1. INTESTINAL OBSTRUCTION
R.NANDINII
GROUP K1

2. OVERVIEW:
•CLASSIFICATION
•COMMON CAUSES OF OBSTRUCTION
•CLINICAL FEATURES
•INVESTIGATION
•TREATMENT

3. Accounts for 5% of all acute surgical admissions
Patients are often extremely ill requiring prompt
assessment, resuscitation and intensive monitoring
Obstruction
A mechanical blockage arising from a structural abnormality that presents a
physical barrier to the progression of gut contents.
Ileus
is a paralytic or functional variety of obstruction
Obstruction is:
-Partial or complete
-Simple or strangulated
INTRODUCTION

4. CLASSIFICATION

5. DYNAMIC OBSTRUCTIONDYNAMIC OBSTRUCTION
(MECHANICAL)(MECHANICAL)

6. CAUSES OF I.O (DYNAMIC)CAUSES OF I.O (DYNAMIC)

7. PATHOPHYSIOLOGY:

8. OBSTRUCTION BY ADHESIONS
• Peritoneal irritation local fibrin production produces adhesions between apposed surfaces
• 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

9. TREATMENT OF ADHESIVE OBSTRUCTION
INITIALLY TREAT 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
LAPAROSCOPIC ADHESIOLYSIS IN CASES OF CHRONIC
SUBACUTE OBSTRUCTION

10. HERNIA
• ACCOUNTS FOR 20% OF SBO
• COMMONEST 1. FEMORAL HERNIA
2. ID INGUINAL
3. UMBILICAL
4. OTHERS: INCISIONAL
• THE SITE OF OBSTRUCTION IS THE NECK OF HERNIA
• THE COMPROMISED VISCUS IS WITH IN THE SAC.
• ISCHAEMIA OCCURS INITIALLY BY VENOUS OCCLUSION, FOLLOWED BY
OEDEMA AND ARTERIALC OMPROMISE.
• ATTEMPT TO DISTINGUISH THE DIFFERENCE BETWEEN:
• INCARCERATION
• SLIDING
• OBSTRUCTION
• STRANGULATION IS NOTED BY:
• PERSISTENT PAIN
• DISCOLOURATION
• TENDERNESS
• CONSTITUTIONAL SYMPTOMS

11. VOLVULUS
A TWISTING OR AXIAL ROTATION OF A
PORTION OF BOWEL ABOUT ITS
MESENTERY. WHEN COMPLETE IT
FORMS A CLOSED LOOP
OBSTRUCTION ISCHEMIA
CAN BE PRIMARY OR SECONDARY:
 1°: CONGENITAL MALFORMATION OF THE GUT
(E.G: VOLVULUS NEONATORUM, CECAL OR
SIGMOID VOLVULUS)
 2°: MORE COMMON, DUE TO ROTATION OF A
PIECE OF BOWEL AROUND AN ACQUIRED
ADHESION OR STOMA
COMMONEST SPONTANEOUS TYPE
IN ADULT IS SIGMOID, CAN BE
RELIEVED BY DECOMPRESSION PER
ANUM
SURGERY IS REQUIRED TO PREVENT
Features: palpable tympanic lump
(sausage shape) in the midline orleft
side of abdomen.
Constipation, abdominal distension
(early & progressive)

12. ACUTE INTUSSUSCEPTIONACUTE 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
An intussusception is
composed of three
parts :
the entering or inner
tube;
the returning or middle
tube;
the sheath or outer tube
(intussuscipiens).

13. CLASSICALLY, A PREVIOUSLY
HEALTHY INFANT PRESENTS WITH
COLICKY PAIN ANDVOMITING (MILK
THEN BILE).
BETWEEN EPISODES THE CHILD
INITIALLY APPEARS WELL.
LATER, THEY MAY PASS A
‘REDCURRANT JELLY’ STOOL.
Red currant jelly
stools

14. LARGE BOWEL OBSTRUCTION
• DISTINGUISHING ILEUS FROMMECHANICAL OBSTRUCTION IS CHALLENGING
• ACCORDING TOLAPLACE’S LAW: MAXIMUMPRESSURE IS AT THE MAXIMUMDIAMETERAREA
CAECUMIS AT THE GREATEST RISKOF PERFORATION
• PERFORATION RESULTS IN THE RELEASE OF FORMEDFEACES WITHHEAVY BACTERIAL
CONTAMINATION
AETIOLOGY:
1. CARCINOMA:
THE COMMONEST CAUSE, 18% OF COLONIC CA. PRESENT WITHOBSTRUCTION
2. BENIGN STRICTURE:
DUE TODIVERTICULARDISEASE, ISCHEMIA, INFLAMMATORY BOWEL DISEASE.
3. VOLVULUS:
-SIGMOIDVOLVULUS/CAECAL VOLVULUS
4. HERNIA.
5. CONGENITAL : HIRSCHPRUNG, ANAL STENOSIS ANDAGENESIS

