SlideShare une entreprise Scribd logo
1  sur  6
Télécharger pour lire hors ligne
bbinyunus2002@gmail.com Page 1
ADHESIVE INTESTINAL OBSTRUCTION. WHAT A RESIDENT SHOULD KNOW.
DR BASHIR BIN YUNUS
OUTLINE
 INTRODUCTION
 PATHOPHYSIOLOGY
 CLINICAL FEATURES
 MANAGEMENT
 PREVENTION OF ADHESIONS
 PERITONEAL ADHESION INDEX
 CONCLUSION
INTRODUCTION
Intra-abdominal adhesions are the most common cause of small bowel obstruction (SBO) in
industrialised countries, accounting for approximately 65-75% of cases. Estimated risk of SBO;
Appendectomy 1-10%, cholecytectomy 6.4%, intestinal surgery 10-25%, restorative proctocolectomy
17-25%. There is a changing trend in causes of intestinal obstruction in semi-urban Nigerian
hospitals; adhesive obstruction is the commonest cause. Obstructed hernia becoming increasingly less
common.
Causes;
1. Post operative in most cases
2. Post inflammatory with or without operation; peritonitis, appendicitis, acute pelvic infection.
3. Foreign body; materials used during surgery- sutures, gauze, talc powder from gloves
4. Bowel ischemia
5. Radiation induced enteritis
6. Inflammatory bowel disease
7. Specific conditions like tuberculosis, malignancy
Types;
1. Type 1; fibrinous adhesion occur during 5-10th
post surgical period. It usually get resolve
completely. It is avascular and flimsy.
2. Type 2; fibrous adhesion. Becomes collagenised and vascularised
PATHOPHYSIOLOGY
The peritoneal fluid contains inflammatory cells including leucocytes and macrophages. These cells,
along with the mesothelium secrete various cellular mediators that have roles in peritoneal healing.
Following peritoneal injury, there is bleeding and increase vascular permeability with leakage of
protein rich fluid (esp. fibrinogen) from injured surface.
The inflammatory cells release pro-inflammatory cytokines and activation of the complement and
coagulation cascade. Activation of the coagulation cascade results in formation of thrombin, which is
necessary for the conversion of fibrinogen to fibrin. Fibrin functions to restore injured tissue and once
generated, is deposited along peritoneal surfaces. It causes adjacent organs or injured serosal surfaces
to coalesce.
bbinyunus2002@gmail.com Page 2
Under normal circumstance, degradation of this filmy fibrous adhesion by locally released proteases
of the fibrinolytic system occurs with 72hours of injury. The fibrinolysis allows mesothelial cells to
proliferate and the peritoneal defects to be restored within 4 to 5 days, preventing the permanent
attachment of adjacent surfaces.
If fibrinolysis does not occur within 5-7 days, or if local fibrinolytic activity is reduced, the fibrin
matrix persists. The matrix gradually becomes organized as collagen-secreting fibroblast infiltrate the
matrix. Over time, it becomes cellular structure that contains arterioles, venules, capillaries and nerve
fibres.
In the body systems, there is maintenance of balance between the Activators and inhibitors of
fibrinolysis.
Activators;
 Tissue plasminogen activator( tPA)- most important
 Urokinase- like plasminogen activator uPA
They activate plasminogen to plasmin which in turn degrades extracellular matrix including fibrin.
Inhibitors;
 Plasminogen activator inhibitors ( PAI). PAI-1 (dominant) and PAI-2
PAI prevents the formation of plasmin bydirectly binding to and inhibiting tPA and uPA.
Under normal conditions, fibrinolytic capacity exceeds coagulation in the peritoneum. However,
conditions causing peritoneal injury depress the fibrinolytic capacity. Cytokines especially TGF-B
release contributes to a decrease in peritoneal fibrinolytic capacity and may have role in preventing
the early dissolution of fibrous adhesions.
CLINICAL FEATURES
1. Abdominal pain: colicky type, recurrent and episodic (commonest symptom)
2. Distension , vomiting
3. Constipation
4. Previous surgical scars commonly observed.
NB:
 Gilroy Bevan triad of adhesive pain;
o Pain gets aggravated or relieved on change of posture
o Pain in the region of old abdominal scar
o Tenderness is elicited by pressure over the scar
 Presents with features of obstruction initially and later features of strangulation-toxicity,
fever, tachycardia, guarding, rigidity and rebound tenderness may occur.
 Adhesions may be asymptomatic for many years but later become symptomatic.
bbinyunus2002@gmail.com Page 3
INVESTIGATIONS
1. Plain Xray abdomen shows dilated bowel loops (investigation of choice)
2. Contrast enhanced CT scan; features of strangulation;
a. Intramesenteric fluid
b. Mesenteric oedema, congestion
c. Bowel wall thickening more than 2mm
d. Reduce mural enhancement in strangulated bowel compared to adjacent
bowel.
e. Whirl sign. Small bowel volvulus
3. E/U,Cr, FBC, Blood grouping.
MANAGEMENT
Expectant management
1) IV fluid
2) N-G tube
3) IV antibiotics
4) Urethral catheter
5) An enema saponis or use of flatus tube insertion may be considered
6) Observation
a) Half-hourly pulse and blood pressure
b) Four-hourly measurement of abdominal girth
c) N-G tube drainage- amount and colour
d) Passage or otherwise of flatus
e) Persistence or otherwise of pain
