1. INTESTINAL OBSTRUCTION
Prepared by :
Maziyana Musa
Wong Soo Ching
Supervised by :
Dr.Koh Cher Hui

2. OUTLINE
 Definition
 Causes & Classification
 Sign and Symptoms
 Investigation
 Management
 Take home messagers

3. Definition : impairment or arrest of the passage of
contents through the intestine.
Involve either small or large bowel.
It can be partial or complete obstruction.

4. CLASSIFICATION
 Nature
 Site of obstruction
 Blood supply
 Rate
 Small bowel or large bowel

5. Nature
 Dynamic
mechanical obstruction
 Adynamic
no structural obstruction
ie: paralytic ileus – absence of normal peristalsis
contraction.
Causes :1. post-abdominal surgery
2. electrolyte imbalance
ie hypokalaemia
3. intra or retroperitoneal inflammation
ie appendicitis, diverticulitis
4. reduce blood supply to abdomen
ie mesentric artery ischaemia

6. Location
 Intraluminal
- colorectal carcinoma
- constipation (faecal impaction)
- foreign body
 Intramural
- strictures
ie Crohns, Diverticular Disease, due to
radiation
- acute pseudo-obstruction
ie Olgivie Syndrome

7.  Extramural
- adhesion
- hernia
- volvulus
-bowel twisted on its mesentry which
cause rapid, severe strangulated
obstruction
-common site : sigmoid
- intussusception
bowel telescoped into its distal segment
Peritonitis
Previous abdominal
surgery
Congenital adhesion
band
obstructed
strangulated

8. Blood supply
 Simple obstruction
- without vascular compromise
- ingested fluids, foods, gas and digestive
secretion accumulate above obstruction.
- proximal bowel distended
- bowel wall become edematous as reduce
secretion and absorption function of mucosa
 Strangulated obstruction
- compromise blood flow
- usually associated with hernia, volvulus and
intussusception
- can progress to infarction and gangrenous bowel
in 6hours

9.  Closed loop obstruction
- 2 points along the course of bowel are obstructed
at a single location, thus forming closed loop
obstruction
- ie : recto sigmoid tumour which caused intestinal
obstruction.
- Proximal bowel distends and decompression
into small bowel depends on competency of ileo
caecal valve.
- Competent ileo caecal valve prevent
decompression and lead to distension of large
bowel particularly caecum.
- Increase intraluminal pressure of caecum impedes
blood flow which then can results in caecum
perforation.

10. Rate
 Acute
sudden onset, rapidly progressive abdominal
pain, vomiting, constipation and abdominal
distension.
 Chronic
sign and symptoms of intestinal obstruction
slowly develop over time.

11.  Small bowel obstruction
- sudden onset
- abdominal pain
- vomiting
- constipation
- AXR : central, valvulae conniventes
 Large bowel obstruction
- mild symptoms that develop gradually
- constipation
- abdominal distension
- crampy abdominal pain
- vomiting
- AXR : peripheral, haustra

12. 4 Cardinal features of IO
 Abdominal pain
 Vomiting
 Constipation
 Abdominal distension

13. How To Approach Intestinal
Obstruction?
Visible scar -band
-adhesion
Palpation
• hernial orifices
• large, slightly tender,
mobile
• mass changes its position
with colicky pain
• tender indurated mass
• hard impacted masses
-incarcerated
-strangulated hernia
+torsion
+intussusception
-mass of Ascaris worms
+intraperitoneal abscess
-fecaloma
GENERAL EXAMINATION:

14. Percussion - tympanic sound
Auscultation -runs of borborygmi
-tinkling high pitched
musical sounds
Rectal examination
• fresh blood and mucus
• hard mass of faeces
• hard mass in the
rectovesical pouch
-strangulating lesion
-carcinoma of large gut
-intussusception
+constipation
-extraintestinal tumour

15. How To Initiate Investigation?
Lab investigation:
• FBC
• BUSE
• Clotting profile
• Arterial blood gasses
• Optional (ESR, CRP,
Hepatitis profile, tumour
markers)
-high Hb and hematocrit
-leukocytosis
-anaemia
+electrolytes depletion
Radiological:
• X-RAYS -Gas pattern
-Fluid level
-Masses shadow
-Fecal pattern

16. • USE -free fluid
-masses
-mucosal folds
-pattern of paristalsis
• CT, MRI, Contrast studies -level of obstruction
-partial or complete
-cause of the obstruction
• Optional (colonoscopy,
endoscopy, laparoscopy)

17. Large Bowel: Small Bowel:
•Peripheral
•Diameter ~8 cm
•Presence of haustration
•Central
•Diameter ~5 cm
•Vulvulae coniventae
•Ileum: may appear tubeless

18. Multiple air fluid levels located centrally-
small bowel obstruction
Small bowel volvulus-coffee bean
appearance.

19. Air fluid level centrally-
small bowel obstruction
Small intestinal invagination

20. How to manage intestinal
obstruction?
 Conservative
 Operative
 Conservative treatment
 Nasogastric tube
 to help decompress the dilated bowel
 aspirate it with a 20 or 50 ml syringe half- hourly
 CBD
 To monitor urine output

21.  IV Fluids
 Normal saline or lactated ringer’s solution for intravascular
volume depletion
 Electrolytes correction
 Guided by test results
 Analgesic
 Opioid pain relievers may be used for patients with
severe pain
 Antibiotics
 If bowel ischemia or infarction is suspected

22.  Operative
 repair of hernias
 removal of foreign bodies
 lysis of the offending adhesions
 Resection
 colostomy.

23. Indication For Surgery:
 Immediate intervention:
 Evidence of strangulation (hernia….etc)
 Signs of peritonitis resulting from perforation or
ischemia
 In the next 24-48 hours
 Clear indication of no resolution of obstruction (
Clinical, radiological).
 Diagnosis is unclear in a virgin abdomen
 Intermediate stage
 The cause has been diagnosed and the patient is
stabalised

24. Take Home Messages:
 The 4 main Cardical signs of intestinal obstruction are
Abdominal pain, Abdominal distention, Vomiting and
Constipation.
 Always examine for hernia orifice.
 Follow-up lab results and correction of electrolyte
imbalance.
 Always request for Supine, Erect and CXR.
 Always provide adequate resusitation to the patient.
 Always be attentive of signs of peritonitis resulting
from perforation or ischemia of bowel.

25. References :
- Manipal manual of surgery by K Rajgopal Shenoy
- Life in the fast lane journal
- Surgery International Journal
- www.meb.uni-bonn.de
- www.merckmanuals.com
- www.radiologyassistant
- emedicine.medscape.com