INTESTINAL

OBSTRUCTION
By
Luwasi N.
Afolabi T.
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 Outline

Introduction
Definition
Classification
Aetiology
 Clinical features
 Diagnosis (Radiological investigations)
Treatment
Conclusion

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 INTRODUCTION
Intestinal obstruction is one of the commonest cause of acute
abdomen world-wide. it is also known as bowel obstruction.

DEFINITION
Intestinal Obstruction is defined as partial or complete
blockage of the bowel that results in the failure of intestinal
contents (gas, food, or digestive juice) to pass through it.

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 ANATOMY
The gastrointestinal tract (GIT) involves structures from the
mouth to the anus and other accessory structures. Anatomically
the gastrointestinal tract is divided into
a. Upper GI tract involving structures from the mouth to
the major duodenal papillae .

b. Middle GI tract from the Major duodenal papillae to the

junction between the right 2/3 and left 1/3 of the transverse
colon .
c. The lower GI tract from the left 1/3 of transverse colon
to the anus

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 CLASSIFICATION
Based on the following:-
i. By the site of the obstruction in relation to the bowel
wall:
- In the lumen
- In the wall
- Outside the wall
ii. By the surgical pathology:
- Simple
- Strangulating
- Closed loop obstruction.
iii. By the site:
- Large or small bowel obstruction
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- High, middle or low bowel obstruction.
 CLASSIFICATION
iv, Bowel obstruction can also be can be categorized as either:
DYNAMIC (Mechanical)
it’s a structural type of obstruction in which there is
peristalsis working against an obstruction in an attempt to
overcome it. It is divided into
- upper Gastrointestinal/ small bowel obstruction
occurring in the upper and mid gut
- lower gastrointestinal/large bowel obstruction occurring in
the lower gut
ADYNAMIC (paralytic ileus) is a functional bowel
obstruction where there is no peristalsis due to intestinal atony
without any form of mechanical obstruction
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intestinal obstruction 5/2/2021 8
 Aetiology

Ileus:- One or more loops of bowel lose their ability to propagate the
peristaltic waves because of some local irritation or inflammatory
process.

Causes of ileus include:

 Post operative state
 Peritonitis
 Pancreatitis
 Appendicitis
 Cholesytitis
 Gastoenteritis
 Trauma
 Renal colic
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 Low potassium
 MECHANICAL OBSTRUCTION
Mechanical obstruction occurs when the lumen of the small
bowel is completely or partially occluded by an intrinsic or
extrinsic process.
Approximately 2/3 of these are small bowel in origin.
Causes:-
Congenital
 Atresia, stenosis, webs, bands
 Duplication cysts
 Internal hernia
 External hernia – umbilical, inguinal, femoral
 Malrotation / midgut volvulus
 Meconium ileus
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 Acquired causes.
 Impacted faeces
 Parasitic infestations – ascariasis
 Gallstone ileus
 Tumours
 Diverticulitis
 Crohn’s disease
 Radiation injury
 Adhesion
 Volvulus
 Strangulated hernia
 Intussusception
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 Clinical features

It usually presents with:-

 Abdominal Pain
 Vomiting
 Constipation
 Abdominal distension
 Other features can be based on the underlying cause.

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RADIOLOGICAL INVESTIGATIONS
 Plain radiograph
- chest x-ray ( if perforation is suspected)
- supine abdominal x-ray
- erect abdominal x-ray
 Computer tomography
 Contrast studies
 Ultra sound
 Magnetic resonance imaging (not usually done)

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 CHEST XRAY
 Erect chest x-ray is essential so as to rule out the presence of
pneumoperitonium from bowel perforation due to the
obstruction.
 It can detect up to 1ml of free air in the peritonium but the
patient has to be in the erect position for 3 minutes.

 Lateral decubitus position in patients unable to stand erect.

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 Frontal chest radiograph showing pneumoperitoneum
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 PLAIN ABDOMINAL RADIOGRAPH
The plain X-ray is very important in confirming the presence or
absence of intestinal obstruction. It is usually done in two
positions
a) Erect
b) supine

This two views are combined as they provided objective

assessment of air-fluid levels and free air in the abdominal cavity

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 PLAIN ABDOMINAL RADIOGRAPH

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 MECHANICAL OBSTRUCTION- SMALL
BOWEL

1. Multiple dilated loops ( >3cm) proximal to the

point of obstruction
2. Collapsed small bowel distal to the obstruction
3. Step-ladder appearance:- small bowel loops stack
on each other as they dilate. ( Usually from the
jejenum to the ileum).
4. Numerous Air-fluid level proximal to the
obstruction.
5. String of pearl sign and slit of air signs.
6. Little or no gas in the rectum.
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 SMALL BOWEL OBSTRUCTION FINDINGS
Small bowel obstruction accounts for over 80% of cases
a) Supine abdominal x-ray

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 Small bowel obstruction findings
b) Erect abdominal x-ray

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 Small bowel obstruction findings
c) Pseudotumour
 This is a finding that is seen in a gasless abdominal
obstruction.
 Bowels are completely filled with fluid.
 No Air fluid levels.

