intestinal obstruction by dr.usman haqqani

Intestinal Obstruction

Dr.Usman HaqqaniTMO

Surgical B

Hayatabad Medical complex peshawar

Classification

• According to obstructing site• Small bowel obstruction

• Large bowel obstruction

• According to presentation• Acute obstruction

• Chronic obstruction

• Acute on chronic obstruction

• Subacute obstruction

• According to blood flow• Simple obstuction

• Strangulated obstuction

• Primary

• External

• Closed loop obstruction

AETIOLOGY

CAUSES OF INTESTINAL OBSTRUCTION

Dynamic causes

Intraluminal

impaction

foreignbodies

bezoars

gallstones

Intramural

stricture

malignancy

Extramural

bands/adhesions

hernia

Volvulus

Intussusception

Adynamic causes

Paralytic ileus

Mesenteric vascular occlusion

Pseudo -obstruct

Common causes of obstruction

ADHESION

TUMOR

Common causes of obstuction

IncidenceSmall Bowel

(85%)

Cancer (75%)

Diverticulos.(10%)

Volvulus(10%)

Miscellan.(10%)In Eastern Countries& Middle

East volvulus accounts for > 50% of causes of colon obstruction

COLON(15%)

Adhesions(80%)

Hernia(10%)

Tumors(5%)

Miscellan.(5%)

etiology:

I. Adhesions(40%of causes)A. Postoperative:

• Commonest after lower abdominal and gynaecological surgery

• Patients can present as early as 4 weeks postop.but often 1-5 years postoperative.

B.Inflamatory:• Cholecystitis

• Appendicitis

• PID

• T.B

• Peritonitis

ADHESIVE INTESTINAL OBSTRUCTION

ADHESIVE INTESTINAL OBSTRUCTION

Etiology(small bowel)

II. Hernia(12% of causes)A. External: Inguinal ; Femoral; Umbilical

B. Internal:Sites

Foramen of Winslow

Defect in the mesentery or transverse mesocolon

Defect in the broad ligament

Diaphragmatic hernia

Duodenal/caecal/appendiceal retroperitoneal fossae

Strangulated small bowel loop(strangulated inguinal hernia)

Neoplasms(15% of causes)

Colorectal carcinoma:

• 75% occure in Rectosigmoid colon

• 15-20% of colorectal cancer present with obstruction

• LT.colon commonest site of obstruction due to constricting lesion&solid faeces

strictures

A.Congenital: Intestinal Atresia

B. Inflammatory:

Crohns Disease

Tuberculosis

C. Neoplastic:Lymphoma

Carcinoid

Volvulus

• Twisting or axial rotation of a portion of bowel about its mesentery

• Primary or secondary

Malrotation & neonatal volvulus• Treatment:

• The volvulus is reduced, the transduodenal band(Ladd’s band) divided, the duodenum mobilised & the mesentry freed.

• Appendicectomy is routinely performed to avoid diagnostic difficulty with appendicitis in the future.

• Infarcted bowel necessitates resection.

Intussusception:

• Invagination of segment of bowel(intussusceptum) into another(intussuscepien).

• it is often antegrade

• Most common:

ileocolic(ileocaecal)

Ileo-ileal

A. Primary: infants & young children

Due to lymphoid hypertrophy of terminal ileum

B. Secondary: adult

Due pathological lead point :

Meckles diverticulum ;polyp ;submucous lipoma ; haemangiomas;Lymphoproliferative disease

Intussusception

JEJUNO-JEJUNAL INTUSSESCEPTION(IN ADULT)

Bolus Obstruction

1. Gall stones• In the elderly

• Classically there is impaction about 60 cm proximal to the ileocaecal valve

2. FoodOccur after partial or total gastrectomy when unchewedarticles can pass into the small bowel

3. Stercolith• In association with jejunal diverticulum or ileal stricture

4. Trichobezoar• Firm masses of undigested hair balls

5. Phytobezoar• Firm masses of fruit or vegetable fibres

6. Worms• In children

• Ascaris Lumbricoides

Adynamic obstruction

I. Paralytic Ileus:

There is Reflex Inhibition of Peristaltaic Activity of Small intestine due to increase sympathetic Drive. smooth muscle become unresponsive to neural and hormonal stimuli

Causes:

1) Postlaparotomy: after Abd.Pelvic surgery

I. Paralytic ileus( CAUSES)

2) Intra-abdominal Sepsis

3) Abdomino-pelvic Trauma (Retroperitoneal Haematoma)

Other Contributing Factors:

Electrolytes Imbalance

Uraemia

Drugs: Narcotics ; Antichlonergices; phenothiazines

II. Acute colonic pseudo-obstruction

It is massive colonic dilatation affecting caecum and Rt.colon with presentation of colonic obstruction without mechanical blockage

Occurs in

Elderly hospitalised patients with major TRAUMA;ILLENESS; MAJOR NON-INTESTINAL SURGERY

ETIOLOGICAL FACTORES

Major non-operative TRAUMA

SEPSIS

Myocardial infarction ; Heart Failure

Major Abdomino-pelvic Surgery

Orthopedic Surgery

Gynecological ; Neurosurgical Procedures

Cerebrovasular accident ; Spinal cord Injury

Advanced Malignancy

Respiratory ; Renal Failure

Drugs: Opiates; phenothiazines ;Chanel blockers

III. Acute mesenteric ischemia

1. Embolic: (50%)

• Affects SMA

• Occur secondary to MI; Atrial Fibrilation

2. Trombotic(20%)

due to acute thrombosis on top of pre-existing atherosclerosis of visceral artery

3. SHOCK:

• hypovolemic & septic

HISTORY

• Acute obstruction

• Sudden onset of central abdominal colicky pain

• Vomiting (party digested food>>mucoid>>greenish>>feculant)

• Abdominal distention

• Absolute constipation

• Chronic obstruction

• Constipation

• Abdominal distention

• Abdominal pain( bouts of colic pain in hyopogastrium)

• VOMITING DELAYED FOR 2-3 DAYS

PHYSICAL EXAMINATION

INSPECTION

Abdominal distention, scars, visible peristalsis.

