Intestinal Obstruction

* Intestinal Obstruction

* Abdomen- Bowel sound
Present- Mechanical obstruction Not present- Adynamic obstruction (no gas under diaphragm) Perforation (gas under diaphragm)

* Objectives

Pathophysiology – dynamic, adynamicCardinal features – history, examinationCauses – small, large gut obstructionIndications – contraindications for conservative Mx

* Obstruction

Dynamic – peristalsis, mechanical obstructionAdynamic- paralytic ileus, non propulsive Mesenteric vascular obstruction or, pseudo obstruction

* Dynamic Obstruction

Pain, distention, vomiting, absolute constipationTwo- small gut – high , low Large gut Acute , chronic, acute on chronic or, sub-acuteSimple – intact vascularityStrangulated – compromised vascularity

* Intestinal obstruction: Causes

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* Causes –Dynamic obstruction Intra-luminal –impaction, FB, Bezoars, gallstonesIntramural- strictures, malignancyExtra-luminal- bands/adhesions, hernia, volvulus, intussusception

* Adynamic obstruction-causes

Paralytic ileus Mesenteric vascular occlusion Pseudo obstruction

* Pathophysiology

Proximal gut dilates- altered motilityBelow the obstruction – normal motility, immobileProximal – increased peristalsis, dilates, reduced peristalsis, flaccidGas- bacteria. Aerobic/anaerobic, 90% N2Fluid- dig. Juices,

* Pathophysiology

Dehydration and electrolyte imbalance Reduced intake Defective absorption Vomiting Sequestration in gut

* Strangulation

Blood supply compromised Venous return first affected, arterial Hemorrhagic infarction Translocation and systemic exposure to microbes/ toxins Morbidity/ mortality- age, extent, Peripheral vascular failure

* Closed loop obstruction

Strangulation Distention Necrosis perforation



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* Acute Intestinal Obstruction-CP

Location, age of obstruction, pathology, ischemia Pain Vomiting Distension Constipation Dehydration, Hypokalemia, fever, abdomen tenderness


* Pain – severe, colicky, umbilical, lower abdomenIncreases with peristalsis, later reducesSevere pain - strangulation

* Vomiting

High obstruction- violent Low obstruction- slow onset nausea/vomit Gradually digestive food changes to feculent material

* Distension

Greater if distal obstruction Visible peristalsis Peristalsis delayed in colonic obstruction Absent in Mesenteric vascular obstruction


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* Constipation
AbsoluteRelativeAbsent in – Richter’s hernia, gallstone, MVO, Pelvic abscess, partial obstruction

* Dehydration

Vomiting, fluid sequestration Dry skin, poor venous filling, sunken eyes, oliguria Raised blood urea, Hb, - secondary polycythemia

* Hypokalemia

K, amylase, LDH – strangulation, raised TLC or, leucopeniaFever – indicates – ischemia, perforation, inflammationHypothermia – septic shock

* Abdomen tenderness

Localized – ischemiaPeritonitis – infarction or, perforation

* Strangulation

Diagnosis is clinicalFeatures of obstructionPersistent pain, Shock, local tendernessNon-responsive to conservative MxHernia strangulation – tender, irreducible, absent cough impulse, recent increase in size

* Radiology

Supine/ erect plain abdomen films Small gut- central, transverse, no gas-colon Jejunum- valvulae connivantes Ileum- featureless Cecum- round gas in RIF Large gut- haustral folds

* Supine

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* Sigmoid volvulus

Dilated, no haustral pattern Small gut- air and fluid levels More the fluid levels, more distal the lesion


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* Inv:

Plain x ray- impacted foreign bodyFluid levels – non obstructing conditions – inflammatory bowel disease, acute pancreatitis, abdominal sepsis

* Treatment

3 measures Intestinal drainage Fluid and electrolyte replacement Relief of obstruction

* Surgical Mx

Mx of segment at the site of obstruction The distended proximal bowel Underlying cause of obstruction

* Supportive

NG tube drainage Na , water replacement Antibiotics

* Large gut

Ca or diverticular diseaseContrast study – pseudo-obstructionCaecal perforation- caecostomy, ileostomy

* Adhesions/bands

CommonestFibrin – adhesions-fibrinous, fibrousAppendectomy , gynaecological op.Bands- congenital, bacterial peritonitis, greater omentum causing bandMx- conservative – 72 hrs –lap adhesiolysis

* Special obstructions

Int. hernia – foramen of Winslow, hole in the mesentery, hole in transverse colon, defects in broad ligament, cong diaphragmatic hernia, paraduodenal fossae, intraperitoneal fossaeMx- release the ring, reduction of hernia

* Enteric strictures

TB, Crohn’s, Ca, lymphomas, stricturoplastyBolus obstruction – food, gall stone, trichobezoars, phytobezoars, stercoliths, worms

* Ac Intussusception

Proximal gut enters distal gutAdults – lead point, polyp, submucosal lipoma, tumor, Colo-colic – adultsPathology- inner tube, outer tube, returning of middle tubeStrangulating obstruction- ileoileal, ileocaecal, ileocolic

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* Clinical picture

Severe attacks of pain – lasts few minutesLater - red currant jelly stoolExam –between episodes-50-60% sausage shaped lump – empty RIF –Sign de DanceP/R – blood stained fingerLater vomit, distension


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* Radiology

Plain film – absent caecal gasBa enema- claw signCT scanMx- Hydrostatic reduction with enemaOperative reductionRecurrent – 5%- anchorage of ileum to ascending colon

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* Differential diagnosis

Acute enterocolitis Henoch Schoenlein perpura Rectal prolapse

* Volvulus

Axial rotation of bowel at its mesenteryCongenital or secondarySmall intestine, caecum, sigmoid-commonSmall gut- spontaneous, vegetable consumption – untwistCaecal – clockwise- females- lap . Untwist, resection if gangrene

* Sigmoid

Anticlockwise Bands, overloaded colon, large mesocolon, narrow pelvic mesocolic attachment

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* Treatment

Flexible sigmoidoscopy/ rigidLaparotomy- untwistingViable – fixing to retroperitoneumResection – Paul Mickulikz- gangreneSigmoid colectomy/ Hartmann’s procedure later re-anastomosis

* Compound volvulus

Rare, ile-osigmoid knotting Gangrene Laparotomy - Decompression, resection and anastomosis


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* Thanks