intestinal obstruction mostafa abou ali professor of surgery suez canal university

INTESTINAL INTESTINAL OBSTRUCTIONOBSTRUCTION

MOSTAFA ABOU ALIMOSTAFA ABOU ALI

PROFESSOR OF PROFESSOR OF SURGERYSURGERY

SUEZ CANAL SUEZ CANAL UNIVERSITYUNIVERSITY

INTESTINAL OBSTRUCTIONINTESTINAL OBSTRUCTION

A. Overview of the ProblemA. Overview of the Problem - Concept- Concept - Common Types- Common Types - Common Causes- Common Causes

B. General Management B. General Management GuidelinesGuidelines

-- Clinical DiagnosisClinical Diagnosis - Paraclinical Diagnosis- Paraclinical Diagnosis - Treatment- Treatment

CLINICAL QUESTIONSCLINICAL QUESTIONS

1. WHAT IS OPERATIONAL CONCEPT OF 1. WHAT IS OPERATIONAL CONCEPT OF INTESTINAL OBSTRUCTION?INTESTINAL OBSTRUCTION?

DEFINITION: PROBLEMDEFINITION: PROBLEM of the of the intestinal intestinal

contents to pass through contents to pass through normallynormally

(Problem, motility, inability difficulty, failure)(Problem, motility, inability difficulty, failure)

INTESTINAL OBSTRUCTION- INTESTINAL OBSTRUCTION- SMALL INT. AND LARGE INT.SMALL INT. AND LARGE INT. (starting (starting

from the duodenumfrom the duodenum))


22a. How is intestinal obstruction a. How is intestinal obstruction classified in terms of degree of classified in terms of degree of obstruction?obstruction?

PARTIALPARTIAL intestinal obstruction intestinal obstruction COMPLETECOMPLETE intestinal intestinal

obstruction obstruction


2b. How is intestinal obstruction 2b. How is intestinal obstruction classified in terms of itsclassified in terms of its CAUSE CAUSE??

• • MECHANICALMECHANICAL

• • NON MECHANICALNON MECHANICAL


CARDINAL SIGNS AND CARDINAL SIGNS AND SYMPTOMS:SYMPTOMS:

Presence of the cardinal signs andPresence of the cardinal signs and

symptoms of intestinal symptoms of intestinal obstructionobstruction

plus high-pitched bowel soundplus high-pitched bowel sound


33a. What are reliable signs and a. What are reliable signs and symptomssymptoms (more than 90% certainty) (more than 90% certainty) that will indicate mechanical that will indicate mechanical intestinal obstruction?intestinal obstruction?

Presence of the cardinal signs andPresence of the cardinal signs and

symptoms of intestinal obstruction symptoms of intestinal obstruction plus Palpable abdominal mass and/or plus Palpable abdominal mass and/or high-high-

pitched bowel soundpitched bowel sound

Presence of the cardinal signs Presence of the cardinal signs andand

symptoms of intestinal symptoms of intestinal obstructionobstruction

plus high-pitched bowel soundplus high-pitched bowel sound

The normal flow of intestinal The normal flow of intestinal contents can be blocked by a contents can be blocked by a

Mechanical obstruction or by a Mechanical obstruction or by a

Functional obstruction that occurs Functional obstruction that occurs because of impaired intestinal because of impaired intestinal motilitymotility. . An acute abdomen often An acute abdomen often ensuesensues..

Mechanical obstructions are Mechanical obstructions are common and have various benign common and have various benign and malignant causes. If not and malignant causes. If not treated expeditiously (usually by treated expeditiously (usually by surgical removal of the cause), surgical removal of the cause), mechanical obstructions can mechanical obstructions can rapidly become lethal. rapidly become lethal.


Acute obstruction occurs over Acute obstruction occurs over hours to days and has a rapidly hours to days and has a rapidly evolving course, whereas evolving course, whereas

Chronic obstruction may have a Chronic obstruction may have a slow course with malnutrition, slow course with malnutrition, constipation, and other signs of constipation, and other signs of chronic illness.chronic illness.


TYPESTYPES

SIMPLE OBSTRUCTION.SIMPLE OBSTRUCTION.

STRANGULATING OBSTRUCTION.STRANGULATING OBSTRUCTION.

Closed loop obstructionClosed loop obstruction. .

IntussusceptionsIntussusceptions..

Perforating obstructionPerforating obstruction


Closed loop obstructionClosed loop obstruction. .

IntussusceptionsIntussusceptions..

Perforating obstructionPerforating obstruction... . The The most common area of perforation most common area of perforation when the colon is obstructed is the when the colon is obstructed is the cecumcecum..