f) Presence or otherwise of abdominal tenderness or rebound tenderness
Reasons to abandon expectant management for laparotomy;
I. A rising pulse rate and or falling BP. Indicative of worsening of general condition
II. Increasing girth suggestive of increasing distension of gut
III. Persistence of abdominal pain indicative of continuing obstruction
IV. Increasing amount of N-G tube aspiration or change in colour from clear or bilous to brown.
Suggestive of worsening of obstruction
V. Tenderness, rebound tenderness and or guarding or rigidity or palpable tender mass denoting
onset of strangulation.
Duration for non-operative management;
Some surgeons advocate operative intervention in any patient who fails to show improvement within
48 hours. Others advocate a more liberal use of nonoperative therapy, citing a mean time to
successful resolution of up to 4.6 days.
However, prompt operative intervention is mandatory in patient who develop signs and symptoms
suggestive of strangulation obstruction. These parameters include fever, tachycardia, leukocytosis,
localized tenderness, continuous abdominal pain and peritonitis.
The presence of any three of these signs has 82% predictive value for strangulation, presence of four
has near 100% predictive value for strangulation.
bbinyunus2002@gmail.com Page 4
Operative management
ADHESIOLYSIS;
 Open
 Laparoscopic: is becoming popular, safer, ideal with less recurrent adhesion rate and gives
good results
NB; laparotomy can predispose to more subsequent adhesions.
Approach; At laparotomy, safe entrance may be best achieved by approaching this from the extreme
of the previous incision at virgin area rather than going through the mid portion of the incision.
Once in the peritoneal cavity, first is to identify site and cause of obstruction. Release fibrous
adhesions with sharp dissection. Inspect bowel for viability non-viable bowel should be resected.
Explore all four quadrants look for bowel injury or nonviable segments.
NOBLE’S PLICATION OF INTESTINE;
In noble placation of the intestine, adjacent coils of small intestine, arranged parallel are sutured at the
antimesenteric ends to prevent in-going for further recurrent adhesion. The bowel is initially freed
from the DJ junction to the ileocecal junction. Placation starts from above. Done for recurrent
adhesions.
CHILDS-PHILLIPS MESENTERIC PLICATION;
Similarly, after freeing the bowel from adhesions from DJ junction to the ileocecal junction, the
mesentry is plicated 2-3cm from the bowel. It prevents crumpling of bowel and adhesion formation.
PREVENTION OF ADHESIONS
1. Gentle handling of bowel
2. Use gloves free of talc
3. Prevention of spillage of content of viscous
4. Ensure meticulous hemostasis
5. Copious lavage of abdomen with saline, get rid of cloths before closure.
6. Careful placement of drain
7. Pulling omentum over bowel before closure to prevent adhesion of bowel to laparotomy scare
8. Instillation of drugs;
a. Hyaluronidase
b. Dextran 70
c. Amniotic membrane
d. Streptokinase
e. recombinant tPA
f. steroids
9. laparoscopic procedure
To this day, there is no means of completely preventing post-operative adhesion formation.
bbinyunus2002@gmail.com Page 5
PERITONEAL ADHESION INDEX
This is a classification system for adhesion to standardize their definition. It is based on the
macroscopic appearance of adhesions and their extent to the different region of the abdomen. The
surgeon can assign the index ranging from 1-30, there by giving the precise description of the intra
abdominal condition.
Regions of the abdomen;
 Right upper
 Epigastrium
 Left upper
 Left flank
 Left lower
 Pelvis
 Right flank
 Central
 Bowel to bowel
Adhesion grade score;
0 – no adhesion
1 – filmy adhesion, blunt dissection
2 – strong adhesions, sharp dissection
3 – very strong vascularised adhesion, sharp dissection, damage hardly preventable.
PAI is then estimated by computing the adhesion grade score for each of the regions. It ranges
from 1-30
A standardized classification and quantification of adhesion allows more integration of results from
several studies and comprehensive approach to the management.
COMPLICATIONS OF ADHESIONS
 Intestinal obstruction
 Secondary female infertility
 Ectopic gestation
 Chronic abominal and pelvic pain
bbinyunus2002@gmail.com Page 6
REFERENCES
1. Attad JP, MacLean AR. Adhesive small bowel obstruction: epidemiology, biology and
prevention. Can J Surg 2007, 50:4 p 291-300
2. Coccolilni et al. Peritoneal adhesion index(PAI): proposal of a score for the ignored
iceberg of medicine and surgery. World journal of emergency surgery 2013,8:6 p3-5.
3. McGregor AL. Treatment of chronic adhesive obstruction by noble procedure. S A Med
J 1956, 30:9 p937-941
4. Guido M S et al. Small bowel obstruction. In: Maingot’s Abdominal operation. 12th
ed.,
McGrawHill; 2013. 600-607
5. SRB manual of surgery. 5th
ed.,Jaypee Brothers; 2016.p934-936.
6. Naaeder SB, Tandoh JFK. Acute intestinal obstruction.In: BAJA’s principles and
practice of surgery including pathology in the tropics. 5th
ed., Repro India Ltd; 2015.
601p

