Intestinal Obstruction: Yohannes T
Intestinal Obstruction: Yohannes T
Intestinal Obstruction: Yohannes T
Yohannes T.
2014 G.C.
Outline
Definition
Classifications
Pathophysiology
Clinical manifestations
Physical Examination
Investigations
Management
Definition
Worms
Adynamic: peristalsis may be absent or it
may be present in non propulsive form like in
pseudo-obstruction
2 - Onset :
acute
chronic
3 - Site :
small bowel obstruction
large bowel obstruction
4 - Simple or Strangulated
Pathophysiology
4 - Distension:
the lower the site of obstruction
the more bowel there is available
to distend
Other manifestations
1 - Dehydration
2 - Electrolyte imbalance e.g. hypokalemia
3 - Fever
4 - symptoms and signs of peritonitis
X-Ray:
small bowel obstruction appear
with multiple air-fluid levels as
stepladder pattern
volvulae conniventae
o distended large bowel tends to lie peripherally
and to show the Haustrations
Ultrasound :
for intussusception
and describe nature of
a mass
CT scan :
usefull to detect :
lesions, tumors,...
Management of Intestinal Obstruction
General management of intestinal obstruction:
GI drainage - NG-tube
fluid and electrolyte replacement
relief of obstruction- e.g. rectal tube
surgical Rx is necessary for most cases of IO
Types of adhesions:
Early (fibrinous): may disappear in days 15
Late (Fibrous): usually happen after 07 days
Prevention of adhesions:
good surgical technique
washing of the peritoneal cavity with saline to
remove clots
minimising contact with gauze
covering anastomoses and raw peritoneal surfaces
Management
Early NG-tube insertion, resuscitation,...
Late usually surgery (release of obstructing band)
Volvulus
twisting or axial rotation of a portion of bowel
about its mesentry
Primary : occurs secondary to congenital malrotation of
the gut, abnormal mesenteric attachments or congenital
bands
Secondary: more common than primary, occurs due to
rotation of a piece of bowel around an acquired
adhesion or stoma
Volvulus is less common in small bowel than in
large bowel
Large bowel rotation may occur in two sites:
Cecum
clock-wise twist
Sigmoid
anticlockwise twist
more common
Dx: plain radiograph shows massive colonic
distension
Mx: decompression, resection and anastomosis
Adynamic
Paralytic ileus
Types:
postoperative: self limiting within 24-72 hours.
Infection
metabolic
reflex ileus
Presentaion:
abdominal distension
effortless vomiting.
on P/E tympanic abdomen, no return of bowel
sounds on auscultation
Management: preventive
N/G suction and restriction of oral intake.
maintenance of electrolyte imbalance.
specific Rx the primary cause must be
removed.
if Ileus is prolonged, a laparotomy should be done.
Acute mesenteric ischemia:
the superior mesenteric vessels are the visceral vessels
most likely to be affected by embolization and thrombosis,
which is more common.
occlusion at the origin of the SMA is almost invariably the
result of thrombosis
embolisation occurs usually at the origin of middle colic
artery.
Sources of embolization of (SMA):
Lt atrial fibrilation
mural MI
atheromatous plaque from aortic aneurysm.
mitral valve vegetation associated with endocarditis
Clinical features:
sudden severe abdominal pain out of proportion to
physical findings
persistent vomiting
abdominal tenderness at the beginning, and lately there
will be rigidity
Investigation:
Leucocytosis with high percentage of neutrophil
PT, PTT, INR, Doppler ultrasound, angiography
Management:
full resuscitation and embolectomy
revascularization of SMA in early diagnosed embolic
cases
References
Bailey and Loves: Short Practice of
Surgery, 25th ed