3. Introduction
Definition
• Stoppage of the cranio-caudal movement
of bowel contents due to narrowing or
complete blockage of the bowel lumen.
• It is one of the commonest surgical
emergencies worldwide.
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4. Introduction
• It is commoner in the small bowel than the
large bowel.
• It is important to make early and correct
diagnosis.
• Treatment must be prompt & appropriate
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5. Classification
• Dynamic / Adynamic
• Acute / Chronic / Acute on chronic
• High / Low
• Simple / Strangulated / Close loop
• Complete / Partial
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6. Adynamic Ileus
• Paralytic ileus
• It is due to paralysis of intestinal
musculature
• Characterized by absence of peristalsis &
pain
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7. Dynamic Ileus
• Peristalsis is working against a mechanical
obstruction.
• It may be acute or chronic.
• Associated with abdominal pain
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18. Aetiology
3. Intramural
i. Atresia
ii. Anorectal anomalies
iii. Intussusception
iv. Aganglionic megacolon
v. Tumours
vi. Inflammatory lesions
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24. COMMON CAUSES OF INTESTINAL
OBSTRUCTION ACCORDING TO AGE
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25. Causes of Adynamic Ileus
Metabolic
Medications Post. Operative
ileus
cases
Response to
localized Neuropathic
Inflammatory disorders
process
Diffuse Retroperitoneal
peritonitis process
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30. Intra-abdominal surgery
Motility usually returns for the:
• small bowel within 24 – 48 hrs.
• gastric within 48 hrs.
• colonic within 3-5 days.
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32. Simple Obstruction
• Below the
obstruction, the bowel
exhibits normal
peristalsis and
absorption until it
becomes empty, when
it contracts and
becomes immobile.
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33. Simple Obstruction
• Above the
obstruction, peristalsis
is increased to
overcome the
obstruction, If the
obstruction is not
relieved the bowel
begins to dilate
resulting in flaccidity
and paralysis.
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34. Simple Obstruction
• The gases are mostly
from swallowed air
and products of
putrefaction & of
intestinal contents by
bacteria.
• The fluids are mainly
digestive juices
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35. Simple Obstruction
• The fluids accumulate
due to loss of the
absorbing surface of
bowel & disordered
fluid & electrolyte
transport in the
obstructed segment.
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36. Simple Obstruction
• When raised intraluminal pressure is more
than venous pressure, there would be
venous congestion, oedema of the wall, &
mvt of fluid from the plasma into the gut
lumen & peritoneal cavity.
• Death from intestinal obstruction is due to
loss of water & electrolytes
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37. Simple Obstruction
• The higher the level of obstruction, the
earlier the onset of fluid & electrolytes
imbalance.
• In high obstruction, metabolic acidosis is
common because the fluid loss is acid.
• In low obstruction, metabolic acidosis is
likely bcs the sequestered fluid alkaline.
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38. Strangulation Obstruction
• When the pressure of the occluding band
exceeds the venous pressure
• Venous engorgement of gut wall
• Dilatation of intramural lymph channels
that carry multiplying bacteria from
mucosa surface into systemic circulation.
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39. Strangulation obstruction
• If the strangulated loop is long, release of
the obstruction may cause severe endotoxic
shock because of faster absorption of
toxins & bacteria from the devitalized gut.
• Increased venous pressure ► rupture of
capillaries ► bleeding into the lumen, wall
of the gut & peritoneal cavity.
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40. Strangulation obstruction
• Necrosis of tissues may be due to
i. Tight occluding band obstruct arterial
supply
ii. Reflex arterial spasm to venous
congestion
iii. Thrombosis of intramural & mesenteric
veins due to stasis of venous
engorgement
iv. Hypoxia enhances the growth of
anaerobic bacteria
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41. Closed Loop Obstruction
• Afferent & efferent
limbs of bowel are
obstructed.
• Typically seen in
colonic obstruction
with competent
iliocaecal valve
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42. Closed loop obstruction
• The rich bacterial floral adds to the
production of gases
• Rapid distension ► ↑luminal pressure ►
circulation impairment ► bowel necrosis
& perforation ► fulminant peritonitis.