Contenu connexe

Tendances

Abdominal hernias by dr. nitin
Abdominal hernias by dr. nitinAbdominal hernias by dr. nitin
Abdominal hernias by dr. nitin
9841258238
 

Tendances (20)

Management of Appendicular Lump
Management of Appendicular LumpManagement of Appendicular Lump
Management of Appendicular Lump
 
Sigmoid volvulus/ Generalised abdominal pain
Sigmoid volvulus/  Generalised abdominal painSigmoid volvulus/  Generalised abdominal pain
Sigmoid volvulus/ Generalised abdominal pain
 
Penetrating Abdominal Trauma Emergency Management
Penetrating Abdominal Trauma Emergency ManagementPenetrating Abdominal Trauma Emergency Management
Penetrating Abdominal Trauma Emergency Management
 
WOUND DEHISCENCE
WOUND DEHISCENCEWOUND DEHISCENCE
WOUND DEHISCENCE
 
Acute limb ischemia
Acute limb ischemiaAcute limb ischemia
Acute limb ischemia
 
Abdominal trauma
Abdominal traumaAbdominal trauma
Abdominal trauma
 
Abdominal hernias by dr. nitin
Abdominal hernias by dr. nitinAbdominal hernias by dr. nitin
Abdominal hernias by dr. nitin
 
Open inguinal hernia repair / operative surgery
Open inguinal hernia repair / operative surgeryOpen inguinal hernia repair / operative surgery
Open inguinal hernia repair / operative surgery
 
Right hemicolectomy
Right hemicolectomyRight hemicolectomy
Right hemicolectomy
 
Principles of bowel anastomosis
Principles of bowel  anastomosisPrinciples of bowel  anastomosis
Principles of bowel anastomosis
 
Obstructive jaundice
Obstructive jaundiceObstructive jaundice
Obstructive jaundice
 
Splenic trauma
Splenic traumaSplenic trauma
Splenic trauma
 
Splenectomy
SplenectomySplenectomy
Splenectomy
 
Pancreatic Trauma
Pancreatic TraumaPancreatic Trauma
Pancreatic Trauma
 
Management of intestinal obstruction
Management of intestinal obstructionManagement of intestinal obstruction
Management of intestinal obstruction
 
Inguinal hernia repair
Inguinal hernia repairInguinal hernia repair
Inguinal hernia repair
 
Acute appendicitis &lump
Acute appendicitis &lumpAcute appendicitis &lump
Acute appendicitis &lump
 
Paralytic ileus
Paralytic ileusParalytic ileus
Paralytic ileus
 
Femoral hernia - Groin swellings
Femoral hernia - Groin swellingsFemoral hernia - Groin swellings
Femoral hernia - Groin swellings
 
Damage control surgery
Damage control surgeryDamage control surgery
Damage control surgery
 

Similaire à Adhesive intestinal obstruction

Enterocutaneous fistulas ppt
Enterocutaneous fistulas pptEnterocutaneous fistulas ppt
Enterocutaneous fistulas ppt
Prabha Om
 
Enterocutaneous fistulas ppt
Enterocutaneous fistulas pptEnterocutaneous fistulas ppt
Enterocutaneous fistulas ppt
Prabha Om
 
Git j club gastric polyps.
Git j club gastric polyps.Git j club gastric polyps.
Git j club gastric polyps.
Shaikhani.
 
Neonatal Necrotizing Enterocolitis
Neonatal Necrotizing EnterocolitisNeonatal Necrotizing Enterocolitis
Neonatal Necrotizing Enterocolitis
sumona keya
 
Neonatal Necrotizing Enterocolitis
Neonatal Necrotizing EnterocolitisNeonatal Necrotizing Enterocolitis
Neonatal Necrotizing Enterocolitis
sumona keya
 
Pelvic gynecology intervention, complications and significance of teamwork co...
Pelvic gynecology intervention, complications and significance of teamwork co...Pelvic gynecology intervention, complications and significance of teamwork co...
Pelvic gynecology intervention, complications and significance of teamwork co...
Rustem Celami
 

Similaire à Adhesive intestinal obstruction (20)

Enterocutaneous fistula
Enterocutaneous fistulaEnterocutaneous fistula
Enterocutaneous fistula
 
Surgical Complications
Surgical ComplicationsSurgical Complications
Surgical Complications
 
Enterocutaneous fistulas ppt
Enterocutaneous fistulas pptEnterocutaneous fistulas ppt
Enterocutaneous fistulas ppt
 
Enterocutaneous fistulas ppt
Enterocutaneous fistulas pptEnterocutaneous fistulas ppt
Enterocutaneous fistulas ppt
 
Bowel endometriosis: a surgical red flag
Bowel endometriosis: a surgical red flagBowel endometriosis: a surgical red flag
Bowel endometriosis: a surgical red flag
 
Enterocutaneous Fistula (general surg).pptx
Enterocutaneous Fistula (general surg).pptxEnterocutaneous Fistula (general surg).pptx
Enterocutaneous Fistula (general surg).pptx
 
Pedunculated Lipoma of the Caecum Causing Colocolic Intussusception in an Adult
Pedunculated Lipoma of the Caecum Causing Colocolic Intussusception in an AdultPedunculated Lipoma of the Caecum Causing Colocolic Intussusception in an Adult
Pedunculated Lipoma of the Caecum Causing Colocolic Intussusception in an Adult
 
Git j club gastric polyps.
Git j club gastric polyps.Git j club gastric polyps.
Git j club gastric polyps.
 
