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Intestinal obstruction

Intestinal obstruction . Discussion for final year mbbs undergraduates

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Intestinal obstruction

  1. 1. INTESTINAL OBSTRUCTION
  2. 2. CLASSIFICATION DYNAMIC  Peristalsis working against a mechanical obstruction ADYNAMIC  No mechanical obstruction  No peristalsis
  3. 3. Causes DYNAMIC INTRALUMINAL  Fecal impaction  Foreignbody  Bezoars  Gall stone INTRAMURAL  Stricture  Malignancy  Intususception  Volvulus EXTRAMURAL  Bands of adhesion  hernia ADYNAMIC  Paralytic ileus  Pseudo obstruction
  4. 4. Pathophysiology  Bowel proximal to obstruction dilates ↓ Distal bowel - normal peristalsis & absorption→later empty &collapses  Initially proximal peristalsis increased→later reduction in peristaltic strength ↓ flaccidity and paralysis Proximal distention is caused by 1. gas 2.fluid
  5. 5. gas  Significant overgrowth of both aerobic and anaerobic bacteria  Reabsorption – oxygen & corbondioxide  Nitrogen and hydrogen sulphide fluid  24 hrs  Saliva -500ml, bile- 500ml ,pancreatic secretion - 500ml ,gastric secretion-1L  Accumulates & absorption –retarded Dehydration & electrolyte loss Reduced oral intake Defective absorption Vomiting Sequestration in the bowel lumen Transudation of fluid in to peritoneal cavity
  6. 6. Strangulation – Blood supply is compromised and the bowel becomes ischaemic  CAUSES DIRECT PRESSURE ON THE BOWEL WALL  Hernial orifices  Adhesions / Bands INTERRUPTED MESENTERIC BLOOD FLOW  Volvulus  Intussuseption INCREASED INTRALUMINAL PRESSURE  Closed loop obstruction
  7. 7. Closed loop obstruction  Bowel is obstructed at both the proximal and distal points  Malignant stricture of the colon with a competent ileocaecal valve ↓ Inability of distended colon to decompress itself in to the small bowel ↓ Increase in luminal pressure ↓ necrosis and perforation
  8. 8. Internal hernia  Portion of small intestine becomes entrapped in one of the retroperitoneal fossae or in a congenital mesenteric defect  SITES OF INTERNAL HERNIA  the foramen of winslow  a defect in the mesentery / transverse mesocolon/ broad ligament  congenital or acquired diaphragmatic hernia  Duodenal retro peritoneal fossae- left paraduodenal and right duodenojejunal  Caecal /appendiceal retroperitonel fossae- sup, inf, and retrocaecal  Intersigmoid fossa
  9. 9. Obstruction from enteric strictures  Small bowel – secondary to TB / Crohns disease  Subacute or chronic presentation  Mx- resection and anastomosis
  10. 10. Bolus obstruction  Gallstone  Food  Stercolith  Worms  Trychobezoars and phytobezoars
  11. 11. Gallstone ileus  60 cm proximal to ileo-caecal valve Rigler’s triad  Small bowel obstruction  Pneumobilia  Atypical metallic shadow on abdominal x ray
  12. 12. Trichobezoar  Usually seen in psychiatric patients  Ingestion of hair
  13. 13. phytobezaors  High fibre intake  Inadequate chewing  Previous gastric Sx  Hypochlorhydria  Loss of gastric pump mechanism
  14. 14. Stercoliths  Jejunal diverticulum and ileal stricture
  15. 15. Worms  Ascaris lumbricoids
  16. 16. Common causes of intra-abdominal adhesins Acute inflammation Sites of anastomoses, of raw areas, trauma, ischaemia Foreign material Talc ,starch ,gauze, silk infection Peritonitis, TB Chronic inflammatory condditions Crohn’s disease Radiation enteritis
  17. 17. Prevention of adhesions  Good surgical technigue  Washing of the peritonela cavity with saline to remove clots  Minimising contact with gauze  Covering anastomosis and raw peritoneal surfaces
  18. 18. Laproscopic technique  May reduce post op adhesins  Others  Hyaluronidase  Hydrocortisone  Silicone  Dextran  Polyvinylpropylene  Chondroitin  Streptomycin  Anticoagulants  Antihistamines  NSAIDS  Streptokinase
  19. 19. Bands  Usually only one band is culpable  Congenital, e.g. obliterated vitellointestinal duct;  A string band following previous bacterial peritonitis  A portion of greater omentum, usually adherent to the parietes
  20. 20. Acute intussusception  One portion of the gut invaginate in to an immediately adherent segment;  Almost invariably-proximal in to the distal  MC in children ( 5-10 months ; peak incidence)  Hyperplasia of Peyer’s patches in the terminal ileum  Weaning – loss of passively acquired maternal immunity  Common viral pathogens
  21. 21. Associated pathological lead points in children  Meckels diverticulum  Polyp  Duplication  HSP  Appendix
