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1 INTESTINAL OBSTRUCTION By Dr. Sami abd alhameid University of Dongola SUDAN

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2 Definition The term intestinal obstruction refers to any form of impedance to the normal passage of the bowel contents through the small or large intestine. It is a common cause of acute abdominal pain.

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3 Causes of intestinal obstruction I. Dynamic: (mechanical obstruction) A) Intraluminal: 1.Impaction. 2.Forign body. 3.Bezoar (tricho-bezoar & phyto-bezoar) 4.Gall stone. 5.Stercolith. B) Intramural: 1.Stricture (crohn's disease, T.B). 2.Malignancy. 3.Congenital atresia. C) Extramural: 1.Bands & Adhesion. 2.Hernia. 3.Volvulus. 4.Intussusception. 5.Tumor.

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4 Causes of intestinal obstruction II. A dynamic: (functional obstruction) A) Paralytic ileus. (small bowel). B) Mesenteric vascular occlusion. C) Pseudo-obstruction. (large bowel).

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5 Classification of intestinal obstruction Small bowel obstruction & Large bowel obstruction. Mechanical obstruction & Functional obstruction. Simple obstruction & Strangulated obstruction. Partial obstruction & Complete obstruction. -Acute obstruction -Sub acute obstruction -Acute on chronic obstruction. -Chronic obstruction.

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6 MAINPRIZE'S SURGICAL TUTORIALS QUIZ Q2                                                                    What does this image show? How would you manage this case?

Small bowel obstruction : 

7 Small bowel obstruction Symptoms: 1-Abdominal pain. 2-Vomiting 3-Constipation. 4-Distention.

Abdominal pain : 

8 Abdominal pain Most people who have small-bowel obstruction experience crampy abdominal pain that comes in waves. The pain is around the navel .

Vomiting : 

9 Vomiting Small-bowel obstructions usually cause vomiting. The vomit usually is green if the obstruction is in the upper small intestine and brown if it is in the lower small intestine

Constipation : 

10 Constipation Constipation and inability to pass gas are signs of bowel obstruction. However, when the bowel is partially blocked, a person may have diarrhea and pass gas. Someone with a complete obstruction may have a bowel movement if there is stool below the obstruction.

Distention : 

11 Distention With blockages of the lower small intestine, the epigastric area may be distended, or bloated.

Mechanical obstruction : 

12 Mechanical obstruction Aetiology 5% of small bowel obstruction account for acute surgical addmision. In UK the commonest causes are : (60% adhesion) (20% strangulated hernia) (5% malignancy) (5% vulvulous)

Pathophysiology : 

13 Pathophysiology Proximal dilatation occurs above obstructing lesion Results in the accumulation of gas and fluid and reduced reabsorption Dilation of the gut wall produced mucosal oedema This impairs venous and then arterial blood flow Intestinal ischaemia eventually results in infarction and perforation of that segment of bowel Ischaemia also results in bacterial and endotoxin translocation The overall effect is progressive dehydration, electrolyte imbalance and systemic toxicity

Clinical feature : 

14 Clinical feature Colicky central abdominal pain Vomiting - early in high obstruction Abdominal distension - extent depends on level of obstruction Absolute constipation - late feature of small bowel obstruction Dehydration associated with tachycardia, hypotension and oliguria Features of peritonism indicate strangulation or perforation

Investigation : 

15 Investigation Supine abdominal X-ray shows dilated small bowel May be normal if no air fluid interfaces Valvulae coniventes differentiate small from large intestine Erect abdominal film rarely provided additional information

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Management : 

18 Management Adequate resuscitation prior to surgery is vital May require more than 5 litres of intravenous crystalloid Adequacy of resuscitation should be judged by urine output or central venous pressure Surgery in under resuscitated patient is associated with increased mortality If obstruction presumed to be due to adhesions and there are no features of peritonism Conservative management for up to 48 hours is often safe Requires regular clinical review If features of peritonism or systemic toxicity present Need to consider early operation Exact procedure will depend on underlying cause

Indications for surgery : 