Enterocutaneous fistulas
Enterocutaneous fistulasEnterocutaneous fistulas
Enterocutaneous fistulas
 
Enterocutaneous fistulas
Enterocutaneous fistulasEnterocutaneous fistulas
Enterocutaneous fistulas
 
Intussusception
IntussusceptionIntussusception
Intussusception
 
inflammatory bowel diseases, what`s new ?
inflammatory bowel diseases, what`s new ?inflammatory bowel diseases, what`s new ?
inflammatory bowel diseases, what`s new ?
 
Abdominal Problems In Children
Abdominal Problems In ChildrenAbdominal Problems In Children
Abdominal Problems In Children
 
Intussusception in adults
Intussusception in adultsIntussusception in adults
Intussusception in adults
 
Neonatal Necrotizing Enterocolitis
Neonatal Necrotizing EnterocolitisNeonatal Necrotizing Enterocolitis
Neonatal Necrotizing Enterocolitis
 
Neonatal Necrotizing Enterocolitis
Neonatal Necrotizing EnterocolitisNeonatal Necrotizing Enterocolitis
Neonatal Necrotizing Enterocolitis
 
Pelvic gynecology intervention, complications and significance of teamwork co...
Pelvic gynecology intervention, complications and significance of teamwork co...Pelvic gynecology intervention, complications and significance of teamwork co...
Pelvic gynecology intervention, complications and significance of teamwork co...
 
inflammatoryboweldisease-170427143138.pdf
inflammatoryboweldisease-170427143138.pdfinflammatoryboweldisease-170427143138.pdf
inflammatoryboweldisease-170427143138.pdf
 
Inflammatory bowel disease
Inflammatory bowel diseaseInflammatory bowel disease
Inflammatory bowel disease
 
ENTEROCUTANEOUS FISTULA
ENTEROCUTANEOUS FISTULAENTEROCUTANEOUS FISTULA
ENTEROCUTANEOUS FISTULA
 

Plus de Bashir BnYunus

Plus de Bashir BnYunus (20)

MALIGNANT BOWEL OBSTRUCTION.pdf
MALIGNANT BOWEL OBSTRUCTION.pdfMALIGNANT BOWEL OBSTRUCTION.pdf
MALIGNANT BOWEL OBSTRUCTION.pdf
 
SURGERY RESISDENCY.pptx
SURGERY RESISDENCY.pptxSURGERY RESISDENCY.pptx
SURGERY RESISDENCY.pptx
 
management of Liver cancers
management of Liver cancersmanagement of Liver cancers
management of Liver cancers
 
Breast cancer
Breast cancerBreast cancer
Breast cancer
 
MALIGNANT BOWEL OBSTRUCTON
MALIGNANT BOWEL OBSTRUCTONMALIGNANT BOWEL OBSTRUCTON
MALIGNANT BOWEL OBSTRUCTON
 
Colorectal cancer
Colorectal cancerColorectal cancer
Colorectal cancer
 
Obstructive jaundice
Obstructive jaundiceObstructive jaundice
Obstructive jaundice
 
Gastrectomy
GastrectomyGastrectomy
Gastrectomy
 
Management of acute pancreatitis
Management of acute pancreatitisManagement of acute pancreatitis
Management of acute pancreatitis
 
Mesenteric vascular occlusion
Mesenteric vascular occlusionMesenteric vascular occlusion
Mesenteric vascular occlusion
 
Management of abdominal vascular injury
Management of abdominal vascular injuryManagement of abdominal vascular injury
Management of abdominal vascular injury
 
Endocrine pancreatic tumour
Endocrine pancreatic tumourEndocrine pancreatic tumour
Endocrine pancreatic tumour
 
Metastatic colorectal liver cancer
Metastatic colorectal liver cancerMetastatic colorectal liver cancer
Metastatic colorectal liver cancer
 
Paget disease of the breast
Paget disease of the breastPaget disease of the breast
Paget disease of the breast
 
Use of implant in surgery
Use of implant in surgeryUse of implant in surgery
Use of implant in surgery
 
Surgical treatment for peptic ulcer disease
Surgical treatment for peptic ulcer diseaseSurgical treatment for peptic ulcer disease
Surgical treatment for peptic ulcer disease
 
Surgery tutorials for medical students
Surgery tutorials for medical studentsSurgery tutorials for medical students
Surgery tutorials for medical students
 
Blood and blood transfusion
Blood and blood transfusionBlood and blood transfusion
Blood and blood transfusion
 
Asepsis in surgery
Asepsis in surgeryAsepsis in surgery
Asepsis in surgery
 
Hemorrhoidectomy
HemorrhoidectomyHemorrhoidectomy
Hemorrhoidectomy
 

Dernier

Dehradun Call Girls Service {8854095900} ❤️VVIP ROCKY Call Girl in Dehradun U...
Dehradun Call Girls Service {8854095900} ❤️VVIP ROCKY Call Girl in Dehradun U...Dehradun Call Girls Service {8854095900} ❤️VVIP ROCKY Call Girl in Dehradun U...
Dehradun Call Girls Service {8854095900} ❤️VVIP ROCKY Call Girl in Dehradun U...
Sheetaleventcompany
 