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Abdominal xray showing fluid filled bowel loops
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 SMALL BOWEL OBSTRUCTION

 Small bowel obstruction nearly filled with fluid.

 The bowel is nearly filled with fluid except for some small air
trapped within the Valvulae conniventes

In supine position it gives the stretch/slit sign

In erect position it gives the string of pearl sign

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 LARGE BOWEL OBSTRUCTION
It accounts for over 20% of cases. It shows prominent haustration
which are incomplete folding of the large bowel unlike the
complete ones in small bowel obstruction .

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 The large bowel signs depend on the competency of the
ileocaecal valve.

 Competent ileocaecal valve:- there is a danger of caecal

perforation due to ischaemia.
The critical diameter is 9cm (caecum).
Dilatation of the large bowel beyond this may indicate
immediate surgical intervention.

 Incompetent ileocaecal valve:- the small bowel will also

dilate with excess gas and the appearances look similar to
ileus.
 
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intestinal obstruction 5/2/2021 28
 SBO VS LBO
Small Bowel (SB) Large Bowel(LB)
Valvulae present absent
conniventes
Haustra absent present
Diameter 3 - 5cms . Over 5cm

Radius of smaller radius of larger radius of

curvature curvature curvature

Solid faeces absent present

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 FUNCTIONAL ILEUS - LOCALIZED

1. Persistently dilated loops- Sentinel loops

( same loops are dilated in different views:-
erect, supine).
2. Dilated loops > 3cm
3. Air-fluid levels
4. Gas in the rectum/sigmoid

Site:- usually small bowel

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 FUNCTIONAL ILEUS- LOCALIZED

Abdominal xray showing sentinel loops in both supine and prone

views
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 FUNCTIONAL ILEUS- GENERALIZED

1. Dilation of the entire bowel is seen

2. Air-fluid levels ( many)
3. Gas in the rectum/ sigmoid

Sites:- large and small bowel

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 FUNCTIONAL ILEUS- GENERALIZED

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O Overall, plain films are diagnostic in 50-60%, equivocal in 20-
30% and misleading in 10-20%.

O When plain films findings are unequivocal in complete or high

grade obstruction, further imaging modalities will be required.

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 Contrast studies

Contrast studies are required when:-

 Plain film finding are equivocal or normal, but clinical

features remain or are intermittent in suspected partial or
chronic small bowel obstruction, the patient may undergo
contrast studies or Computed Tomography.

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 Contrast enhanced coned down view abdominal xray
showing
intestinal large bowel obstruction.
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 ENTEROCLYSIS

 This is the use of a contrast agent administered through the NG

tube or by (small bowel enema) using fluoroscopy, can be
performed.

 It may be preferred to oral barium for small bowel studies

because of reduced transit time and better luminal distension.

 It is useful in determining the presence of obstruction and

differentiating partial from complete obstruction. The imaging
modality could be CT to give better resolution

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 Barium meal/follow through and barium enema

O These are the traditional contrast study of small and large

bowels respectively and are relevant in our environment.

O Barium suspensions are contradicted when intestinal

perforation is possible, when immediate surgery is highly
likely (due to the risk of peritoneal spillage) or in rare cases of
allergy.

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 Computed tomography scan( CT)
O CT is advantageous because the entire small and large bowels
are rapidly assessed (as opposed to contrast studies) and
dilatation is easily diagnosed.

O A transition point of abrupt change in caliber can be

identified as the site of obstruction.
O A mass can be seen at the transition point if the obstruction is
due to a tumour.
O Extraluminal air can also be appreciated in cases of
perforation.
O Intravenous and oral contrast enhancement can be applied

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 Ultrasound scanning
 It is readily available.
 It is be useful in cases of high grade obstruction,
intussusception, tumours and complications of bowel
perforation.

Features observed:-
 Fluid filled and oedematous/thickened bowel loops can be
seen.
 Bowel paralysis can be observed ( absent peristalsis)
 Decreased peristalsis
 For small bowel obstruction the plicae circularis (keyboard
sign) can
intestinal be seen.
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 Ultrasound scanning

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 Magnetic Resonance Imaging
(MRI) has fared less well than CT in the imaging of bowel
obstruction.
 This is because of their poorer spatial resolution.

 Also longer acquisition times has seriously hampered depiction of

the intestines because of artefacts from peristalsis.

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 TREATMENT
Principles involve:-

 Instituting gastrointestinal drainage

 Restoring fluid and electrolyte balance
 Treating the underlying cause
 Instituting conservative and or operative
management

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 CONCLUSION
Radiological investigations are very vital in
the diagnosis, and subsequently management of
intestinal obstruction
Hence the importance of having a good grasp of
the normal and pathologic features cannot be
overemphasized.

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 THANK YOU FOR LISTENING

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 REFERENCES
 Learning Radiology by William Herring
 Class lecture notes
 Principles of surgery by BADOE
 www.radiopedia.org

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