction ;
•-Losses due to vomiting;
•-sequestration in the bowel lumen

34.  Strangulating obstruction is obstruction
with compromised blood flow; it occurs in
nearly 25% of patients with small-bowel
obstruction.
 It is usually associated with hernia,
volvulus, and intussusceptions.
 Strangulating obstruction can progress to
infarction and gangrene in as little as 6 h.


35. .
 Venous obstruction
occurs first, followed
by arterial occlusion,
resulting in rapid
ischemia of the bowel
wall.
 The ischemic bowel
becomes edematous
and infarcts, leading
to gangrene and
perforation. In large-
bowel obstruction,
strangulation is rare
(except with volvulus)

37.  Closed loop obstruction is a specific
type of obstruction in which two
points along the course of a bowel
are obstructed at a single location
thus forming a closed loop.
 Usually this is due to adhesions, a
twist of the mesentery or internal
herniation.

38.  In the large bowel it is known as a
volvulus.
 In the small bowel it is simply known
as small bowel closed loop obstruction.
 Obstruction to the blood supply occur
either from the same mechanism which
caused obstruction or by the twist of
the bowel on mesentery.

39.  Hernia
 Intussusceptions
 Volvulus
 Peritoneal Adhesion & Band
 Bolus obstruction: Gallstone
 Food
 Trichobezoars & phytobzoars
 Worms

41.  An intussusceptions is a medical condition
in which a part of the intestine
has invaginated into another section of
intestine.
 Usually proximal loop invaginate in to the
distal bowel.
 Rarely distal loop may invaginate into the
proximal loop this is called retrograde
intussusceptions.

42.  Condition is more commonly seen in
infants & young children.
 More often in iliocaecal region.
 Complication – Intestinal obstruction,
gangrene, perforation and peritonitis.

43.  The first sign of Intussusception in an
otherwise healthy infant may be sudden,
loud crying caused by abdominal pain.
 Infants who have abdominal pain may
pull their knees to their chests when they
cry.
 The pain of Intussusception comes and
goes, usually every 15 to 20 minutes at
first.

44. i. Stool mixed with blood and mucus (also
known as “redcurrant jelly" stool because of
its appearance)
ii. Vomiting
iii. A "sausage-shaped" mass felt
upon palpation of the abdomen, with
concavity towards umbilicus
iv. Lethargy

46. •REDUCING THE TERMINAL PART OF THE INTUSSUSCEPTION :
•REDUCING IS ACHIEVED BY SQUEEZING THE MOST DISTAL PART OF
THE MASS IN CEPHALAD DIRECTION

47.  Abnormal twisting of a
portion of the
gastrointestinal tract,
usually the intestine,
which can impair blood
flow.
 Volvulus can lead to
gangrene and death of the
involved segment of the
gastrointestinal tract.

48.  More common in female in fourth and
fifth decades and usually presents
acutely with the classic feature of
obstruction.
 Rotation always occurs in clock wise
direction.
 Ischemia is common.

51.  Rare in Europe and USA
but common in Eastern
Europe and Africa.
 Symptoms resembles that
of large bowel obstruction.
 Rotation is always occurs
in anticlockwise direction.

52. Flexible sigmoidoscopy/ rigid
sigmoidoscopy
Laparotomy- untwisting

53. SIGMOID VOLVULUS

54. Intestinal
obstruction
Vomiting
Distention
constipation
Pain

55.  Clinical obstruction of intestinal
obstruction vary according to :
a. The location of the obstruction;
b. The age of the obstruction;
c. The underlying pathology;
d. The presence or the absence of the
intestinal obstruction;

56.  Pain is the first
symptom encountered,
it occurs suddenly and
is usually severe..
 It is colicky in nature
and usually centered on
the umbilicus (small
bowel) or lower abdomen
(large bowel).
 The pain coincides with
the increasing
peristaltic activity

57.  The more distal the obstruction
,the longer the interval between
the onset of symptoms and the
appearance of nausea and
vomiting .
 More proximal the obstruction,
more the frequency.
 The interval ,frequency &
nature of vomitus depends on
the site of obstruction

58.  In high bowel obstruction :
 the interval is shorter
 Bile stained vomitus
 Vomiting is more frequent and copious ;
 And is relieved by decompressing the
obstructed bowel

59.  In low bowel obstruction :
 the interval is longer may last for a day
or two
 Feculent vomitus
 vomiting is less frequent and does not
cause any relief.


60.  Pyloric obstruction
 Watery and acidic vomitus
 Large bowel obstruction
 Uncommon and late symptoms.

61.  Long standing low small bowel
obstruction-
 feculent material.
 Strangulation- blood.

62.  In the small bowel, the
degree of distention is
dependent on the site of
obstruction & is greater the
more distal the lesion.
 Central abdomen is
distended in low small
bowel obstruction.
 Distention is much less in
high small bowel
obstruction.

63.  Failure to pass flatus or faeces through
the rectum is important symptom of
bowel obstruction.
 It may be classified as
1. ABSOLUTE
2. RELATIVE

64.  Visible peristalsis may be present if the
abdomen is examined carefully.
 Mostly seen in proximal loops.
 Borborygmi is quite loud ,does not
require stethoscope to hear it .
 In auscultation sound of hyper
peristalsis coinciding with attack of
colic characteristic feature f intestinal
obstruction.