15. HIGHSMALL BOWEL OBSTRUCTION
VOMITING OCCURS EARLY ANDIS PROFUSE WITH
RAPIDDEHYDRATION.
DISTENSION IS MINIMAL WITHLITTLE EVIDENCE OF
FLUIDLEVELS ON ABDOMINAL RADIOGRAPHY
LOWSMALL BOWEL OBSTRUCTION
PAIN IS PREDOMINANT WITHCENTRAL DISTENSION.
VOMITING IS DELAYED.
MULTIPLE CENTRAL FLUIDLEVELS ARE SEEN ON
RADIOGRAPHY
LARGE BOWEL OBSTRUCTION
DISTENSION IS EARLY ANDPRONOUNCED.
PAIN IS MILDANDVOMITING ANDDEHYDRATION ARE
LATE.
THE PROXIMAL COLON ANDCAECUMARE DISTENDED
ON ABDOMINAL RADIOGRAPHY
CLINICAL FEATURESCLINICAL FEATURES
CARDINAL
FEATURES:
Colicky pain
Vomiting
Abd distention
Constipation
OTHER FEATURES:
Dehydration
Hypokalaemia
Pyrexia
Abd tenderness

16. PHYSICAL EXAMINATIONPHYSICAL EXAMINATION
INSPECTION
ABDOMINAL DISTENTION, SCARS, VISIBLE
PERISTALSIS.
PALPATION
MASS, TENDERNESS, GUARDING
PERCUSSION
TYMPHANIC, DULLNESS
AUSCULTATION
BOWEL SOUND ARE HIGH PITCH AND INCREASE IN

17. INVESTIGATIONS:
• LAB:
• FBC (LEUKOCYTOSIS, ANAEMIA, HEMATOCRIT, PLATELETS)
• CLOTTING PROFILE
• ARTERIAL BLOOD GASSES
• U& CRT, NA, K, AMYLASE, LFT AND GLUCOSE, LDH
• GROUP AND SAVE (X-MATCH IF NEEDED)
• OPTIONAL (ESR, CRP, HEPATITIS PROFILE)
• RADIOLOGICAL:
• PLAIN ABDOMINAL XRAYS
• USS ( FREE FLUID, MASSES, MUCOSAL FOLDS, PATTERN OF PARISTALSIS,
DOPPLER OF MESENTERIC VASULATURE, SOLID ORGANS)
• OTHER ADVANCED STUDIES (CT, MRI, CONTRAST STUDIES)

18. Fluid levels with gas above;
‘stepladder pattern’. Ileal
obstruction by adhesions; patient
erect.
Supine radiograph from a patient with
complete small bowel obstruction
shows distended small bowel loops in
the central abdomen with prominent
valvulae conniventes (small white
arrow)
Figure 3. Lateral decubitus view
of the abdomen, showing air-fluid
levels consistent with intestinal
obstruction (arro ws).

19. THE DIFFERENCE BETWEEN SMALL AND
LARGE BOWEL OBSTRUCTION
Large bowel Small Bowel
•Peripheral ( diameter 6 cm
max)
•Presence of haustration
•Central ( diameter 3 cm max)
•Vulvulae coniventae
•Ileum: may appear tubeless

20. ROLE OF CT
• USED WITH IV CONTRAST, ORAL AND RECTAL CONTRAST
(TRIPLE CONTRAST).
• ABLE TO DEMONSTRATE ABNORMALITY IN THE BOWEL
WALL, MESENTERY, MESENTERIC VESSELS AND
PERITONEUM.
• IT CAN DEFINE:
• THE LEVEL OF OBSTRUCTION
• THE DEGREE OF OBSTRUCTION
• THE CAUSE: VOLVULUS, HERNIA, LUMINAL AND MURAL
CAUSES
• THE DEGREE OF ISCHAEMIA
• FREE FLUID AND GAS
• ENSURE: PATIENT VITALLY STABLE WITH NO RENAL
FAILURE AND NO PREVIOUS ALERGY TO IODINE
• FIGURE: AXIAL COMPUTED TOMOGRAPHY SCAN
SHOWING DILATED, CONTRAST-FILLED LOOPS OF BOWEL
ON THE PATIENT’S LEFT (YELLO W ARRO WS), WITH
DECOMPRESSED DISTAL SMALL BOWEL ON THE
PATIENT’S RIGHT (RED ARROWS). THE CAUSE OF
OBSTRUCTION, AN INCARCERATED UMBILICAL HERNIA,
CAN ALSO BE SEEN (GREENARRO W), WITH PROXIMALLY
DILATED BOWEL ENTERING THE HERNIA AND
DECOMPRESSED BOWEL EXITING THE HERNIA.Source: Jackson, PG. & Raiji M., Evaluation and Management of Intestinal Obstruction, January 2011, American Academy of Family Physicians