  22. 22. Lead points in adults  Polyp eg; Peutz jeghers syndrome  Submucosal lipoma  Other tumors
  23. 23. Pathology
  24. 24. 3 parts  The Entering or inner tube- intussusceotum  The returning or middle tube  The sheath or outer tube – intussuscipiens  The part that advances apex, the mass- intussusception and neck is the junction of entering layer with the mass
  25. 25. Volvulus  Twisting or axial rotation of a portion of bowel abouts its mesentery  Causes obstruction ( > 180 degree tortion)  If tight – vasocular occlusion in the mesentery( 360 degree)  Primary or secondary  May involve small intestine, caecum or sihmoid colon  Neonatal midgut volvulus sec to midgut malrotation is life threatening  Commonest spontaneous type in adult – SIGMOID  Sigmoid volvulus – relieved by decompression per anum  Surgery – to prevent or relieve ischaemia
  26. 26. Clinical features  Abdominal pain  Abdominal distention  Vomiting  Absolute constipation
  27. 27. classifications High small bowel Low small bowel Large bowel Simple strangulated Complete Incomplete
  28. 28. Intestinal obstruction with out constipation  Richter’s hernia  Gallstone ileus  Mesenteric vascular occlusion  Functional obstruction associated with pelvic abcess  Partial obstruction
  29. 29. Other manifestations  Dehydration  Hypokalaemia  Pyrexia  Abdominal tenderness
  30. 30. Pyrexia  Oncet of ischaemia  Intestinal perforation  Infalammation oe abcess associated with obstructive disease
  31. 31. Abdominal tenderness  Localised tenderness- impending ischaemia  Diffuse tenderness- perforation peritonitis
  32. 32. c/f; strangulation  Constant severe pain  Tenderness with rigidity and peritinism  Shock
  33. 33. c/f; intussusception  Redcurrant jelly stool  Sousage shaped lump  Empty right iliac fossa- sign of dance
  34. 34. c/f; sigmoid volvulus  Abdominal distention  constipation
  35. 35. investigations  Abdominal x ray – erect- ; multiple air fluid level  abdominal xray - supine ; jejunanum –conniventose ; ileum- featureless colon-haustral fold CECT ABDOMEN
  36. 36. IMAGING IN INTUSSUSCEPTION  Barium enema – claw sign  USG-DOUGHNUT APPEARANCE OF CONCENTRIC RINGS IN TRANSVRSE COLON  CT – target sign
  37. 37. X ray finding – volvulus  Coffee bean appearance
  38. 38. Treatment  Supportive management  Surgical management
  39. 39. Supportive management  NPO  RT- aspiration  IV - Fluids
  40. 40. Surgical management  INDICATION FOR EARLY SURGICAL INTERVENTION  Obstructed external hernia  Clinical features s/o strangulation  Obstruction in a ‘virgin’ abdomen
  41. 41.  In complete obstruction with out evidence of intestinal ischaemia, surgery may be deferred until the patient is fully resuscitated  In adhesive obstruction conservative management may be adviced for up to 72 hrs
  42. 42. Surgical interventions Laparotomy and assess  Site of obstruction  Nature of obstruction  Viability of the gut
  43. 43. Operative decomression  Retrograde milking of small bowel content to stomach  Savage’s decompresser with in a seromuscular purse string suture
  44. 44.  Adhesiolysis  Resection  Bypass  Proximal decompression
  45. 45. Treatment of adhesions  adheiolysis
  46. 46. Rx of recurrent intestinal obstructiom caused by adhesions  Noble’s plication  Child Philips transmesenteric plication  Intestinal intubation
  47. 47. Rx of intussusception  Non operative reduction- air or barium enema  CONTRA-INDICATIONS  Signs of perforation/ peritonitis  Known pathological lead point  Profound shock
  48. 48.  Surgery - when radiological reduction is failed or contra –indicated  Reduction- gently compressing the most distal part of the intussusception towards its origin  Resection and anastomosis- irreducible or one complicated by infarction or pathological lead point
  49. 49. Rx of acute large bowel obstruction  Emergency right hemicolectomy Removal of lesion in the caecum, ascending colon, hepatic flexure, proximal transverse colon If the lesion is irremovable – proximal stoma or ileo- transverse bypass
  50. 50.  For lesion in the left colon or recto sigmoid- resection should be done followed by a) anastomosis  b)paul mikulicz procedure  c)hartmann’s peocedure
  51. 51. Rx of sigmoid colon Sigmoidoscopy +insertion of flatus tube detortion of sigmoid and fixation to anterior abdominal wall sigmoidectomy

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