19 Indications for surgery Absolute Generalised peritonitis Localised peritonitis Visceral perforation Irreducible hernia

20 Relative Palpable mass lesion 'Virgin' abdomen Failure to improve Indications for surgery

Trial of conservatism : 

21 Trial of conservatism Incomplete obstruction Previous surgery Advanced malignancy Diagnostic doubt - possible ileus

Paralytic ileus : 

22 Paralytic ileus Functional obstruction most commonly seen after abdominal surgery Also associated with trauma, intestinal ischaemia, sepsis Small bowel is distended throughout its length Absorption of fluid, electrolytes and nutrients is impaired Significant amounts of fluid may be lost from the extracellular compartment

Clinical features : 

23 Clinical features recent operation or trauma Usually history of Abdominal distension is often apparent Pain is often not a prominent feature If no nasogastric tube in-situ vomiting may occur Large volume aspirates my occur via nasogastric tube Flatus will not be passed until resolution of the ileus Auscultation will reveal absence of bowel sounds

Investigation : 

24 Investigation Plain abdominal x-ray may show dilated loops of small bowel Gas may be present in the colon If doubt as to whether there is a mechanical or functional obstruction Water soluble contrast study may be helpful

Management : 

25 Management Prevention is better than cure Bowel should be handled as little as possible Fluid and electrolyte derangements should be corrected Sources of sepsis should be eradicated For an established ileus the following will be required Nasogastric tube Fluid and electrolyte replacement No drugs are available to reverse the condition Usually resolves spontaneously after 4 or 5 days



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27 15% colorectal cancers present with obstruction Most patients are over 70 years old Risk of obstruction greatest with left sided lesions Usually present at a more advanced stage 25% have distant metastases at presentation Perforation can occur at site of tumour or in a dilated caecum

Clinical presentation : 

28 Clinical presentation Caecal tumours present with small bowel obstruction Colicky central abdominal pain Early vomiting Late absolute constipation Variable extent of distension

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29 Left sided tumours present with large bowel obstruction Change in bowel habit Absolute constipation Abdominal distension Late vomiting

Investigation : 

30 Investigation Plain supine abdominal x-ray will show dilated large bowel Small bowel may also be dilated depending on competence of ileocaecal valve

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Management : 

32 Management All patients require Adequate resuscitation Prophylactic antibiotics Consenting and marking for potential stoma formation

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33 At operation Full laparotomy should be performed Liver should be palpated for metastases Colon should be inspected for synchronous tumours

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34 Appropriate operations include Right sided lesions – right hemicolectomy Transverse colonic lesion – extended right hemicolectomy Left sided lesions – various options

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35 Three-staged procedure Defunctioning colostomy Resection and anastomosis Closure of colostomy Three stage procedure will involve 3 operations! Associated with prolonged total hospital stay Transverse loop colostomy can be difficult to manage

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36 Two-staged procedure Hartmann’s procedure Closure of colostomy With two-staged procedure only 60% of stomas are ever reversed

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37 One-stage procedure Resection, on-table lavage and primary anastomosis With one-stage procedure stoma is avoided Anastomotic leak rate of less than 4% have been reported

Mortality : 

38 Mortality Irrespective of option total perioperative mortality is about 10%

Neonatal intestinal obstruction : 

39 Neonatal intestinal obstruction Neonatal intestinal obstruction can be due to a variety of causes Presenting clinical features are often similar Bile-stained vomiting is never normal in a neonate and implies obstruction 95% of babies pass meconium within the first 24 hours of life Failure to pass meconium is also a feature of obstruction The degree of abdominal distension is variable

Intussusception : 

40 Intussusception Occurs when one part of bowel invaginates (intussusceptum) into an adjacent section (intussuscipiens)  Results in intestinal obstruction and venous compression If uncorrected it can result in arterial insufficiency and necrosis

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42 It is the commonest abdominal emergency between 3 months and 2 years Peak incidence is between 6 and 9 months Most cases are idiopathic with the lead point due to enlarged Peyer's patches  Usually due to a viral infection 5% are due to polyp, Meckel's diverticulum, duplication cyst or tumour Commonest site involved is the ileocaecal junction