PALPATION

Mass, tenderness, guarding

PERCUSSION

Tymphanic, dullness

AUSCULTATION

Bowel sound are high pitch and increase in

Frequency

DIGITAL RECTAL EXAMINATION

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, Contrast studieS)

Errect abdomen x ray

with air fluid levels Supine radiograph

distended small bowel

loops in the central

abdomen with prominent

valvulae conniventes (

white arrow)

Figure 3. Lateral decubitus view of the abdomen, showing air-fluid levels (arrows).

The Difference between small and large bowel obstruction

Small BowelLarge bowel

•Central ( diameter 3 cm max)

•Vulvulae coniventae

•Peripheral ( diameter 6 cm max)

•Presence of haustration

Abdominal X-RayWhat is Diagnosis?(1) Dilated Colon >6cm(2) Effacement of Haustrae

Peripherally located(3) Multiple Air Fluid Levels

Large Bowel Obstruction

Rule of 3,6,9: suspect obstruction if small

bowel dilated >3cm; large bowel >6cm, cecum >9cm.

Cecal volvulus • Sigmoid volvulus

• Intussusception

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 (yellow arrows), with decompressed distal small bowel on the patient’s right (red arrows). The cause of obstruction, an incarcerated umbilical hernia, can also be seen (green arrow), 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 (AAFP), 83: 2 (160-164)

Role of barium gastrografin studies

• As: follow through, enema

• Useful in recurrent and chronic obstruction

• Can be used to distinguish adynamic and mechanical obstruction

Barium should not be used in

a patient with peritonitis

intussuseption• Bird beak sign in cecalvolvulus

Intussuseption

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

Academy of Family Physicians (AAFP), 83: 2 (160-164)

TREATMENT

• URGENT RESUSCITATION

• NBM

• NG tube(bowel decompression)

• Cathetrization

• IV fluids (correct fluid and electrolyte disturbances)

• Start IV antibiotics (if indicated)

• Optimise Cardio respiratory status

• Consenting

• Bowel preparation

• Workup for surgery

• Close clinical and Radiological monitoring

II. SURGICAL INTERVENTION

1. URGENT:

• Strangulation / Suspected Strangulation

• Closed-Loop Obstruction

• Complete Obstruction

• Pnumoperitonium/ Peritonitis

2. Elective Cases

• Adhesive Small intestine Obstruction NO Strangangulation

( Observe&Mointoring For 48-Hours )

• Incomplete Small intestine or Colonic Obstruction:

Investigate With Contrast Studies

3. NOT TO OPERATE

• PARALYTIC ILEUS

• ACUTE COLONIC PSEUDO-OBSTRUCTION

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

General steps of Surgery

• At first most importantly the caecum is identified

collapsed distended

(small gut obstruction) (large gutobstruction)

Site of obstruction is identified

Nature of the obstruction is identified & removed

Viability of the gut is assesed

Gut is viable it is not viable

Gut is put inside the ResectionAnastomosis

Abdomen.

• Abdomen closed in layers using Non-absorbable sutures.

Comparison between Viable & Non-viable Gut

Features of viable gut

• Pinkish

• Luster-present

• Peristaltic movement-present

• When pricked by a needle-bleeding from the surface

• Pulsation-present in mesenteric vessels

Features of non-viable gut

• Blackish

• Absent

• Absent

• There Is no bleeding

• No pulsation

If still we are doubtful-

• Warm saline soaked mop over the doubtful area & 100% O2 is administered

• If colour becomes normal with peristalsis,then it is viable.

Other means of checking Viability

1. Doppler study

2. Fluorescence study

Management of bowel obstruction• Intussusception

• Reduction by hydrostatic pressure

• Operative reduction

• Volvulus neonatorum

• Early laprotomy

• Whole Midgut is delivered

• Untwisting is done in opposite direction

• Transduodenal band of lad is devided

• Cecal volvulus

• Laprotomy

• Balooned cecum defalted by needle

• Untwisting in anticlockwise direction

• Cecostomy is performed

• Sigmoid volvulus

• Deflation sigmoidoscopy

• Operative

• Laprotomy

• Untwisted in clockwise direction

• Rectal tube passed simultaneously to deflate

• Paralytic ileus• Remove primary cause• Decompress GI distension• Fluid and electrolyte balance • If not relieved laparotomy exclude hidden cause

• Acute Mesenteric Occlusion• Anti-coagulant• Embolectomy• Revascularization• Colectomy

• Adhesions• Conservative treatment should not be prolonged beyond 72

hours.• divide only the causative adhesion(s) and limit dissection

MANAGEMENT FOR LARGE BOWEL OBSTRUCTION

(IF Lesion/Mass is removable)•Right sided lesions – right hemicolectomy•Transverse colonic lesion – extended right hemicolectomy

(if lesion/Mass is irremovable)•Proximal stoma

•Colostomy•Ileostomy if ileocecal valve is incompetent•Ileotransverse enterostomy

•Left sided lesions – various options

Two-staged procedure•Resection and anastomosis with defunctioning colostomy

•Closure of colostomy

Two-staged procedure•Hartmann’s procedure

•Closure of colostomy

One-stage procedure•Resection, on-table lavage and primary anastomosis

Complications associated with 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.