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INTESTINAL OBSTRUCTION

Dr.Yunus Yavuz

Intestinal obstruction1. Definition2. Sites of obstruction

Small bowelLarge bowel

3. Causes of the obstructionLesions extrinsic to the bowel wallLesions intrinsic to the bowel wallIntraluminal obturator lesions

4. Types of intestinal obstructionMechanical obstruction vs. AdynamicileusPartial vs. CompleteSimple vs. StrangulatedHigh vs. lowSmall bowel vs colon

5. Clinical picture

Radiogical testsFluid and electrolyte status

6. Treatment of intestinal obstruction

1. Definition

INTERRUPTION IN THE PASSAGE OF

INTESTINAL CONTENTS



3. Causes of the obstructionLesions extrinsic to the bowel wallLesions intrinsic to the bowel wall

Intraluminal obturator lesions4. Types of intestinal obstructionMechanical obstruction vs. AdynamicileusPartial vs. CompleteSimple vs. StrangulatedHigh vs. lowSmall bowel vs colon

5. Clinical picture



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2. Sites of obstruction

Small Bowel vs. Large Bowel Scenario

prior operations, change in bowel habits

Clinical picture

scars, masses/ hernias, amount ofdistension/ vomiting

Radiological studies

gas in colon?, volvulus?, transition point,mass

(Almost) always operate on LBO, often treatSBO non-operatively

Common Causes of Small BowelObstruction (SBO)

60%20%

10%

5%5%

Adhesions

Neoplasms

Hernias

Crohns

Miscellaneous

2.Sites of obstruction

Common Causes of Large Bowel Obstruction(LBO)

Colon cancer

Diverticulitis

Volvulus

Hernia

Unlike SBO, adhesions very unlikely to

produce LBO

frequency

2. Sites of obstruction Intestinal obstruction1. Definition2. Sites of obstruction


3. Causes of the obstructionLesions extrinsic to the bowel wallLesions intrinsic to the bowel wall

Intraluminal obturator lesions4. Types of intestinal obstructionMechanical obstruction vs. AdynamicileusPartial vs. CompleteSimple vs. StrangulatedHigh vs lowSmall bowel vs colon

5. Clinical picture



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Outside the wall

Inside the wall

Inside the lumen

3. Causes of obstructionLesions Extrinsic to Intestinal Wall

Adhesions (usually postoperative)

Hernia

External (e.g., inguinal, femoral, umbilical, orventral hernias)

Internal (e.g., congenital defects such as

paraduodenal, foramen of Winslow, anddiaphragmatic hernias or postoperative secondaryto mesenteric defects)

Neoplastic

Carcinomatosis, extraintestinal neoplasm Intra-abdominal abscess/ diverticulitis

Volvulus (sigmoid, cecal)

3. Causes of obstruction

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CT scan through the mid abdomen shows dilated small bowel loopsfilled with fluid and decompressed ascending and descending colon.

These are typical CT findings in small bowel obstruction.

CT scan of the abdomen of a patient with a mechanical bowelobstruction secondary to an abscess in the right lower quadrant

(arrow). Multiple dilated and fluid-filled loops of small bowel are noted.

Barium radiograph demonstrates obstruction of the third portion of theduodenum secondary to superior mesenteric artery compression as aconsequence of burn injury.

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upon strainingupon strainingat restat rest

Congenital indirect inguinal herniaCongenital indirect inguinal hernia

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Lesions Intrinsic to Intestinal Wall

Congenital

Malrotation

Duplications/cysts

Traumatic

Hematoma

Ischemic stricture

Infections

Tuberculosis Actinomycosis

Diverticulitis

Neoplastic

Primary neoplasms

Metastaticneoplasms

Inflammatory

Crohn's disease

Miscellaneous

Intussusception

Endometriosis

Radiationenteropathy/stricture


CT scan of a patient withCrohn's disease demonstratesmarked thickening of the

bowel (arrows) with a high-grade partial small bowel

obstruction and dilatedproximal intestine.

Resection of the ileum, ileocecal valve, cecum,and ascending colon for Crohn's disease of

the ileum. Intestinal continuity is restored byend-to-end anastomosis.

CT scan of abdomen demonstrates asmallbowel neoplasm (arrow).

Barium radiograph demonstrates atypical "apple-core" lesion (arrows)caused by adenocarcinoma of thesmall bowel, producing a partialobstruction with dilated proximalbowel.

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Large circumferential mucinous adenocarcinoma of the jejunum.

Small bowel leiomyosarcoma(malignant gastrointestinalstromal tumor) withhemorrhagic necrosis.