Clinical features : 

43 Clinical features Intermittent colicky abdominal pain and vomiting Each episode classically last 1-2 min and recurs every 15-20 min Passage of blood - 'red currant jelly' per rectum Sausage shaped abdominal mass Diagnosis confirmed with water soluble contrast enema or ultrasound

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Treatment : 

47 Treatment Resuscitation with intravenous fluids and nasogastric tube Attempt reduction with air or contrast enema under radiological guidance If peritonitis, shock or failed reduction requires surgery If bowel necrosis requires resection with primary anastomosis

Duodenal atresia : 

48 Duodenal atresia Occurs in 1 in 10,000 live births Site of obstruction is most commonly in 2nd part of duodenum Proximal duodenum become hypertrophied 50% are associated with polyhydramnios 60% of such pregnancies are complicated or end prematurely Can often be diagnosed with antenatal ultrasound 30% of babies with duodenal atresia have Down's syndrome Other associated abnormalities are cardiac anomalies, malrotation and biliary atresia Postnatally presents with bilious or non-bile stained vomiting X-ray may show a 'double-bubble' and no gas within the bowel

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Management : 

50 Management A nasogastric tube should be passed Intravenous fluid resuscitation should be given Major cardiac and other defects should be excluded Duodenoduodenostomy should be performed when resuscitated

Other atresias : 

51 Other atresias Atresias of the small bowel and colon are less common Often associated with polyhydramnios Bilious vomiting and distension are key features x-ray will show dilated bowel and a gas-free rectum A nasogastric tube should be passed Intravenous fluid resuscitation should be given At operation, dilated proximal bowel should be resected or tapered A primary anastomosis may be possible

Hirschsprung,s Disease : 

52 Hirschsprung,s Disease Due to absence of autonomic ganglion cells in Auerbach's plexus of distal large intestine Commences at internal sphincter and progresses for variable distance proximally Affects 1 in 5000 live births Male : female ratio 4:1 Some appear to be due to autosomal dominant inheritance 75% cases confined to recto-sigmoid 10% cases have total colonic involvement

Clinical features : 

53 Clinical features 80% present in neonatal period with delayed passage of meconium Followed by increasing abdominal distension and vomiting Accounts for 10% of neonatal intestinal obstruction Child is at increased risk of enterocolitis and perforation Occasionally presents with chronic constipation in infancy

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Diagnosis : 

55 Diagnosis Barium enema - Contracted rectum, cone shaped transitional zone and proximal dilatation Anorectal manometry - No recto-sphincteric inhibition reflex on rectal distension Rectal biopsy shows: Absent ganglion cells in submucosa Increased acetylcholinesterase cells in muscularis mucosa Increased unmyelinated nerves in bowel wall

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Treatment : 

57 Treatment Initial defunctioning stoma to relieve obstruction Bypass of affected segment - Duhamal or Soave bypass Excision of aganglionic segment - Swenson procedure

Meconium ileus : 

58 Meconium ileus Commonest cause of neonatal intraluminal intestinal obstruction 80% cases are associated with cystic fibrosis Cystic fibrosis occurs in 1 in 2000 live births Inherited as an autosomal recessive trait Viscid pancreatic secretions cause autodigestion of pancreatic acinar cells Resulting meconium is abnormal and putty-like in consistency Meconium becomes inspissated in the lower ileum There is a microcolon Presents with bilious vomiting and distension usually on first day of life Passage of meconium is delayed Meconium filled loops of bowel may be palpable X-ray may show a 'ground-glass' appearance, especially in the right upper quadrant

Management : 

59 Management Gastrografin enemas may be successful in 50% of patients If unsuccessful, surgery will be required Limited resection and stomas may be required

complications : 

60 complications Peritonitis from bowel perforation secondary to over-strenuous attempts at reduction of volvulus or intussusception Misdiagnosis of an ileus secondary to intra-abdominal infection as large bowel obstruction, with consequent delay in treatment Intra-abdominal abscess from anastomotic leakage Pneumonia from aspiration during emesis Dehydration Electrolyte disturbance

