Dr.Pankaj Kumar Assistant Professor Surgical Gastroenterology One of the common cause of acute abdomen May lead to high morbidity and mortality if not treated correctly It can be classified into two types: Dynamic (mechanical) Adynamic Dynamic: where peristalsis is working against a mechanical obstruction. Adynamic: mechanical element is absent - Peristalsis my be absent(paralytic ileus) -May be present in non propulsive form. (mesenteric vascular occlusion or pseudo-obstruction) gallstones. 2.Extramural: adhesion.Intraluminal: impacted faeces. 3. foreign bodies. Bezoars. tumors .DYNAMIC 1. volvulus.Intramural: tumors. hernias. intussusception. inflammatory strictures. Large bowel obstruction (LBO) early pronounced distension.g.also can be divided into: 1. -carcinoma -diverticulitis or volvulus . Small bowel obstruction (SBO) -high ->early perfuse vomiting rapid dehydration -low->predominant pain. dehydration late e. mild pain vomiting. and central distention Vomiting delayed multiple central air-fluid levels seen on AXR 2. lower abdominal colic & obstipation followed by distension. Subacute obstruction : incomplete obstruction. distension. . Chronic obstruction: -usually in large bowel . early vomitting and constipation. Acute on chronic: short history of distension & vomiting against background of pain & constipation.usually in small bowel -obstruction with severe colicky central abdominal pain. Acute obstruction:. Simple: blockage without interfering with vascular supply Strangulation: significant impairment of blood supply most commonly associated with hernia. . intussusception. volvulus. mesentric infarction. adhesions/Bands -surgical emergency Closed loop obstruction: bowel is obstructed at both the proximal and distal end. Adhesions.40% Tumors -15% Inflamatory.15% Obstructed hernia-12% Intraluminal-10% Miscellaneous -8% . Irrespective of etiology or acuteness of onset: Proximal to obstruction Increased fluid secretion abdominal distention Accumulation of gas abdominal distention Increased intraluminal pressure Vomiting Dehydration Dilatation of bowel Reflex contraction of smooth muscle colicky pain Increased peristalsis to overcome obstruction increased bowel sounds If obstruction not overcome bowel atony Decreased reabsorption with time and flaccidity to prevent vascular damage from high pressure Distal to obstruction: nothing is passed & bowel collapse constipation . The four cardinal features of intestinal obstruction: -abdominal pain -vomiting -distension -constipation Vary according to:location of obstruction Duration of obstruction underlying pathology intestinal ischemia . colicky in nature.if it becomes continuous.does not usually occurs in paralytic ileus.Abdominal pain . . Vomiting -starts early in SBO and late in LBO -As obstruction progresses vomitus alters from digested food to faeculent due to enteric bacterial overgrowth Distension -more with lower obstruction . around the umbilicus in SBO while in the lower abdomen in LBO . think about perforation or strangulation. Obst. -mesentric vascular occlusion. -diarrhea may be present with partial obstruction .constipation is either absolute (no feces or flatus) cardinal feature of complete Int. or relative (flatus passed).obstruction associated with pelvic abscess.Constipation -more with lower or complete obstruction . . it does not apply in -Richter’s Hernia -Gallstone obturation. urea & hematocrit. obst. Secondary polycythemia due to raised B. Inflamation associated with int. Dehydration More common in small bowel obstruction. Pyrexia Onset of ischemia.due to repeated vomiting . Intestinal perforation. . In strangulation: severe constant abdominal pain fever tachycardia tenderness with rigidity/rebound tenderness. shock . masses. hernial orifices Palpation tenderness. peristalsis. hypotension dry mucus membrane. rigidity Percussion tympanitic abdomen Auscultation high pitched bowel sound or silent abdomen *Examine rectum for mass. masses. scars. decreased skin turgor. feces or it may be empty in case of complete obstruction .General examinationVital signs Signs of dehydration –tachycardia. blood. decreased urine output Inspection distension. Hemogram .WBC (neutrophiliastrangulation) Hyper kalemia. hyperamylasemia & raised LDH may be associated with stangulation. volvulus) Contrast x-ray CT abdomen. Plain AXR Sigmoidoscopy (carcinoma. . Fluid level appears later than gas shadow Two fluid level in small bowel considered normal. When distended by gas: Jejunum is characterized by valvulae conniventes(completely pass across the width & regularly placed) Ileum is featureless. No. of fluid level is proportional to degree of obstruction and distal site in small bowel. Colon shows haustral folds. Caecum is shown by rounded gas shadow in RIF. . Ba-follow through is contraindicated in acute intestinal obstruction. . Associated with large ammount of gas in caecum. Colonic obstruction does not commonly give rise to small bowel fluid level unless advanced. usually surgical .Relief of obstruction. Three main measures.GI drainage Fluid &Electrolyte replacement . and pulse 2 hourly -abdominal examination 8 hourly -Broad spectrum antibiotics initiated earlyreduce bacterial overgrowth. .Treatment Conservative: -Nasogastric aspiration by Ryles tube -IV fluids.volume varies depending on dehydration -NPO -urinary catheter -check temp. Surgery should be delayed till resuscitation is complete unless signs of strangulation and evidence of closed-loop