1. Supervisor : Dr. Hilda
Prepared by:
Ahmad Iqbal Syafiq
Zuhratun Nazihah

2. • DEFINITION
• CLASSIFICATION
• CAUSES
• HISTORY
• EXAMINATION
• INVESTIGATION
• PSEUDO-OBSTRUCTION
• MANAGEMENT
• SURGERY : INDICATIONs
• TAKE HOME MESSAGES

3. • Intestinal obstruction is
blockage of bowel that prevents
the contents of the intestine
from passing through.

4. • Paralytic ileus
- Postoperative
- Inflammatory
- Metabolic
- neurogenic
Mechanical
Functional
• Extramural
• Intramural
• Intraluminal

5. Mechanical
Extramural
• Adhesions
• Hernia
• Volvulus
• Neoplasms
Intramural
• Neoplasms
• Stricture
• Intussuception
Intraluminal
• Gallstones
• Fecal
impaction
• Bezoar
• Foreign body
• Intramural
haematoma

6. • ELDERLY – carcinoma, diverticulitis, sigmoid
volvulus
• ADULT – hernia, adhesion, carcinoma
• PAEDIATRICS – intussusception, congenital
hypertrophic pyloric stenosis, atresia
(duodenum, ileum), meconium obstruction,
volvulus neonatorum

7. Pathophysiology

8. Pathophysiology
• Bowel distal to obstruction collapse
• Bowel proximal to obstruction distends and becomes hyperactive
(distension due to intestinal secretions and swallowed air)
• Bowel wall becomes edematous. Fluid electrolytes accumulate in
the wall and lumen (third space loss)
• Bacteria proliferate in the obstructed bowel
• As the bowel distends, intramural vessels become
stretched/compromised
• Ischemia and necrosis

9. • 4 Cardinal Signs :
• Abdominal pain
• Nausea & vomiting
• Abdominal distension
• Absolute constipation
• Others :
• Dehydration, hypotension, tachycardia, pyrexia,
abdominal tenderness, empty rectum on DRE, high
pitched bowel sound.

10. • Pain
• Small bowel :
- periumbilical and colicky
- comes in spasm
- builds up in crescendo
- then tappers off
- regular pain at intervals of 2-3 minutes
• Large bowel : below the umbilicus & comes at intervals
of 6-10 minutes.
• Severe & continuous pain suggest strangulation
obstruction.

11. • Vomiting
• The higher the obstruction, the vomiting is more
severe
• In large bowel obstruction vomiting comes later and
sometimes patient may not vomit at all.
• As obstruction progresses the character of the vomitus
alters (digested food  feculent material; as a result
of the presence of enteric bacterial overgrowth)

12. • Abdominal distention
• The more distal the obstruction, the more distention
of abdomen.
• Visible peristalsis may be present.
• Constipation
• May pass feces or flatus if early onset
• Occurs early in lower large bowel obstruction
• Occurs late in high small bowel obstruction
• Absolute constipation is a feature of complete
intestinal obstruction.

13. • In high small bowel obstruction,
vomiting occurs early and is profuse with rapid
dehydration. Distension is minimal
• In low small bowel obstruction,
Vomiting is delayed. pain is predominant with central
distension.
• In large bowel obstruction,
distension is early and pronounced. Pain is mild and
vomiting and dehydration are late.

14. Inspection
• 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

15. 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

16. • Blood
• FBC:
• Hb  anaemic
• PCV  elevated due to dehydration
• TWBC  normal or elevated (strangulation, ischemia,
perforation)
• RP:
• dehydration
• electrolyte imbalance (hypokalemia, hyponatremia)
• ABG:
• alkalosis  proximal obstruction (severe vomiting)
• acidosis  strangulation

17. • Radiological
• AXR
• Gas pattern
• Fluid level
• Masses shadow
• Fecal pattern
• Chest X-Ray
• Elevated diaphragm
• Air under diaphragm
• Aspiration

18. • USG:
• to differentiate mechanical obstruction & paralytic ileus,
• poor visualization of gas filled structure,
• only useful in selected patient ie pregnant, when CT is
contraindicated, in critically ill patients
• Free fluid
• Masses
• Mucosal folds
• Pattern of peristalsis
• CT scan:
• level of obstruction (transition point)
• Causes (hernias, inflammatory changes, masses)
• sign of strangulation, ischemia, perforation

19. Large Bowel: Small Bowel:
•Peripheral
•Presence of haustration, diameter
>8 cm
•distended caecum a rounded gas
shadow in the right iliac fossa. >10cm
diameter.
•Central
•jejunum  valvulae conniventes
•Ileum  featureless
•Diameter >5 cm
•No gas is seen in the colon

20. Pseudo-obstruction
DEFINITION
• Describes an obstruction that occurs in the absence of
mechanical cause or acute intra abdominal disease
• Diagnosis of exclusion in the absence of mechanical cause
CAUSES
• Idiopathic
• Metabolic
• Severe trauma
• Shock
• Septicaemic
• Retroperitoneal irritation
• Drugs

21. Ogilvie’s Syndrome
• Acute large bowel obstruction
• Absence of mechanical cause
• AXR – evidence of colonic obstruction, usually marked cecal
distension
• Single contrast water soluble barium enema, CT scan and
colonoscopy can be done
• Once diagnosis confirmed, treat with colonoscopic decompression
• Recurrence occurs in 25%
• Complication – cecal perforation
• Repeat colonoscopy with simultaneous placement of flatus tube
may be required
• Surgical intervention – subtotal colectomy and ileorectal
anastomosis

22. Principles of Treatment
• Gastrointestinal drainage
• Fluid and electrolytes replacement
• Relief of obstruction
• Surgical intervention
• necessary for most cases
• Need to be delayed until resuscitation is complete

23. Early Management
• ABC
• Resuscitation
• Oxygen supply
• fluid replacement with hartman or normal saline
• Nasogastric decompression
• KNBM
• NG tube with free flow or 4hly aspirate
• Close monitoring
• BP, PR, Temp, Input/output, CVP
• Antibiotic s cover
• Analgesia

24. Indication For Surgery
• Immediate intervention
• Evidence of strangulation
• Signs of peritonitis resulting from perforation or ischemia
• In the next 24-48H
• Clear indication of no resolution of obstruction (clinical or
radiological)
• Diagnosis is unclear in virgin abdomen

25. Take Home Message
• 4 cardinal signs of intestinal obstruction are abdominal pain,
abdominal distension, vomiting and constipation
• Pseudo-obstruction is the diagnosis of exclusion in the
absence of mechanical obstruction
• Decompress the obstructed gut (NGT!!)

26. • Replace fluid and electrolytes loses
• Strict IO (CBD is least, CVP - especially in elderly, immuno
compromised patient)
• CT if only patient is stable and cause of obstruction is unclear
• Surgical intervention promptly if signs of peritonitis or
strangulation, underlying cause needs surgical treatment ie
colonic carcinoma or hernias or patient does not improve with
conservative treatment

27. References
• http://www.primary-surgery.org/ps/vol1/ch-10.pdf
• Bailey & Love’s Short Practice Of Surgery 25th edition