Russian Call Girls Lucknow Just Call 👉👉7877925207 Top Class Call Girl Service...
Russian Call Girls Lucknow Just Call 👉👉7877925207 Top Class Call Girl Service...Russian Call Girls Lucknow Just Call 👉👉7877925207 Top Class Call Girl Service...
Russian Call Girls Lucknow Just Call 👉👉7877925207 Top Class Call Girl Service...
adilkhan87451
 
💚Call Girls In Amritsar 💯Anvi 📲🔝8725944379🔝Amritsar Call Girl No💰Advance Cash...
💚Call Girls In Amritsar 💯Anvi 📲🔝8725944379🔝Amritsar Call Girl No💰Advance Cash...💚Call Girls In Amritsar 💯Anvi 📲🔝8725944379🔝Amritsar Call Girl No💰Advance Cash...
💚Call Girls In Amritsar 💯Anvi 📲🔝8725944379🔝Amritsar Call Girl No💰Advance Cash...
Sheetaleventcompany
 
Call Girls in Gagan Vihar (delhi) call me [🔝 9953056974 🔝] escort service 24X7
Call Girls in Gagan Vihar (delhi) call me [🔝  9953056974 🔝] escort service 24X7Call Girls in Gagan Vihar (delhi) call me [🔝  9953056974 🔝] escort service 24X7
Call Girls in Gagan Vihar (delhi) call me [🔝 9953056974 🔝] escort service 24X7
9953056974 Low Rate Call Girls In Saket, Delhi NCR
 
🌹Attapur⬅️ Vip Call Girls Hyderabad 📱9352852248 Book Well Trand Call Girls In...
🌹Attapur⬅️ Vip Call Girls Hyderabad 📱9352852248 Book Well Trand Call Girls In...🌹Attapur⬅️ Vip Call Girls Hyderabad 📱9352852248 Book Well Trand Call Girls In...
🌹Attapur⬅️ Vip Call Girls Hyderabad 📱9352852248 Book Well Trand Call Girls In...
Call Girls In Delhi Whatsup 9873940964 Enjoy Unlimited Pleasure
 

Dernier (20)

Call Girls Jaipur Just Call 9521753030 Top Class Call Girl Service Available
Call Girls Jaipur Just Call 9521753030 Top Class Call Girl Service AvailableCall Girls Jaipur Just Call 9521753030 Top Class Call Girl Service Available
Call Girls Jaipur Just Call 9521753030 Top Class Call Girl Service Available
 
Premium Call Girls In Jaipur {8445551418} ❤️VVIP SEEMA Call Girl in Jaipur Ra...
Premium Call Girls In Jaipur {8445551418} ❤️VVIP SEEMA Call Girl in Jaipur Ra...Premium Call Girls In Jaipur {8445551418} ❤️VVIP SEEMA Call Girl in Jaipur Ra...
Premium Call Girls In Jaipur {8445551418} ❤️VVIP SEEMA Call Girl in Jaipur Ra...
 
Dehradun Call Girls Service {8854095900} ❤️VVIP ROCKY Call Girl in Dehradun U...
Dehradun Call Girls Service {8854095900} ❤️VVIP ROCKY Call Girl in Dehradun U...Dehradun Call Girls Service {8854095900} ❤️VVIP ROCKY Call Girl in Dehradun U...
Dehradun Call Girls Service {8854095900} ❤️VVIP ROCKY Call Girl in Dehradun U...
 
Russian Call Girls Lucknow Just Call 👉👉7877925207 Top Class Call Girl Service...
Russian Call Girls Lucknow Just Call 👉👉7877925207 Top Class Call Girl Service...Russian Call Girls Lucknow Just Call 👉👉7877925207 Top Class Call Girl Service...
Russian Call Girls Lucknow Just Call 👉👉7877925207 Top Class Call Girl Service...
 
Call Girls Service Jaipur {8445551418} ❤️VVIP BHAWNA Call Girl in Jaipur Raja...
Call Girls Service Jaipur {8445551418} ❤️VVIP BHAWNA Call Girl in Jaipur Raja...Call Girls Service Jaipur {8445551418} ❤️VVIP BHAWNA Call Girl in Jaipur Raja...
Call Girls Service Jaipur {8445551418} ❤️VVIP BHAWNA Call Girl in Jaipur Raja...
 
Top Rated Pune Call Girls (DIPAL) ⟟ 8250077686 ⟟ Call Me For Genuine Sex Serv...
Top Rated Pune Call Girls (DIPAL) ⟟ 8250077686 ⟟ Call Me For Genuine Sex Serv...Top Rated Pune Call Girls (DIPAL) ⟟ 8250077686 ⟟ Call Me For Genuine Sex Serv...
Top Rated Pune Call Girls (DIPAL) ⟟ 8250077686 ⟟ Call Me For Genuine Sex Serv...
 
