Intestinal Obstruction

Intestinal Obstruction

Dr Aqeel Shakir Mahmood
Assistant Professor
Consultant General and Laparoscopic Surgeon

FRCS –( London)

• Today we will be talking about intestinal obstruction
• Definition
• Review of Basics History and Examination Differential Diagnosis Investigation
• Fluid prescription Clinical algorithm

• Definition

• Clinical condition,
• Due to; failure of the intestine small or large to pass
• gas, liquid and solid material.

• Review of the Basics

• Pathophysiology
• The 3 pains / The 3 guts Causes


• Intestinal Obstruction; Pathophysiology
• Blocked Lumen
• Distension (solid, liquid, gas); Pain, vomit, constipation
• Increased Wall tension; Perforation Ischaemia
• Closed and Open loops

• Closed and Open loops

• Review of the Basics

• Pathophysiology
• The 3 pains / The 3 guts Causes

• The 3 Pains

• Visceral
• Referred Somatic


• Visceral Pain
• Is a pain that results from the activation of nociceptors of the thoracic pelvic or abdominal viscera (organs)

• Referred Pain

• It’s when the pain is located away from or adjacent to the organ involved

• Somatic Pain

• When the parietal peritoneum is inflammed;
• Pain is severe Breathing shallow Movement impaired Tenderness marked

• The 3 guts

• There are 3 main guts to be aware of when it comes to pain

• Fore gut

• The 3 guts
• There are 3 main guts to be aware of when it comes to pain
• Fore gut Mid gut

• The 3 guts

• There are 3 main guts to be aware of when it comes to pain
• Fore gut Mid gut Hind gut


• The 3 guts; Based upon arterial supply

• Fore-gut

• Mid-gut Hind-gut

• The Fore-gut

• In the distribution of the Coeliac artery

• Extends from the lower esophagus to half way down D2
• Pain is referred to the epigastrium

• The Mid-gut

• In the distribution of the Superior Mesenteric artery

• Extends from half way down D2 to the distal transverse colon
• Pain is referred to the umbilicus


• What is this?

• The Hind-gut

• In the distribution of the Inferior Mesenteric artery

• Extends from the distal transverse colon to the rectum
• Pain is referred to the hypogastrium

• Review of the Basics

• Pathophysiology
• The 3 pains / The 3 guts Causes

• Causes of Intestinal obstruction

• Classification based upon;
• lumen, wall, outside and combinations
• open and closed loop Identify dangerous types simple and complex Clinically useful
• small intestine, large intestine Clinical and Radiological


• common and rare (Clinical)

• Lumen, Wall, Outside and Combinations

• Lumen; Gallstone, Beezoar, Foreign Body

• Wall; Stricture

• Outside; Volvulus, Hernia, Adhesions, Metastases
• Combinations; Intussusception

• Lumen

• Wall

• Outside

• Causes of Intestinal obstruction
• Classification based upon;

• lumen, wall and outside

• Small Intestine, Large Intestine common and rare

• Small Intestine

• Post operative adhesions
• Stuck onto tumor or inflammatory mass somewhere Hernia; External, Internal
• Volvulus Intussusception Crohn’s stricture Ischaemic stricture

• Tumors of the small intestine

• Operative Findings; Small bowel volvulus

• Large Intestine

• Colo-rectal cancer
• Volvulus; Sigmoid, Caecal Inflammatory Stricture


• Causes of Intestinal obstruction
• Classification based upon;

• lumen, wall and outside

• small intestine, large intestine Common and Rare

• Common and Rare

• Common;
• Post operative adhesions
• Herniae; Groin, Femoral and Inguinal, Incisional Colorectal Cancer

• Rare; Internal hernia

• Presenting Complaint
• Abdominal Pain
• Vomiting Distension
• Constipation, Complete, obstipation

• Pain

• Site
• Radiation Type Severity
• Onset and Duration
• Aggravating and Relieving factors Associated symptoms


• Site

• Whats this?

• Whats this?

• Whats this?

• Past history

• Had this before?
• Previous surgery Other illness (drugs)

• Examination

• Overall state; distressed, comfortable, cachexia


• Vital signs

• State of Hydration

• Abdominal Examination; distension, peristalsis, tenderness, mass
• Hernial orifices, Perineum, Rectal, Genitalia, Femoral Pulses

• Inspection

• Inspection

• Clinical approach

• Has the patient got intestinal obstruction?
• Is it simple or complicated? What is the fluid deficit?
• What is the level of the obstruction? What is the cause of the obstruction?

• Differential Diagnosis

• Obstuction or Pseudo-obstruction


• Of the pain; Abdominal, Non Abdominal
• Of the distension; Fluid, Flatus, Fat, Faeces, Fetus,

• Investigation

• Blood; U & E, FBC, Amylase, Muscle Enzymes,

• Radiological; PFA, Erect CXR, CT scan, Enemas.

• Radiology
• Quite simple,
• Gaseous distension, what is distended? Fluid levels, fluid distension
• Transition zone, any gas distally? Contrast wont pass, show mass

• Radiology, Small bowel obstruction

• Operative Findings; Small bowel obstruction

• Radiology; CT, Small bowel obstruction

• Operative Findings; Small bowel obstruction

• Radiology; PFA, Large bowel obstruction

• Radiology; CT, Large bowel obstruction

• Operative Findings; Large bowel obstruction

• Thanks