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Intestinal obstruction

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Diagnosis and management of intestinal obstruction

Publié dans : Santé & Médecine
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Intestinal obstruction

  1. 1. Intestinal Obstruction By Mohamed Mourad Assistant Lecturer of General Surgery
  2. 2. Definition • Any condition interferes with normal propulsion and passage of intestinal contents. Peristalsis is working against a mechanical obstruction DYNAMIC (MECHANICAL) Result from atony of the intestine with loss of normal peristalsis, in the absence of a mechanical cause. or it may be present in a non-propulsive form (e.g. mesenteric vascular occlusion or pseudo- obstruction) ADYNAMIC (FUNCTIONAL)
  3. 3. Classification Classification Cause mechanical ileus Duration Acute Chronic Extent Partial Complete Type Simple Complex Closed loop strangulation
  4. 4. Mechanical obstruction Intraluminal • Impaction • Foreign bodies • Bezoars • Gallstone Intramural • Congenital atresia • Stricture • Malignancy(15%) Extramural • Bands/ adhesion(40%) • Hernia (12%) • Volvulus • Intussusception • Tumor-benign/malignant
  5. 5. Mechanical obstruction • This mechanical obstruction can be partial ( lumen narrowed but allow transit some content) or complete ( lumen totally obstruction) this classify to: A. Simple obstruction (no vascular impairment) B. Closed loop ( both ends are obstructed e.g volvulus) C. Strangulation obstruction
  6. 6. Functional obstruction • Either paralysis or dysmotility of intestinal peristalsis. • Postoperative ileus is the most common form of functional bowel obstruction.
  7. 7. Epidemiology • 1% of all hospitalization • 3% of emergency surgical admissions • Adhesion is the most common cause of intestinal obstruction • Mortality rate range between – 3% for simple bowel obstruction to – 30% when there is strangulation or perforation
  8. 8. 40% 16% 14% 14% 10% 3% 3% Adhesions Hernia Small Intest volvolus Intussusception Sigmoid volvolus Ascaris Large bowel tumor 80% with gangrenous bowel segments 70 % of the patients were below the age of 15 years Intestinal obstruction Pattern in Africa
  9. 9. Etiology Mechanical bowel obstruction • Small bowel obstruction: – Adhesion 60% – Hernia 20% – Neoplasm 5% – Volvulus 5%. – Others: IBD - gall stone - foreign body - intussusception. • Large bowel obstruction : – Cancer 60%. – Diverticular disease 15%. – Volvulus 15%. – Others: hernia – fecal impaction - IBD.
  10. 10. Etiology Functional bowel obstruction 1. Vascular occlusion ileus. 2. Adynamic or inhibition ileus : – Post operative. – Metabolic causes: DKA- hyponateremia-hypokalemia – hypomagnesaemia. – Drugs: morphine –TCA-antacid-anticonvulsant. – Intra-abdominal inflammation—sepsis—occult wound infection. – Pneumonia—renal stone—retroperitoneal hematoma—fracture spine and ribs. 3. Spastic ileus. ( intestine remain contracted and no propulsive) causes are: – Uremia. – Porphyria. – Heavy metal poison.
  11. 11. PATHOPHYSIOLOGY
  12. 12. Pathophysiology
  13. 13. Pathophysiology (cont.)
  14. 14. Pathophysiology Proximal bowel dilated & develops altered motility  dilate  reduce peristaltic strength  flaccidity & paralysis (prev. vascular damage due to inc. intraluminal pressure Distal to obs. Bowel exhibits normal peristalsis & absorbtion  become empty  contract & become immobile Distention is by gas & fluid -Gas: aerobic & anaerobic growth -Fluid: Digestive juices & retarded absorption Dehydration & electrolytes loss: Reduced oral intake, defective intestinal absorption, loses from vomiting & sequestration in bowel of lumen.
  15. 15. NOTE • According to LAPLACE’s law: maximum pressure is at the maximum diameter AREA Caecum is at the greatest risk of perforation
  16. 16. Pathophysiology • Dehydration results from: – Reduced oral intake, – Defective intestinal absorption, – Loses from vomiting & sequestration in bowel of lumen.
  17. 17. Diagnosis History and physical examination • Four cardinal symptoms 1. Pain 2. Vomiting 3. Distension 4. obstipation). • Location and characteristic of pain?? • Examination : o Vital signs.( PR-Temp-BP) o Hydration status. o Abdominal and rectal examinations
  18. 18. Physical Examination • INSPECTION – Abdominal distention, scars, visible peristalsis. • PALPATION – Mass, tenderness, guarding – Examination of hernial orifices • PERCUSSION – Tympanic, dullness • AUSCULTATION – Bowel sound are high pitch and increase in frequency – Or silent.
  19. 19. Difference between High & Low intestinal obstruction HIGH LOW BEGINNING Acute Slow, insidious GENERAL CONDITION Early compromission preserved PAIN Crampy pain in paroxism Less intensity VOMITING Early, profuse, biliary Late, feculent may be absent ABDOMINAL DISTENTION Moderate, upper quadrant Early, intense CONSTIPATION + +++ ELECTOLYTES Cl, K, Na rapid loss Late hydro electrolytic imbalance
  20. 20. Diagnosis Laboratory • CBC: – Increase PCV (dehydration ) and increase in WBC. • KFT: – Increase in BUN and creatinine . • Lactate concentration-amylase-lactic dehydrogenase useful but not sensitive – To rule out necrosis • ABG: – metabolic alkalosis and respiratory acidosis.