Most Beautiful Call Girl in Bangalore Contact on Whatsapp
Most Beautiful Call Girl in Bangalore Contact on WhatsappMost Beautiful Call Girl in Bangalore Contact on Whatsapp
Most Beautiful Call Girl in Bangalore Contact on Whatsapp
 
💚Call Girls In Amritsar 💯Anvi 📲🔝8725944379🔝Amritsar Call Girl No💰Advance Cash...
💚Call Girls In Amritsar 💯Anvi 📲🔝8725944379🔝Amritsar Call Girl No💰Advance Cash...💚Call Girls In Amritsar 💯Anvi 📲🔝8725944379🔝Amritsar Call Girl No💰Advance Cash...
💚Call Girls In Amritsar 💯Anvi 📲🔝8725944379🔝Amritsar Call Girl No💰Advance Cash...
 
Top Quality Call Girl Service Kalyanpur 6378878445 Available Call Girls Any Time
Top Quality Call Girl Service Kalyanpur 6378878445 Available Call Girls Any TimeTop Quality Call Girl Service Kalyanpur 6378878445 Available Call Girls Any Time
Top Quality Call Girl Service Kalyanpur 6378878445 Available Call Girls Any Time
 
Call Girls in Gagan Vihar (delhi) call me [🔝 9953056974 🔝] escort service 24X7
Call Girls in Gagan Vihar (delhi) call me [🔝  9953056974 🔝] escort service 24X7Call Girls in Gagan Vihar (delhi) call me [🔝  9953056974 🔝] escort service 24X7
Call Girls in Gagan Vihar (delhi) call me [🔝 9953056974 🔝] escort service 24X7
 
Independent Call Girls In Jaipur { 8445551418 } ✔ ANIKA MEHTA ✔ Get High Prof...
Independent Call Girls In Jaipur { 8445551418 } ✔ ANIKA MEHTA ✔ Get High Prof...Independent Call Girls In Jaipur { 8445551418 } ✔ ANIKA MEHTA ✔ Get High Prof...
Independent Call Girls In Jaipur { 8445551418 } ✔ ANIKA MEHTA ✔ Get High Prof...
 
Call Girls Madurai Just Call 9630942363 Top Class Call Girl Service Available
Call Girls Madurai Just Call 9630942363 Top Class Call Girl Service AvailableCall Girls Madurai Just Call 9630942363 Top Class Call Girl Service Available
Call Girls Madurai Just Call 9630942363 Top Class Call Girl Service Available
 
🌹Attapur⬅️ Vip Call Girls Hyderabad 📱9352852248 Book Well Trand Call Girls In...
🌹Attapur⬅️ Vip Call Girls Hyderabad 📱9352852248 Book Well Trand Call Girls In...🌹Attapur⬅️ Vip Call Girls Hyderabad 📱9352852248 Book Well Trand Call Girls In...
🌹Attapur⬅️ Vip Call Girls Hyderabad 📱9352852248 Book Well Trand Call Girls In...
 
Andheri East ^ (Genuine) Escort Service Mumbai ₹7.5k Pick Up & Drop With Cash...
Andheri East ^ (Genuine) Escort Service Mumbai ₹7.5k Pick Up & Drop With Cash...Andheri East ^ (Genuine) Escort Service Mumbai ₹7.5k Pick Up & Drop With Cash...
Andheri East ^ (Genuine) Escort Service Mumbai ₹7.5k Pick Up & Drop With Cash...
 
Saket * Call Girls in Delhi - Phone 9711199012 Escorts Service at 6k to 50k a...
Saket * Call Girls in Delhi - Phone 9711199012 Escorts Service at 6k to 50k a...Saket * Call Girls in Delhi - Phone 9711199012 Escorts Service at 6k to 50k a...
Saket * Call Girls in Delhi - Phone 9711199012 Escorts Service at 6k to 50k a...
 
Call Girls Mysore Just Call 8250077686 Top Class Call Girl Service Available
Call Girls Mysore Just Call 8250077686 Top Class Call Girl Service AvailableCall Girls Mysore Just Call 8250077686 Top Class Call Girl Service Available
Call Girls Mysore Just Call 8250077686 Top Class Call Girl Service Available
 
Coimbatore Call Girls in Thudiyalur : 7427069034 High Profile Model Escorts |...
Coimbatore Call Girls in Thudiyalur : 7427069034 High Profile Model Escorts |...Coimbatore Call Girls in Thudiyalur : 7427069034 High Profile Model Escorts |...
Coimbatore Call Girls in Thudiyalur : 7427069034 High Profile Model Escorts |...
 
Andheri East ) Call Girls in Mumbai Phone No 9004268417 Elite Escort Service ...
Andheri East ) Call Girls in Mumbai Phone No 9004268417 Elite Escort Service ...Andheri East ) Call Girls in Mumbai Phone No 9004268417 Elite Escort Service ...
Andheri East ) Call Girls in Mumbai Phone No 9004268417 Elite Escort Service ...
 
Call Girls in Delhi Triveni Complex Escort Service(🔝))/WhatsApp 97111⇛47426
Call Girls in Delhi Triveni Complex Escort Service(🔝))/WhatsApp 97111⇛47426Call Girls in Delhi Triveni Complex Escort Service(🔝))/WhatsApp 97111⇛47426
Call Girls in Delhi Triveni Complex Escort Service(🔝))/WhatsApp 97111⇛47426
 
Call Girls Service Jaipur {9521753030 } ❤️VVIP BHAWNA Call Girl in Jaipur Raj...
Call Girls Service Jaipur {9521753030 } ❤️VVIP BHAWNA Call Girl in Jaipur Raj...Call Girls Service Jaipur {9521753030 } ❤️VVIP BHAWNA Call Girl in Jaipur Raj...
Call Girls Service Jaipur {9521753030 } ❤️VVIP BHAWNA Call Girl in Jaipur Raj...
 