Gross photograph of primary lymphomaof the ileum shows replacement of

all layers of the bowel wall with tumor.

Small bowel lymphoma presents as perforation and peritonitis. Gross pathologic characteristics of carcinoid tumor.A, Carcinoid tumor of the

distal ileum demonstrates the intense desmoplastic reaction and fibrosis ofthe bowel wall. B, Mesenteric metastases from a carcinoid tumor of the smallbowel.

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Intraluminal/ Obturator Lesions

Gallstone

Enterolith

Bezoar

Foreign body


Plain abdominal film demonstrates a number of ingested foreign bodiesin a patient presenting with a small bowel obstruction.

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Adynamic Ileus Is there strangulation?

4 Cardinal Signsfever, tachycardia, localized

abdominal tenderness, leucocytosis

0/4 0% strangulated bowel

1/4 7%

2-3/4 24%

4/4 67%

process accelerated with closed-loopobstruction.

4. Types of bowel obstruction

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Partial vs Complete

Flatus

Residual colonic gasabove peritonealreflection

Adhesions

60-80% resolve withnon-operative Mx

Must show objective

improvement, ifnone by 48hconsider OR

Complete obstipation

No residual colonicgas on AXR

SBFT maydifferentiate earlycomplete from high-grade partial

Almost all should beoperated on within24h


Characteristics of proximal anddistal small bowel obstruction

Proximal Distal

Acute onset Less acute onset

Vomiting prominent Less prominentVomiting not feculent Often feculentPain at frequentintervals Less frequentintervalsDistentionminimal Noticable


CAUSES OF COLONIC OBSTRUCTION INADULTS

Carcinoma (65 %)

Diverticulitis (20 %)

Volvulus (5 %)Others (10 %)

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CLINICAL MANIFESTATIONS OFCOLORECTAL CANCER

Right Colon Left Colon

Anemia Obstructive symptoms

Weight loss Gross blood in stool

Palpable mass Change in bowel habits

Fatigue Characteristic x-ray+sigmoidoscopy

Cancer

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COLONIC OBSTRUCTIONESSENTIALS OF DIAGNOSIS

Constipation-obstipation

Abdominaldistention- sometimes tenderness

Abdominal pain Nausea and vomiting(late)

Characteristic x-ray findings

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4. Types of intestinal obstructionMechanical obstruction vs. Adynamic ileusPartial vs. CompleteSimple vs. StrangulatedHigh vs lowSmall bowel vs colon

5. Clinical pictureSymptoms and signs

Radiogical tests


Colicky abdominal pain

Abdominal distension

Vomiting

Decreased passage of stool or flatus

Typical radiographic picture

plain AXR, contrast CT, UGI/SBFT,

enteroclysis

5. Clinical picture

Pathophysiology

Hypercontractility--hypocontractility

Massive third space losses

oliguria, hypotension, hemoconcentration

Electrolyte depletion

bowel distension--increased intraluminalpressure--impedement in venous return--arterial insufficiency

LOSS OF FLUID AND ELECTROLYTESIN INTESTINAL OBSTRUCTION

into the bowel lumen

into theedematous bowel wall

into the peritoneum

vomiting or NG suction

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Secretion

Absorbtion

Nitrogen70%

Oxygen12%

CO2 8%Hydrgen5%N3 4%

Physical findings:

Tachycardia

Rebound(+)

MuscleguardingLocalisedtenderness

Fever

AuscultationAuscultation: High-pitchedamphoric rushes

(metallic bowel sounds)

Lab: Hyponatremia, Hypocloremia, urineosm.

met. asc. Leukocytosis ( 15-25.000/mm3 )

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Intestinal obstruction

1. Definition2. Sites of obstruction



4. Types of intestinal obstructionMechanical obstruction vs.Adynamic ileusPartial vs. CompleteSimple vs. Strangulated

5. Clinical pictureRadiogical tests

Fluid and electrolyte status


Management of Bowel Obstruction

NEVER LET THE SUN RISE OR FALL

ON A PATIENT WITHBOWEL OBSTRUCTION

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Principles

Fluid resuscitation

Electrolyte, acid-base correction

Close monitoring

foley, central line

NGT decompression

Antibiotics controversial

TO OPERATE OR NOT TO OPERATE

SURGICAL TREATMENT

Preoperativepreparation Partial-completeMalignantbenign

Early posoperative

Nasogastric suction+CVP+Foley Cath.

Fluidand electrolyte resuscitation (Ringerlactate+Saline+K (?)+ANTIBIOTICS (?)

Operative therapy Adhesiolysis, enterotomy,resection,by-pass, ostomy

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