Sigmoid Volvulus : 

61 Sigmoid Volvulus Twisting of loop of intestine around its mesenteric attachment site may occur at various sites in the GI tract Most commonly: sigmoid & cecum Rarely: stomach, small intestine, transverse colon Results in partial or complete obstruction May also compromise bowel circulation resulting in ischemia

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62 Sigmoid volvulus most common form of GI tract volvulus Accounts for up to 8% of all intestinal obstructions Most common in elderly persons (often neurologically impaired) Patients almost always have a history of chronic constipation

Pathophysiology : 

63 Pathophysiology Redundant sigmoid colon that has a narrow mesenteric attachment to posterior abdominal wall allows close approximation of 2 limbs of sigmoid colon à twisting of sigmoid colon around mesenteric axis Other predisposing factors Chronic constipation High-roughage diet (may cause a long, redundant sigmoid colon) Roundworm infestation Megacolon (often due to Chagas dz) Peak age > 50 yrs. Second largest group à children

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64 Torsion usually counterclockwise ranging from 180 – 540 degrees Luminal obstruction generally at 180 degrees Venous occlusion generally at 360 degrees à gangrene & perforation

Signs and symptoms : 

65 Signs and symptoms May present as abdominal emergency Acute distension Colicky pain (often LLQ) Failure to pass flatus or stool (constipation is prevailing feature) Vomiting is late sign

Physical examination : 

66 Physical examination Tympanitic abdomen Abdominal distention +/- palpable mass

Diagnosis : 

67 Diagnosis Abdominal plain films usually diagnostic Inverted U-shaped appearance of distended sigmoid loop Largest  and most dilated loops of bowel are seen with volvulus Loss of haustra Coffee-bean sign à midline crease corresponding to mesenteric root in a greatly distended sigmoid Sigmoid volvulus – bowel loop points to RUQ Cecal volvulus – bowel loop points to LUQ Dilated cecum comes to rest in left upper quadrant Bird’s-beak or bird-of-prey sign à seen on barium enema as it encounters the volvulated loop CT scan useful in assessing mural wall ischemia

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Differential Diagnosis : 

69 Differential Diagnosis Large bowel obstruction due to other causes à sigmoid colon CA Giant sigmoid diverticulum Pseudoobstruction

Complications : 

70 Complications Colonic ischemia Perforation Sepsis

Treatment : 

71 Treatment Derotation & decompression by barium enema or with rectal tube, colonoscope, or sigmoidoscope if no signs of bowel ischemia or perforation Laparoscopic derotation or laparotomy +/- bowel resection Cecopexy à suture fixation of bowel to parietal peritoneum may prevent recurrence Recurrence rate after decompression alone à 50%

Intestinal Pseudo-obstruction : 

72 Intestinal Pseudo-obstruction The term intestinal pseudo-obstruction is used to indicate a syndrome characterized by a clinical picture suggestive of mechanical obstruction in the absence of any demonstrable evidence of such an obstruction in the intestine

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73 Based on clinical presentation, pseudo-obstruction syndromes can be divided into acute and chronic forms

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74 Acute colonic pseudo-obstruction is a clinical condition that appears with symptoms, signs, and radiological findings similar to those of acute large bowel obstruction, without any apparent mechanical cause

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75 Frequency: Recent studies involving more than 13,000 orthopedic and burn patients documented the prevalence of acute colonic pseudo-obstruction to be 0.29%

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76 Acute colonic pseudo-obstruction generally develops in hospitalized patients and is associated with a variety of medical and surgical conditions

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77 The most commonly associated conditions include trauma, pregnancy, cesarean delivery, severe infections, and cardiothoracic, pelvic, or orthopedic surgery

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78 Most recent reports now indicate the mean age to be in the seventh and eighth decades of life the male-to-female ratio (1.5-4:1) The mortality rate in medically treated patients has been documented to be 14%; in surgically treated patients, 30%.

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79 The most serious complication of colonic pseudo-obstruction is perforation of the cecum. The reported incidence of cecal perforation is 3-40%, and the associated mortality rate is 40-50%. Pathophysiology remains unknown

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