obstruction. Cases that show reasons for delay should be monitored continuously for 72 hours in hope of spontaneous resolution e. other need surgical intervention. Some cases will settle by using this conservative regimen. adhesions with radiological findings but no pain or tenderness “The sun should not both rise and set” in cases of unrelieved obstruction.g. . -The nature of obstruction.failure of conservative management . The site of obstruction can be determined by caecum . irreducible hernia .strangulation If the site of obstruction is unknown.Indication for surgery: .tender. -The viability of gut. laparotomy assessment is directed to-The site of obstruction. Surgical treatment Operative decompression required-if dilatation of bowel loops prevent exposure. . Savage’s decompressor used within seromuscular purse-string suture. or if subsequent closure will be compromised. Or large-bore NG tube maybe used for milking intestinal contents into stomach. bowel wall viability is compromised. loss of normal shine 3.The type of surgical procedure depend upon the cause of obstruction viz division of bands. the bowel is inspected for viability.absent peristalsis 2.or bypass *Once obstruction relieved. excision . and if non-viable.green or black color of bowel . Indication of non-viability 1. resection is required.adhesiolysis.loss of pulsation in mesentry 4. If in doubt of viability. multiple ischemic areas. Resection of non viable gut should be done followed by stoma.g. Sometimes a second look laprotomy is required in 24-48 hours e. . bowel is wrapped in hot packs for 10 minutes with increased oxygen and reassessed for viability. which produce adhesions. BANDS Congenital : obliterated vitellointestinal duct. . A portion of greater omentum adherent to parietes. A string band following previous bacterial peritonitis. Most common cause of intestinal obstruction. Peritoneal irritation results in local fibrin production. raw peritoneal surfaces Foreign material: talc. . Covering the anastomosis & raw peritoneal surfaces. Radiation entritis. gauze. Washing the peritoneal cavity with saline to remove the clots. Inflammatory conditions: crohn’s disease. T. silk Infection: peritonitis. starch.Causes of adhesions : Abdominal operation : anastomosis.B. Prevention Good surgical technique. Minimizing contact with gauze. rehydration & nasogastric decompression) It should not be prolonged beyond 72 hrs.v. Usually conservative treatment is curative. Surgery Division of band. (i. . Minimal adhisiolysis. Repeat adhesiolysis alone. . Noble’s plication : adjacent intestinal coils (15-20 cms) are sutured with serosal sutures. Charles-Phillips trans-mesenetric plication. Intestinal intubation : initraluminal tube insertion via a WITZEL jejunostomy or gastrostomy. . paraduodenal & rt. intersigmoid fossae. When a portion of small intestine is entrapped in one of retropritoneal fossae or in a congenital mesentric defect. A hole in mesentry / transverse mesocolon. Congenital/ acquired diaphragmatic hernia. Duodenal retroperitoneal fossae. Sites of internal herniation: Foramen of winslow.Lt. Defects in broad ligaments. Duodenoojejunal. Treatment : to release the constricting agent by division. . It is uncommon in the absence of adhesions. Erosion of large gallstone into duodenum. . -may show a radio opaque gall stone. It tends to occur in elderly. X-ray: small bowel obstruction with air in billiary tree. Treatment : laparotomy & removal /crushing of stone. Present with recurrent obstruction. Unchewed food can cause obstruction. After partial /total gastrectomy. . Laparotomy. Eosinophilia/worm with in gas filled bowel loops. BEZOARS Trichobezoars Phytobezoars WORMS Ascaris lumbricoides Frequently follows initiation of antihelminthic therapy. Treatment similar to gall stone. .) Ideopathic-70% Associated gastroenteritis/UTI. Most common in children(3-9 months.30% Hyperlpasia of Peyer’s patches in terminal ileum can be initiating factor. One portion of gut becomes invaginated with in adjacent segment. ileocolic(77%).polyp. ileoileo-colic(12%). submucosal lipoma/ tumor. . colocolic (2%) & multiple.Returning/ middle tube -Sheath/ outer tube(intussuscipiens) It is an example of strangulating obstruction with impaired blood supply of inner layer. polyp. & appendix. It may be ileoileal(5%).. It is composed of three parts: -Entering/ inner tube(Intussusceptum) . Adults: always with a lead point. In older children intussusception is usually associated with a lead point – meckel’s diverticulum. Severe colic pain. Death may occur from bowel obstruction or peritonitis secondary to gangrene. . vomitting as time progress blood & mucus (the ‘redcurrent’ jelly stool). Abdominal lump(sausage shaped) Emptiness in RIF(the sign of Dance). Henoch-schoenlein purpura. (small bowel mass may be revealed) Differential Diagnosis Acute enterocolitis: faecal matter/ bile is always present. Ba-enema: the claw sign in ileocolic & colocolic cases. Rectal prolapse: projecting mucosa can be felt in continuity with perianal skin . Plain X-ray Abd.: Bowel obstruction with absent caecal shadow gas in ileo-ileal & ileo-colic cases. CT scan in equivocal cases of ileo-ileal intussusception. Irreducible/ gangrenous intussusception: excision of mass & anastomosis. prolonged history (> 48 hrs.contrindications: peritonism. Cope’s method. Operative After resuscitation . . .Laparotmy with reduction.). Theraputic Ba-enema : -in infants. .unlikely to succeed in lead points. to be cont…… .