  21. 21. Diagnosis Radiology • CXR : – Detect extra-abdominal condition present with bowel obstruction e.g. pneumonia. – Presence of pneumoperitoneum indicates perforated viscus.
  22. 22. Diagnosis Radiology • Abdominal X-RAY – Small bowel considered dilated when diameter more than 3 cm while proximal colon 9 cm and the sigmoid 5 cm. – The cause of bowel obstruction can often determined • Presence of pneumobilia suggest G.S ileus. • Sigmoid and cecal volvulus produce pathognomnic images
  23. 23. Radiology Fluid levels with gas above; ‘stepladder pattern’. Ileal obstruction by adhesions; patient erect. Prone radiograph from a patient with complete large bowel obstruction shows distended lagre bowel in the periphery of abdomen with haustration.
  24. 24. NOTE • According to LAPLACE’s law: maximum pressure is at the maximum diameter AREA Caecum is at the greatest risk of perforation
  25. 25. Diagnosis Radiology • Contrast studies: – Indications are controversial. – Identify site and often the cause of obstruction. – Differentiate between colonic and distal small bowel obstruction – Differentiate between ileus-partial and complete obstruction. • Computed tomography: – Recently become valuable in B.O especially when plain films failed in diagnosis or suspect strangulation. – Sensitivity 93% and specificity 100% – Accuracy 94% in diagnosis of BO Barium should not be used in a patient with peritonitis
  26. 26. Treatment • For optimal treatment to be instituted, five questions must be answered: • Is the diagnosis intestinal obstruction?. Is the obstruction is mechanical? . • What is the level of obstruction?. • Is there evidence of bowel wall ischemia or perforation?. • How sever is the associated systemic disorders?.
  27. 27. Treatment A. Resuscitation. B. Conservative treatment 1. Previous surgery. 2. Incomplete obstruction. 3. Advanced malignancy. C. Indications for surgery 1. Generalized or localized peritonitis. 2. Perforation. 3. Strangulated hernia. 4. Closed loop 5. Failure to improve on conservative treatment.
  28. 28. Obstruction by Adhesions • Peritoneal irritation local fibrin production adhesions • As early as 4 weeks post laparotomy. The majority of patients present between 1-5 years Colorectal Surgery 25% Gynaecological 20% Appendectomy 14% • Prevention: • good surgical technique, washing of the peritoneal cavity with saline to remove clots, etc, minimizing contact w/ gauze, covering anastomosis & raw peritoneal surfaces
  29. 29. Treatment of adhesive obstruction • Conservatively provided there is no signs of strangulation; should rarely continue conservative treatment for longer than 72 hours • At operation, divide only the causative adhesion and limit dissection.
  30. 30. Treatment of adhesive obstruction
  31. 31. Obstructed Hernia • Commonest – Femoral hernia – ID inguinal – Umbilical – Others: incisional • Ischaemia occurs initially by venous occlusion, followed by oedema and arterial compromise. • Strangulation is noted by: • Persistent pain • Discolouration • Tenderness • Constitutional symptoms • Loss of impulse with cough
  32. 32. Management For Large Bowel Obstruction • Appropriate operations include: • Right sided lesions – right hemicolectomy • Transverse colonic lesion – extended right hemicolectomy • Left sided lesions – various options
  33. 33. Management of Left Colonic Obstruction • Three-staged procedure 1. Defunctioning colostomy 2. Resection and anastomosis 3. Closure of colostomy • Two-staged procedure 1. Hartmann’s procedure 2. Closure of colostomy • One-stage procedure • Resection, on-table lavage and primary anastomosis • Total colectomy with ileorectal anastomosis
  34. 34. Volvulus • A twisting or axial rotation of a portion of bowel about its mesentery. When complete it forms a closed loop obstruction • Relieved by decompression per anum. • Surgery is required to prevent or relieve ischaemia Features: palpable tympanic lump (sausage shape) in the midline or left side of abdomen. Constipation, abdominal distension (early & progressive)
  35. 35. Volvulus
  36. 36. Acute intussusception • Occurs when one portion of the gut becomes invaginated within an immediately adjacent segment. • Common in 1st year of life • Common after viral illness enlargement of Peyer’s patches • Ileocolic is the commonest variety in child. • Colocolic intussusception commonest in adult
  37. 37. Classically, a previously healthy infant presents with colicky pain and vomiting (milk then bile). Between episodes the child initially appears well. Later, they may pass a ‘red currant jelly’ stool. Red currant jelly stools Acute intussusception
  38. 38. Intussusception
  39. 39. Barium reduction of intussusception Head of intussusception is at hepatic flexure Free flow of contrast into distal small bowel indicates complete reduction Partial reduction
  40. 40. Post Operative Ileus • Prevention – Use of nasogastric suction and – Restriction of oral intake until bowel sound and passage of flatus return – Maintain electrolyte balance • Specific treatment: – Removed primary cause – Decompressed GI distension – If prolong paralytic ileus , consider laparotomy exclude hidden cause and facilitate bowel decompression
  41. 41. THANKSGOOD LUCKANY QUESTION??

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