66.  The accumulation of chyme and gas
gives rise to a feeling of fullness and
causes bloating. This may also give rise
to high-pitched gurgling sounds from
the abdomen

67.  Obstruction and the resulting digestive
inability hampers the absorption of
vitamins and other nutrients from food,
leading to weakness, headache and
dizziness. Even regular activities may
make the individual feel exhausted and
drowsy

68.  Dehydration due to diarrhea and
vomiting, results in the loss of body
fluids and electrolytes. As a response to
this, the body tries to retain water
through lowered urine output.

69.  Dehydration
 Hypokalamia
 Pyrexia
 Abdominal tenderness
 Bowel sound

71.  Inspection
 Palpation
 Percussion
 Auscultation
 Rectal examination

73.  Shape of the abdomen
 Movement of the abdomen wall
 Umbilicus
 Visible loop of bowel/visible peristalsis
 Scar
 Striae
 Prominent veins
 Pubic hair
 Hernial orifices

75.  During colic there may be muscle
guarding.
 Slight tenderness may be present
between attacks of pain.
 Tenderness and rigidity at the sight of
obstruction usually indicate
strangulation.
 All the hernial orifices should be palpated
to exclude the presence of hernia.

77.  Percussion to hear any Dullness or
Resonance related to site of obstruction.
 Tympanic node will be present.
 Tenderness on light percussion suggest
strangulation.

79.  Bowel sounds are Initially Loud and
frequent
 Then as bowel distends the sounds
become more resonant and high pitched
 Eventually becoming amphoric.
 In strangulation bowel sound is
completely absent.

80.  Presence of mass on rectal examination
within or outside the lumen will give a
clue to diagnosis.
 Presence or absence of feces in rectum
should be noted. Absence means
obstruction is higher up. If presence it
should be studied for presence of occult
blood which include mucosal lesion
e.g.cancer,Intussuception or infraction

81.  BLOOD EXAMINATION
 RADIOLOGICAL EXAMINATION

82.  CBC
 Urea & electrolytes
 Serum amylase level
 Metabolic acidosis

83.  A rise white cell count will indicate an
infection.
 Normal or slight rise in W.B.C count:
simple mechanical obstruction.
 Moderate rise in W.B.C count(15000-
20000):strangulation.
 Very high rise in W.B.C count(30000-
40000):primary mesenteric vascular
occlusion.

84.  Derangement may be seen with
vomiting & diarrhea.
 Dehydration will be reflected in raised
serum urea and creatinine.

85.  It is non specific test & may be raised in
cases of small intestinal obstruction.

86.  It occurs due to combined effects of
dehydration ketosis and loss of alkaline
secretion.
 Very common in distal intestinal
obstruction.

88.  Gas fluid levels are the most important
criteria of diagnosis of intestinal
obstruction.
 When obstruction occurs, both fluid and
gas collect in the intestine.
 They produce a characteristic pattern
called "air-fluid levels". The air rises
above the fluid and there is a flat surface
at the "air-fluid" interface.

89. In most cases, the abdominal
radiograph will have the
following features:
1. ileated loops of small
bowel proximal to the
obstruction
2. predominantly central
dilated loops
3. dilatation of loops over
3cm
4. valvulae conniventes are
visible

90. The sigmoid colon is very dilated because it is twisted at the root of its
mesentery in the left iliac fossa (LIF)
The twisted loop of sigmoid colon is said to resemble a coffee bean

91.  Are recommended in patient with a
history of recurring obstruction

92.  CT scan examination is
particularly useful in
patient with a history of
abdominal malignancy,
in postsurgical patients,
and in patient who have
no history of abdominal
surgery and present with
symptoms of bowel
obstruction.

95. 1. An intestinal obstruction is a medical
emergency that requires prompt
medical treatment. Do not attempt to
treat the problem at home. The
appropriate treatment depends on the
type of intestinal obstruction.
2. Initially, a flexible tube may be passed
through your nose or mouth to remove
fluid and gas. This will relieve the
swelling of your belly. Most intestinal
obstructions require surgery.

96. 3. You will be given fluids intravenously for
as many as six to eight hours to relieve
dehydration by restoring electrolyte levels
in the body and to prevent shock during
surgery. This therapy is typically
administered in the hospital or at other
certified health care facilities. .
4. If the affected part of your intestine has
died, the surgeon will perform a resection,
removing the dead tissue and joining the
two healthy ends of the intestine.

98.  Electrolyte imbalance
 Infection
 Jaundice
 Perforation of intestine
 Necrosis and death of intestine

100.  Arsenic alb.
 Aethusa.
 Asafoetida
 Alumina
 Belladonna
 Bryonia alb.
 Bismuth
 China
 Cina
 Carboveg
 Colocynth
 Cocculus ind.
 Ipecac.

101.  Merc. Sol
 Nux vomica
 Opium
 Pulsatilla
 Phosphorus
 Plumbum met
 Ratanhia
 Syzy jumb.
 Veretrum alb
 Zinc met