21. ROLE OF BARIUM GASTROGRAFIN STUDIES
• AS: FOLLOW THROUGH, ENEMA
• LIMITED USE IN THE ACUTE SETTING
• GASTROGRAFIN IS USED IN ACUTE
ABDOMEN BUT IS DILUTED
• USEFUL IN RECURRENT AND CHRONIC
OBSTRUCTION
• MAY ABLE TO DEFINE THE LEVEL AND
MURAL CAUSES.
• CAN BE USED TO DISTINGUISH ADYNAMIC
AND MECHANICAL OBSTRUCTION
Barium should not be used in
a patient with peritonitis

22. Source: Jackson, PG. & Raiji M., Evaluation and Management of Intestinal Obstruction, January 2011, American Academy of Family Physicians

23. Source: Jackson, PG. & Raiji M., Evaluation and Management of Intestinal Obstruction, January 2011, American Academy of Family Physicians

24. • SUPPORTIVE
1. RESUSCITATION
2. RYLE TUBE FREE FLOW WITH 4 HOURLY ASPIRATION
-DECOMPRESSION OF PROXIMAL TO THE OBSTRUCTION, REDUCE SUBSEQUENT
ASPIRATION DURING INDUCTION OF ANESTHESIA AND POST EXTUBATION.
3. IV DRIP NORMAL SALINE / HARTMANN (SODIUM & WATER LOSS DURING IO)
4. BROAD SPECTRUM ANTIBIOTIC (NOT MANDATORY BUT NEED IN ALL PATIENT
UNDERGOING SURGERY.
TREATMENT OF INTESTINAL OBSTRUCTION

25. • SURGICAL
IND: OBSTRUCTED/STRANGULATEDEXTERNAL HERNIA, INTERNAL INTESTINAL
STRANGULATION ANDACUTE OBSTRUCTION
1.MIDLINE INCISION USUALLY LOOK ON CAECUM
2.OPERATIVE DECOMPRESSION
3.LOOK AT VIABILITY OF INTESTINE
4.LARGE BOWEL OBSTRUCTION: COLOSTOMY

26. INDICATIONS FOR SURGERY
• ABSOLUTE
• GENERALISED PERITONITIS
• LOCALISED PERITONITIS
• VISCERAL PERFORATION
• IRREDUCIBLE HERNIA
• RELATIVE
• PALPABLE MASS LESION
• 'VIRGIN' ABDOMEN
• FAILURE TO IMPROVE
• TRIAL OF CONSERVATISM
• INCOMPLETE OBSTRUCTION
• PREVIOUS SURGERY
• ADVANCED MALIGNANCY
• DIAGNOSTIC DOUBT - POSSIBLE ILEUS
Source: http: Surgical Tutor.co.uk

27. MANAGEMENT FORLARGE BOWEL
OBSTRUCTIONAll patients require
•Adequate resuscitation
•Prophylactic antibiotics
•Consenting and marking for potential stoma formation
•At operation
•Full laparotomy should be performed
•Liver should be palpated for metastases
•Colon should be inspected for synchronous tumours
•Appropriate operations include:
•Right sided lesions – right hemicolectomy
•Transverse colonic lesion – extended right hemicolectomy
•Left sided lesions – various options
Source: http: Surgical Tutor.co.uk

28. Three-staged procedure
•Defunctioning colostomy
•Resection and anastomosis
•Closure of colostomy
Two-staged procedure
•Hartmann’s procedure
•Closure of colostomy
One-stage procedure
•Resection, on-table lavage and primary anastomosis
•Three stage procedure will involve 3 operations!
•Associated with prolonged total hospital stay
•Transverse loop colostomy can be difficult to manage
•With two-staged procedure only 60% of stomas are ever reversed
•With one-stage procedure stoma is avoided
•Anastomotic leak rate of less than 4% have been reported
•Irrespective of option total perioperative mortality is about 10%
Source: http: Surgical Tutor.co.uk