CAUSESCAUSES INTESTINAL ADHESIONSINTESTINAL ADHESIONS are the are the

most common cause of obstructionmost common cause of obstruction.. Previous surgical explorationPrevious surgical exploration IdiopathicIdiopathic

They may be They may be DIFFUSEDIFFUSE, involving all , involving all peritoneal structures, or peritoneal structures, or SOLITARYSOLITARY, , blocking only one area of the intestineblocking only one area of the intestine..

ADHESIVE INTESTINAL ADHESIVE INTESTINAL OBSTRUCTIONOBSTRUCTION

HerniasHernias are a second very are a second very common cause of intestinal common cause of intestinal obstructionobstruction. .

A segment of intestine migrates A segment of intestine migrates through a defect in the abdominal wallthrough a defect in the abdominal wall ((external herniaexternal hernia)) or through a or through a mesenteric or omental defectmesenteric or omental defect ((internal herniainternal hernia) ) and becomes and becomes blocked by the narrow ring that is blocked by the narrow ring that is present at the peritoneal present at the peritoneal communication of the herniacommunication of the hernia..

INTESTINAL TUMORS are the INTESTINAL TUMORS are the third most common cause of third most common cause of obstructionobstruction. .

The most common obstructing tumor The most common obstructing tumor is an is an adenocarcinomas of the colon adenocarcinomas of the colon or rectumor rectum. Benign lesions of the . Benign lesions of the small bowel and colon, such as small bowel and colon, such as lipomalipoma, can become the leading point , can become the leading point of an of an IntussusceptionIntussusception. Other . Other malignant tumors, such as malignant tumors, such as carcinoidcarcinoid or or lymphomalymphoma, can obstruct the , can obstruct the intestinal lumen.intestinal lumen.

SEGMOID CARCINOMASEGMOID CARCINOMA

OTHER INTRINSIC LESIONSOTHER INTRINSIC LESIONS within the within the bowel wall or the lumen can cause acute bowel wall or the lumen can cause acute obstructionobstruction..

CONGENITAL LESIONSCONGENITAL LESIONS: : webs, webs, malrotations, and atresiasmalrotations, and atresias

INFLAMMATORY LESIONSINFLAMMATORY LESIONS: : Crohn's Crohn's disease, diverticulitis, ulcerative colitis, and disease, diverticulitis, ulcerative colitis, and infections such as tuberculosisinfections such as tuberculosis

LUMINAL FOREIGN BODIESLUMINAL FOREIGN BODIES: : bezoars, bezoars, parasites, and gallstonesparasites, and gallstones

RADIATION INJURYRADIATION INJURY, , otherother traumatrauma, , oror endometriosisendometriosis

OTHER EXTRINSIC LESIONSOTHER EXTRINSIC LESIONS, , such as such as large intralarge intra--abdominal tumors or abscesses, abdominal tumors or abscesses, can compress the intestinal lumencan compress the intestinal lumen..

NEONATAL INTESTINAL NEONATAL INTESTINAL OBSTRUCTIONOBSTRUCTION

AtresiasAtresias Hirschsprung’s DiseaseHirschsprung’s Disease MalrotationsMalrotations VolvulusVolvulus IntussusceptionIntussusception Incarcerated HerniaIncarcerated Hernia Perforated appendixPerforated appendix

PERFORATED APPENDIX PRESENTED WITH PERFORATED APPENDIX PRESENTED WITH INTESTINAL OBSTRUCTIONINTESTINAL OBSTRUCTION

PERFORATED APPENDIXPERFORATED APPENDIX

Suspect in children 3-5 years old with Suspect in children 3-5 years old with history suggestive of appendicitishistory suggestive of appendicitis

““Bowel obstruction” in a 3-5 year old Bowel obstruction” in a 3-5 year old without obvious etiology is perforated without obvious etiology is perforated appendix until proven otherwiseappendix until proven otherwise

Fever > 101.5 (38.8CFever > 101.5 (38.8C ْْ), WBC > 20 with ), WBC > 20 with bands, diffuse abdominal pain, bands, diffuse abdominal pain, guarding.guarding.

Incarcerated Inguinal HerniaIncarcerated Inguinal Hernia

INTUSSUSCEPTIONINTUSSUSCEPTION

Inversion of the bowel upon itself Inversion of the bowel upon itself secondary to a leading pointsecondary to a leading point

Juvenile Intussusception most Juvenile Intussusception most often idiopathicoften idiopathic Also secondary to Meckel"s Also secondary to Meckel"s

diverticulumdiverticulum Presents 6 months to 2 years of Presents 6 months to 2 years of

ageage As early as 1 monthAs early as 1 month

INTUSSUSCEPTIONINTUSSUSCEPTION

Acute painful episodes followed Acute painful episodes followed by periods of lethargyby periods of lethargy

When incarcerated progress to When incarcerated progress to continuous lethargycontinuous lethargy

May or may not have “currant-May or may not have “currant-jelly” stooljelly” stool But often stool is heme positiveBut often stool is heme positive

Rule out with a left lateral Rule out with a left lateral Decubitus filmDecubitus film