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44. Clinical presentation
The cardinal features of obstruction are
pain, vomiting, distension & constipation but
clinical presentation varies according to:
• Site of obstruction .
• Age of Presentation.
• Underlying pathology.
• The presence or absence of ischemia.
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45. Clinical presentation
1. Abdominal pain
1st
symptom, colicky, intermit
tent , central in small
bowel obstruction, waxes
rapidly & wanes
slowly, relief in between
spasm but persistent pain
between spasms of colicky
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pains.
46. Clinical presentation
2. Abdominal distension
• The lower the site of
obstruction the more
the distension.
• It varies inversely as
the vomiting.
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47. Clinical presentation
2. Abdominal distension
• Central in small bowel
obstruction.
• More in the flanks in
colonic obstruction
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49. Clinical presentation
Pyloric Obstruction
Watery and acidic vomitus
High Small Bowel
Obstruction
Bile-Stained vomitus
Lower Small Bowel
Obstruction
Feculent Vomitus
Large Bowel Obstruction
Uncommon & late
symptom.
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50. Clinical presentation
4. Absolute constipation
• Occurs Early in
“lower” Large Bowel
Obstruction.
• Occurs Late in
“High” Small Bowel
Obstruction.
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53. Examination Findings
Pyrexia
may indicate:
• the onset of ischaemia;
• intestinal perforation;
• inflammation associated with the
obstructing disease.
Hypothermia indicates septicaemic shock.
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54. Inspection
i. Surgical Scars
ii. Hernias
iii. Distention
iv. Visible Peristalsis
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55. Palpation
i. Masses
ii. Hernias
iii. Tenderness
Perform Rectal Exam.
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56. Percussion
• Percuss to hear any Dullness or Resonance
related to site of obstruction.
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57. Auscultation
• Bowel Sounds are Initially Loud and
frequent→ Then as bowel distends the
sounds become more resonant and high
pitched→ Eventually becoming Amphoric
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59. Plain Abdominal X-rays
usually diagnostic of bowel obstruction
in more than 60% of the cases, but
further evaluation (possibly by CT or
barium ) may be necessary in 20% to
30% of cases.
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61. X-RAY
Small Bowel
Obstruction with
characteristic air-
fluid levels. The air
rises above the fluid
and there is a flat
surface at the air-
fluid interface.
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62. X-RAY
• Distended Large
bowel tends to lie
peripherally and to
show the
hustrations of the
Taenia Coli.
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63. Barium Studies
are recommended in patients with a
history of recurring obstruction or low-
grade mechanical obstruction to
precisely define the obstructed segment
and degree of obstruction.
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65. CT Scan
• CT examination is particularly useful in
patients with a history of abdominal
malignancy, in postsurgical patients, and
in patients who have no history of
abdominal surgery and present with
symptoms of bowel obstruction.
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69. Aim of Rx
Aim is to relieve obstruction as soon as
possible before strangulation occurs or
before systemic complications set in.
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70. Supportive Treatment
• Nil per os
• Fluid and electrolyte
• Nasogastric aspiration
• Urethral catheterization
• Antibiotics
• Analgesics
• Correct anaemia
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71. Conservative treatment
• Partial obstruction
• Early post op obstruction
• Obstruction secondary to Crohn’s disease
• Recurrent obstruction
Open surgery if no improvement after
24hrs
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72. Operative Treatment
• Procedure depends on cause of obstruction
• Non-viable gut must be resected
• Questionable gut should be checked for
viability
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73. Non-viable bowel
I. Loss of peristalsis
II. Loss of Sheen
III. Greenish or Black (Not Purple)
IV. Loss of Pulsation in supplying vessels
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74. Specific Rx
• Adhesion obstruction: non operative
• Strangulated Int. / Ext. hernia: release of
obstruction, resection of gangrenous
bowel, repair of defect
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75. Specific Rx
• Intussusception: Hydrostatic / Pneumatic
reduction under fluoroscopy.
• Volvolus: (viable) enema saponis for
detorsion (nonviable appropriate resection
& anastomosis)
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