I.o CME

1. Management of
Intestinal Obstruction
By : Lailatul Hidayah Binti Shamsul Bahri
Jacqline Charles Labo
Supervisor :
Dr Chong HC

2. Content
• Introduction
• Classification
• Pathophysiology
• Clinical presentation
• Investigation
• Management
• Scenario

3. Introduction
Bowel obstruction: the
interruption of normal passage
through the bowel
• Mechanical bowel obstruction:
the interruption of normal
passage through the bowel due
to a structural barrier
• Paralytic ileus: temporary
functional impairment
of peristalsis
According to the site of obstruction
can be classified as:
• Large bowel obstruction (LBO):
cecum, colon, rectum
• Small bowel obstruction (SBO):
duodenum, jejunum and ileum
• Gastric outlet obstruction (GOO):
pyloric channel

4. Classifications
(According to the nature of the obstruction)
1. Partial (incomplete) bowel obstruction
2. Complete bowel obstruction
3. Simple bowel obstruction
4. Complicated bowel obstruction
5. Combined terms

5. Pathophysiology

6. Clinical presentation
Clinical feature SBO LBO
Abdominal pain Colicky, periumbilical Colicky or constant
Vomiting and nausea Early onset
Larger volume of
vomit than LBO
Bilious
Late onset
Initially bilious
Progresses to fecal
vomiting
Constipation or
obstipation
Late onset in proximal
SBO
Early onset in distal
LBO
Abdominal distension Typically less severe
than LBO
Early and significant
abdominal distension
Examination findings Dehydration and possible hypovolemia
(hypotension, dry mucous membrane)
Diffuse abdominal tenderness
Tympanic percussion
Increased high-pitched bowel sounds (early) or
absence of bowel sounds (late)
Collapsed, empty rectum or PR (complete
bowel obs) or impacted stool
Cardinal signs
• Abdominal pain
• Vomiting
• Constipation
• Abdominal distention
• Decreased bowel sounds

7. INVESTIGATION
1. FBC
2. Arterial blood gas (ABG) + Lactate
3. Electrolytes
4. Urea, Creatinine
5. CRP
6. Serum lipase / amylase
7. Glucose Level
LABORATORY

8. INVESTIGATION
• Initial diagnostic study
• Diagnostic of bowel obstruction in 50-80%
• Basic radiological examination :
 Upright chest film
 Upright and supine abdominal films
• DoLateralDecubitusAbdominalfilm→freeairand/orair- fluid
levels.
RADIOLOGICAL
Always request : Supine, Erect and CXR

9. The Difference between small and large bowel
obstruction
Small Bowel
•Central ( diameter > 3 cm )
•Vulvulae coniventae
•Ileum: may appear tubeless
Large bowel
•Peripheral ( diameter >5- 9 cm )
•Presence of haustration

17. INVESTIGATION
Recommended :
• H/O of recurrent obstruction / nonresolving partial SBO
• Partial vs Complete obstruction
• site, degree and often the cause of obstruction.
• A retrograde contrast study for suspected LBO
RADIOLOGICAL
Contrast studies

19. INVESTIGATION
• Specificity and sensitivity > 90% complete obstruction, less for partial
• Used with iv contrast, oral and rectal contrast (triple contrast).
• demonstrate abnormality in the bowel wall, mesentery, mesenteric
vessels and peritoneum.
• Indicated especially when abdominal films are nonspecific or when
strangulation is suspected
RADIOLOGICAL
CT-SCAN

21. TREATMENT
1. Initial Supportive Care
a) IV fluids and electrolytes resuscitation for all
b) NG tube if repeated vomiting
c) Antibiotics for all
d) Analgesia
-Morphine sulfate: 5-10 mg SC/IV/IM every 4 hours initially
-Refer to the acute pain team if intolerable
e). Emergency surgery
- Formation of a stoma
- Anastomosis
Restore faecal stream flow
Remove obstructing lesion

22. Operative Management
• Evidence of a complicated obstruction
• Develop free air or signs of a closed-loop obstruction
• CT shows ischemia, strangulation, or vascular compromise
 Hernia –> Operation
 Adhesions –> Conservative first
 Obstruction –> Remove
 Volvulus –> Derotate and/or operate
 Mesenteric ischemia –> Operate
 Abscess or peritonitis –> Drain and treat
 Intussusception –> Pneumatic or barium reduction or operate

23. 1. Right hemicolectomy
2. Subtotal/total colectomy
3. Hartmann’s procedure

25. CASE DISCUSSION
A 52-year-old female with no past medical or surgical history presented to our
emergency room with two days history of abdominal pain, nausea, vomiting and
obstipation.

26. QUESTIONS
1. What further history should we ask ?
2. What findings expected in examination ?
3. What findings expected in investigation (laboratory & imaging) ?
4. Management for the patient ?

27. • O/E :
PA : Distended abdomen
Discomfort on deep palpation
No peritoneal signs.
Blood Ix :
WBC was mildly elevated and low potassium was replaced.
CT : Concerning for small bowel obstruction

28. Figure 1: CT scan abdomen.
Consistent with small bowel obstruction. Distended small bowel loop (Red arrow).

29. The patient was admitted to the hospital and
small bowel follow-through the following
day revealed moderate distention of the
stomach, multiple distended small bowel
loops and no evidence of contrast in the
cecum at 14 hours consistent with small
bowel obstruction (Figure 2)
Figure 2: Small bowel follow-through.
Distended stomach (Red Arrow).
Distended small bowel (Blue arrow).

30. The patient was taken to the operating room, and
exploratory laparotomy with retrieval of a foreign
body via an enterotomy was performed (Figure
3).
Figure 3: Exploratory laparotomy.
Enterotomy (Blue Arrow).
Pineapple core (Red Arrow).

31. The patient recalled ingesting pineapple core as a source of fiber the day prior to
her symptoms. She did well and was discharged from the hospital.

32. DISCUSSION
Small bowel obstruction (SBO) etiology in developed countries
includes adhesions (74%), Crohn's disease (7%), neoplasia (5%), hernia (2%),
radiation (1%), and miscellaneous (11%). In contrast, developing countries
etiology includes adhesions (34%), hernia (16%), malignancy (13.5%) and
tuberculous stricture (10%) [4].
In the pediatric population foreign body ingestion is a known cause of
abdominal pain, most of which will pass spontaneously and less than 1% will
require surgical removal. Acute intestinal obstruction due to foreign bodies is
rare in adults. Small bowel foreign bodies can cause obstruction, perforation
and bleeding.
Most patients can be managed conservatively or with endoscopic
retrieval and only a small minority will require surgery. Pineapple core known
to have high fiber content led to intestinal obstruction in our patient.

33. CONCLUSION
Patients' presentation after foreign body ingestion is usually
straightforward but on occasions can be extremely subtle. Pineapple core is a
good source of fiber, however, the ingestion of large undigested pieces led to
an intestinal obstruction in our patient

34. References
• UpToDate : Etiologies, clinical manifestation and diagnosis of small
small bowel obstruction in adults
• UpToDate : Management of small bowel obstruction
• BMJ : Small bowel obstruction
Large Bowel Obstruction
• Medscape : Small bowel obstruction treatment and management
• Bailey and Love 27th Edition : Large Bowel Obstruction
• Case report
https://www.cureus.com/articles/18510-small-bowel-obstruction-in-a-virgin-abdomen-a-case-report
THANK YOU.