Bad IntussusceptionBad Intussusception

IntussusceptionIntussusception

VOLVULUSVOLVULUS

Malrotation most common condition Malrotation most common condition resulting in Midgut Volvulusresulting in Midgut Volvulus

Can have Volvulus with normal Can have Volvulus with normal rotationrotation Omphalomesenteric remnantOmphalomesenteric remnant Internal herniaInternal hernia DuplicationDuplication Adhesive small bowel obstructionAdhesive small bowel obstruction

MALROTATIONMALROTATION Most often presents during the Most often presents during the

first few months of lifefirst few months of life Infant with acute onset of bilious Infant with acute onset of bilious

emesisemesis May be diagnosed on UGI for May be diagnosed on UGI for

other reasonsother reasons Malrotation is a surgical urgency Malrotation is a surgical urgency

due to the possibility of Volvulusdue to the possibility of Volvulus VOLVULUS IS A SURGICAL VOLVULUS IS A SURGICAL

EMERGENCYEMERGENCY

MALROTATIONMALROTATION

Normal

HIRSCHSPRUNG’S DISEASE HIRSCHSPRUNG’S DISEASE (CONGENITAL MEGACOLON)(CONGENITAL MEGACOLON)

Male to Female = 9 : 1Male to Female = 9 : 1 Delayed passage of meconium.Delayed passage of meconium. Progressive abdominal distention.Progressive abdominal distention. Colonic obstruction which needs Colonic obstruction which needs

urgent colostomyurgent colostomy Chronic constipation.Chronic constipation. Poor growth and development.Poor growth and development. P/R examination--- painless, gush P/R examination--- painless, gush

stool or empty rectum.stool or empty rectum.

Hirschsprung's Hirschsprung's DiseaseDisease

((Congenital Congenital MegacolonMegacolon))

Hirschsprung’s DiseaseHirschsprung’s Disease

Barium EnemaBarium Enema

TreatmentTreatmentColostomyColostomy

Imperforate Anus: Anal Imperforate Anus: Anal atresiaatresia

ATRESIASATRESIAS EsophagealEsophageal:: aspirate feeds aspirate feeds

immediately, OG tube won’t pass immediately, OG tube won’t pass (non-bilious, but still bad)(non-bilious, but still bad)

DuodenalDuodenal:: bilious vomiting bilious vomiting immediately, “double bubble” on KUB immediately, “double bubble” on KUB with absence of distal gas.with absence of distal gas.

Jejunal:Jejunal: usually present 1usually present 1stst 24 24 hours, large dilated proximal hours, large dilated proximal loop or loopsloop or loops

ATRESIASATRESIAS Ileal:Ileal: may take 24-48 hours before may take 24-48 hours before

bilious emesisbilious emesis

ColonicColonic: rare, may present with : rare, may present with bilious emesis after 2-3 daysbilious emesis after 2-3 days

Anal:Anal: should be diagnosed at birth, should be diagnosed at birth, often a perineal fistula is labeled often a perineal fistula is labeled normalnormal

JEJUNAL ATRESIAJEJUNAL ATRESIA


TREATMENTTREATMENT INTESTINAL ADHESIONSINTESTINAL ADHESIONS are treated by are treated by

surgical lyses of the obstructing bands if the surgical lyses of the obstructing bands if the obstruction does not resolve in several daysobstruction does not resolve in several days..

HERNIASHERNIAS are treated by a reduction of the are treated by a reduction of the contents of the hernia and subsequent contents of the hernia and subsequent repairrepair. . The bowel must always be examined The bowel must always be examined for necrosisfor necrosis..

INTESTINAL TUMORSINTESTINAL TUMORS are treated by are treated by surgical removalsurgical removal..

TREATMENT OF INTRINSIC AND TREATMENT OF INTRINSIC AND EXTRINSICEXTRINSIC lesions depend on the lesion lesions depend on the lesion..

FUNCTIONAL OBSTRUCTIONSFUNCTIONAL OBSTRUCTIONS are blockages in the intestinal flow are blockages in the intestinal flow that result from impaired motility that result from impaired motility (paralytic(paralytic oror adynamic ileus)adynamic ileus)..

- Direct irritation of the intestineDirect irritation of the intestine- - Extra peritoneal causesExtra peritoneal causes, , such as such as

retroperitoneal hematoma or nerve root retroperitoneal hematoma or nerve root compressioncompression. . Retroperitoneal Retroperitoneal dissections, such as a nephrectomy or dissections, such as a nephrectomy or sympathectomy, can cause a prolonged sympathectomy, can cause a prolonged ileusileus..

intestinal obstruction mostafa abou ali professor of surgery suez canal university

Documents

chronic obstruction

intestinal tumors

functional obstruction

strangulating obstruction

common cause of obstruction

impaired intestinal

common types common

common area of perforation