Adhesive intestinal obstruction

  • 1. bbinyunus2002@gmail.com Page 1 ADHESIVE INTESTINAL OBSTRUCTION. WHAT A RESIDENT SHOULD KNOW. DR BASHIR BIN YUNUS OUTLINE  INTRODUCTION  PATHOPHYSIOLOGY  CLINICAL FEATURES  MANAGEMENT  PREVENTION OF ADHESIONS  PERITONEAL ADHESION INDEX  CONCLUSION INTRODUCTION Intra-abdominal adhesions are the most common cause of small bowel obstruction (SBO) in industrialised countries, accounting for approximately 65-75% of cases. Estimated risk of SBO; Appendectomy 1-10%, cholecytectomy 6.4%, intestinal surgery 10-25%, restorative proctocolectomy 17-25%. There is a changing trend in causes of intestinal obstruction in semi-urban Nigerian hospitals; adhesive obstruction is the commonest cause. Obstructed hernia becoming increasingly less common. Causes; 1. Post operative in most cases 2. Post inflammatory with or without operation; peritonitis, appendicitis, acute pelvic infection. 3. Foreign body; materials used during surgery- sutures, gauze, talc powder from gloves 4. Bowel ischemia 5. Radiation induced enteritis 6. Inflammatory bowel disease 7. Specific conditions like tuberculosis, malignancy Types; 1. Type 1; fibrinous adhesion occur during 5-10th post surgical period. It usually get resolve completely. It is avascular and flimsy. 2. Type 2; fibrous adhesion. Becomes collagenised and vascularised PATHOPHYSIOLOGY The peritoneal fluid contains inflammatory cells including leucocytes and macrophages. These cells, along with the mesothelium secrete various cellular mediators that have roles in peritoneal healing. Following peritoneal injury, there is bleeding and increase vascular permeability with leakage of protein rich fluid (esp. fibrinogen) from injured surface. The inflammatory cells release pro-inflammatory cytokines and activation of the complement and coagulation cascade. Activation of the coagulation cascade results in formation of thrombin, which is necessary for the conversion of fibrinogen to fibrin. Fibrin functions to restore injured tissue and once generated, is deposited along peritoneal surfaces. It causes adjacent organs or injured serosal surfaces to coalesce.
  • 2. bbinyunus2002@gmail.com Page 2 Under normal circumstance, degradation of this filmy fibrous adhesion by locally released proteases of the fibrinolytic system occurs with 72hours of injury. The fibrinolysis allows mesothelial cells to proliferate and the peritoneal defects to be restored within 4 to 5 days, preventing the permanent attachment of adjacent surfaces. If fibrinolysis does not occur within 5-7 days, or if local fibrinolytic activity is reduced, the fibrin matrix persists. The matrix gradually becomes organized as collagen-secreting fibroblast infiltrate the matrix. Over time, it becomes cellular structure that contains arterioles, venules, capillaries and nerve fibres. In the body systems, there is maintenance of balance between the Activators and inhibitors of fibrinolysis. Activators;  Tissue plasminogen activator( tPA)- most important  Urokinase- like plasminogen activator uPA They activate plasminogen to plasmin which in turn degrades extracellular matrix including fibrin. Inhibitors;  Plasminogen activator inhibitors ( PAI). PAI-1 (dominant) and PAI-2 PAI prevents the formation of plasmin bydirectly binding to and inhibiting tPA and uPA. Under normal conditions, fibrinolytic capacity exceeds coagulation in the peritoneum. However, conditions causing peritoneal injury depress the fibrinolytic capacity. Cytokines especially TGF-B release contributes to a decrease in peritoneal fibrinolytic capacity and may have role in preventing the early dissolution of fibrous adhesions. CLINICAL FEATURES 1. Abdominal pain: colicky type, recurrent and episodic (commonest symptom) 2. Distension , vomiting 3. Constipation 4. Previous surgical scars commonly observed. NB:  Gilroy Bevan triad of adhesive pain; o Pain gets aggravated or relieved on change of posture o Pain in the region of old abdominal scar o Tenderness is elicited by pressure over the scar  Presents with features of obstruction initially and later features of strangulation-toxicity, fever, tachycardia, guarding, rigidity and rebound tenderness may occur.  Adhesions may be asymptomatic for many years but later become symptomatic.
  • 3. bbinyunus2002@gmail.com Page 3 INVESTIGATIONS 1. Plain Xray abdomen shows dilated bowel loops (investigation of choice) 2. Contrast enhanced CT scan; features of strangulation; a. Intramesenteric fluid b. Mesenteric oedema, congestion c. Bowel wall thickening more than 2mm d. Reduce mural enhancement in strangulated bowel compared to adjacent bowel. e. Whirl sign. Small bowel volvulus 3. E/U,Cr, FBC, Blood grouping. MANAGEMENT Expectant management 1) IV fluid 2) N-G tube 3) IV antibiotics 4) Urethral catheter 5) An enema saponis or use of flatus tube insertion may be considered 6) Observation a) Half-hourly pulse and blood pressure b) Four-hourly measurement of abdominal girth c) N-G tube drainage- amount and colour d) Passage or otherwise of flatus e) Persistence or otherwise of pain f) Presence