29. COMPLICATIONS ASSOCIATEDWITH
INTESTINAL OBSTRUCTION REPAIR
• INCLUDE EXCESSIVE BLEEDING
• INFECTION
• FORMATION OF ABSCESSES (POCKETS OF PUS)
• LEAKAGE OF STOOL FROM AN ANASTOMOSIS
• ADHESION FORMATION
• PARALYTIC ILEUS (TEMPORARY PARALYSIS OF THE INTESTINES)
• REOCCURRENCE OF THE OBSTRUCTION.
Source: http://www.surgeryencyclopedia.com/Fi-La/Intestinal-Obstruction-Repair.html

30. PARALYTIC ILEUS
A STATE IN WHICH THERE IS A FAILURE OF TRANSMISSION OF
PERISTALTIC WAVES 2° TONEUROMUSCULARFAILURE ( IN
AUERBACH’S AND MEISSNER’S PLEXUSES)
STASIS  LEADS TO ACCUMULATION OF FLUID AND GAS WITHIN
BOWEL A/W DISTENSION, VOMITING, ABSENCE OF BOWEL SOUND
AND ABSOLUTE CONSTIPATION
VARIETIES FACTORS: POSTOPERATIVE, INFECTION, REFLEX ILEUS
AND METABOLIC
RADIOLOGICAL: GAS FILLED LOOPS OF INTESTINES WITH
MULTIPLE FLUID LEVELS

32. MANAGEMENT:
ESSENCE OF TREATMENT PREVENTION WITH USE OF
NASOGASTRIC SUCTION AND RESTRICTION OF ORAL INTAKE
UNTIL BOWEL SOUND AND PASSAGE OF FLATUS RETURN
MAINTAIN ELECTROLYTE BALANCE
SPECIFIC TREATMENT:
• REMOVED PRIMARY CAUSE
• DECOMPRESSED GI DISTENSION
• IF PROLONG PARALYTIC ILEUS , CONSIDER LAPAROTOMY EXCLUDE
HIDDEN CAUSE AND FACILITATE BOWEL DECOMPRESSION

33. PSEUDO-OBSTRUCTION
OBSTRUCTION USUALLY COLON- OCCUR IN THE
ABSENCE OF MECHANICAL CAUSE OR ACUTE
INTRA-ABDOMINAL DISEASE.
ASSOCIATED WITH A VARIETY OF SYNDROMES IN
WHICH THERE IS UNDERLYING NEUROPATHY
AND/OR A RANGE OF OTHER FACTORS
IDIOPATHIC SEPTICAEMIA
Metabolic Retroperitoneal irritation
Severe trauma at lumbar area Drugs
Shock Secondary GI involvement

34. Small intestinal pseudo-obstruction Colonic pseudo-obstruction (Ogilvie’s
syndrome, )
This condition may be primary (i.e.
idiopathic or associated with
familial visceral myopathy) or secondary.
The clinical picture consists of recurrent
subacute obstruction.
 The diagnosis is made by the exclusion
of a mechanical cause.
Treatment consists of
initial correction of any underlying disorder.
Metoclopramide and
erythromycin may be of use.
This may occur in an acute or a chronic
form.
presents as acute large bowel
obstruction.
Abdominal radiographs show evidence of
colonic obstruction, with marked caecal
distension being a common
feature.
AXR shows colonic obstruction with
marked caecal distension
Confirmation of absence mechanical
cause by colonoscopy or single contrast
water soluble barium enema or CT.
Once confirmed, treated by colonoscopic
decompression

35. ACUTE MESENTERIC OCCLUSION
• ACUTE ISCHEMIC OF MESENTERIC VESSEL. COMMONLY SMA
• CAUSES: AF, MURAL THROMBOSIS, ATHEROMATOUS PLAQUE FROM AORTIC
ANEURYSM AND VALAVE VEGETATION FROM ENDOCARDITIS
• FEATURES: -SUDDEN ONSET OF SEVERE ABD. PAIN IN PT WITH AF AND
ATHEROSCLEROSIS
-PERSISTENT VOMITING AND DEFECATION THEN PASSAGE OF ALTERED
BLOOD
-HYPOVOLUMIC SHOCK
• INVESTIGATIONS: - NEUTROPHIL LEUKOCYTOSIS
- ABD XRAY: ABSENCE OF GAS IN THICKENED SMALL INTESTINES
• TREATMENT: - ANTI-COAGULANT
- EMBOLECTOMY
- REVASCULARIZATION