or otherwise of abdominal tenderness or rebound tenderness Reasons to abandon expectant management for laparotomy; I. A rising pulse rate and or falling BP. Indicative of worsening of general condition II. Increasing girth suggestive of increasing distension of gut III. Persistence of abdominal pain indicative of continuing obstruction IV. Increasing amount of N-G tube aspiration or change in colour from clear or bilous to brown. Suggestive of worsening of obstruction V. Tenderness, rebound tenderness and or guarding or rigidity or palpable tender mass denoting onset of strangulation. Duration for non-operative management; Some surgeons advocate operative intervention in any patient who fails to show improvement within 48 hours. Others advocate a more liberal use of nonoperative therapy, citing a mean time to successful resolution of up to 4.6 days. However, prompt operative intervention is mandatory in patient who develop signs and symptoms suggestive of strangulation obstruction. These parameters include fever, tachycardia, leukocytosis, localized tenderness, continuous abdominal pain and peritonitis. The presence of any three of these signs has 82% predictive value for strangulation, presence of four has near 100% predictive value for strangulation.
  • 4. bbinyunus2002@gmail.com Page 4 Operative management ADHESIOLYSIS;  Open  Laparoscopic: is becoming popular, safer, ideal with less recurrent adhesion rate and gives good results NB; laparotomy can predispose to more subsequent adhesions. Approach; At laparotomy, safe entrance may be best achieved by approaching this from the extreme of the previous incision at virgin area rather than going through the mid portion of the incision. Once in the peritoneal cavity, first is to identify site and cause of obstruction. Release fibrous adhesions with sharp dissection. Inspect bowel for viability non-viable bowel should be resected. Explore all four quadrants look for bowel injury or nonviable segments. NOBLE’S PLICATION OF INTESTINE; In noble placation of the intestine, adjacent coils of small intestine, arranged parallel are sutured at the antimesenteric ends to prevent in-going for further recurrent adhesion. The bowel is initially freed from the DJ junction to the ileocecal junction. Placation starts from above. Done for recurrent adhesions. CHILDS-PHILLIPS MESENTERIC PLICATION; Similarly, after freeing the bowel from adhesions from DJ junction to the ileocecal junction, the mesentry is plicated 2-3cm from the bowel. It prevents crumpling of bowel and adhesion formation. PREVENTION OF ADHESIONS 1. Gentle handling of bowel 2. Use gloves free of talc 3. Prevention of spillage of content of viscous 4. Ensure meticulous hemostasis 5. Copious lavage of abdomen with saline, get rid of cloths before closure. 6. Careful placement of drain 7. Pulling omentum over bowel before closure to prevent adhesion of bowel to laparotomy scare 8. Instillation of drugs; a. Hyaluronidase b. Dextran 70 c. Amniotic membrane d. Streptokinase e. recombinant tPA f. steroids 9. laparoscopic procedure To this day, there is no means of completely preventing post-operative adhesion formation.
  • 5. bbinyunus2002@gmail.com Page 5 PERITONEAL ADHESION INDEX This is a classification system for adhesion to standardize their definition. It is based on the macroscopic appearance of adhesions and their extent to the different region of the abdomen. The surgeon can assign the index ranging from 1-30, there by giving the precise description of the intra abdominal condition. Regions of the abdomen;  Right upper  Epigastrium  Left upper  Left flank  Left lower  Pelvis  Right flank  Central  Bowel to bowel Adhesion grade score; 0 – no adhesion 1 – filmy adhesion, blunt dissection 2 – strong adhesions, sharp dissection 3 – very strong vascularised adhesion, sharp dissection, damage hardly preventable. PAI is then estimated by computing the adhesion grade score for each of the regions. It ranges from 1-30 A standardized classification and quantification of adhesion allows more integration of results from several studies and comprehensive approach to the management. COMPLICATIONS OF ADHESIONS  Intestinal obstruction  Secondary female infertility  Ectopic gestation  Chronic abominal and pelvic pain
  • 6. bbinyunus2002@gmail.com Page 6 REFERENCES 1. Attad JP, MacLean AR. Adhesive small bowel obstruction: epidemiology, biology and prevention. Can J Surg 2007, 50:4 p 291-300 2. Coccolilni et al. Peritoneal adhesion index(PAI): proposal of a score for the ignored iceberg of medicine and surgery. World journal of emergency surgery 2013,8:6 p3-5. 3. McGregor AL. Treatment of chronic adhesive obstruction by noble procedure. S A Med J 1956, 30:9 p937-941 4. Guido M S et al. Small bowel obstruction. In: Maingot’s Abdominal operation. 12th ed., McGrawHill; 2013. 600-607 5. SRB manual of surgery. 5th ed.,Jaypee Brothers; 2016.p934-936. 6. Naaeder SB, Tandoh JFK. Acute intestinal obstruction.In: BAJA’s principles and practice of surgery including pathology in the tropics. 5th ed., Repro India Ltd; 2015. 601p