intestinal obstruction

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Intestinal Obstruction:

Dr AVINASH PRAKASH 1 st Yr DNB Surg Resident KIMS Intestinal Obstruction

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The Questions that will be answered: What is it? Why does it happen? Where does it happen? How does it present? How is it diagnosed by radiology? How to treat it ?

The common Scenario:

The common Scenario A 50 year old gentleman presents with abdominal pain , distension and absolute constipation . With repeated episodes of vomiting . His vital sign were stable, abdomen distended with diffuse tenderness but minimal peritonitis . Bowel Sounds are hyperactive . The plain abdominal xray was taken on admission.

What are your objectives?:

Obstruction vs ileus? Small vs large bowel? Proximal or distal ? Cause ? strangulated or simple ? How should I start investigating my patient? What is my immediate treatment plan? What are the indications for surgery? What are your objectives?


O n the basis of presence or absence of bowel activity Types Dyanamic A mechanical blockage acting as a barrier to the progression of gut contents . Adynamic : is a paralytic or functional variety of obstruction

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Dyanamic Classification Adyanamic : Intraluminal (Ex. impacted feces ) Intramural (Ex. malignancies ) Extramura l (Ex adhesions ) Peristalsis is absent (Ex. Paralytic ileus ) Peristalsis present in a non-propulsive form (Ex . Pseudo-obstruction )


Causes- Extraluminal Mural Luminal Adhesions Hernia Volvulus Neoplasms Crohns TB Intussusception Congenital F. Body Bezoars Gall stone Food Particles Ascaris

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Normal intraluminal pressure 3-5 cm H2O Int Obstruction up to 10 cm H2O Closed loop obstruction 20-30 cm H2O

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Strangulation is more common in cecum and asc colon as acc to laplace’s law the tension is max at the max diameter Large bowel strangulation is more dangerous as in nearly one third of people ileo cecal valve is competent Colonies/ml Proximal Small intestine 10 6 Distal iluem 10 8 Int obstruction 10 10

Large Bowel Obstruction:

Large Bowel Obstruction Aetiology: 1. Carcinoma 2. Inflammatory bowel disease. 3. Volvulus: 1. Sigmoid Volvulus: 2. Caecal Volvulus 4. Hernia. 5. Congenital : Hirschsprung , anal stenosis and agenesis Distinguishing ileus from mechanical obstruction is challenging Perforation results in the release of formed feaces with heavy bacterial contamination

Clinical Findings 2. Examination:

Clinical Findings 2. Examination Others Systemic examination If deemed necessary. CNS Vascular Gynaecological musculoskeletal Abdominal Abdominal distension and it’s pattern Hernial orifices Visible peristalsis Cecal distension Tenderness, guarding and rebound Organomegaly Bowel sounds High pitched Absent Rectal examination General Vital signs: P, BP, RR, T, Sat dehydration Anaemia, jaundice, LN Assessment of vomitus if possible Full lung and heart examination


PAIN : Depending on the site CLINICAL SYMPTOMS

Initial Management in the ER:

Initial Management in the ER Resuscitate: Air way (O 2 60-100%) IVF : Crystalloids at least 120 ml/h . (determined by estimated fluid loss and cardiac function). NPO. Decompress with Naso -gastric tube and secure in position Insert a urinary catheter (hourly urinary measurements) and start a fluid input / output chart Intravenous antibiotics (no clear evidence) If concerns exist about fluid overloading a central line should be inserted Follow-up lab results and correction of electrolyte imbalance “Never let the sun set or rise on an obstructed bowel ”

How to initially investigate your patient:

How to initially investigate your patient Lab: CBC ( leukocytosis , anaemia, hematocrit , platelets) Clotting profile Arterial blood gasses U& Crt , Na, K, Amylase, LFT and glucose, LDH Group and save (x-match if needed) Optional ( ESR, CRP , Hepatitis profile Radilogical : Plain x-rays USS ( free fluid, masses, mucosal folds, pattern of peristalsis, Doppler of mesenteric vasculature, solid organs) CT, MRI , Contrast studies…… ECG and other investigations for co-morbid factors


Is the small bowel obstructed ? How severe is the obstruction ? Where is it located ? What is the cause ? Is strangulation present ? RADIOLOGY


Diagnostic in 50 % CXR : superior to erect abdo X ray for pneumo peritoneum Abdo X ray : Changes appear in 3-5 hrs if complete obstruction and take days if incomplete obstruction High grade SBO : > 3.6 cm diameter of loops ; 2.5 times more in number ; air fluid levels > 2 ; wider than 2.5 cm and differing in height >2 cm String of beads sign : small bubbles of gas trapped in rows between valvulae conniventes . Diagnostic of SBO (sometimes also in IBD and Ileus) Coffee bean sign: closed loop obstr where the arms of the loop dilated with gas separated by thick intestinal wall Pseudo tumor sign : closed loop fill with fluid looks like soft tissue mass XRAY



Coffee bean sign:

Coffee bean sign


PNEUMOPERITONEUM WITHOUT PERITONITIS Postop Dialysis Laparoscopy Silent healed perforation Chest : pneumonia / emphysema PNEUMO PERITONEUM SIGNS Rigler’s air is present on both sides of the intestine Cupola Air within the median sub phrenic space RUQ gas Air under the diaphragm PSEUDO PNEUMOPERITONEUM Chilaiditi syndrome: bowel interposed Subdiaphragmatic fat Subphrenic abscess Intramural gas: pneumatosis int

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Rigler’s cupola Chilaiditi’s

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LARGEBOWEL SMALL BOWEL Haustra present Absent Number of loops Few Many Valvulae conniventes absent Present in jejunum Distribution of loops Peripheral central Radius of curvature of loops Large Small Diameter 5 cm 3-5 cm Solid feces + - XRAY CATEGORIES Normal <2.5 cm & < 4 loops, normal colon Abnormal but non specific gas Atleast one loop > 2.5cm; > 3 fluid level , normal colon gas Probable SBO Multiple gas fluid levels, small colonic gas Unequivocal SBO Dilated small bowel ; gasless colon


When CT not available Operator dependent modality Obstruction : lumen > 3 cm ; length > 10 cm ; distal seg shows to and fro or whirling motion ( differentiates from ileus ) Cause can be detected Severity : free fluid + ; aperistalsis ; bowel wall thickening > 3 mm ( sugg infarction ) USG


Water soluble contrast gets diluted Poor mucosal detail No therapeutic effect in SBO Follow through : 500 ml of 42 % barium , fluroscopic radiographs at 15-30 min interval till ileo cecal valve. When barium reaches cecum put a rectal tube and insufflate air to distend the rt colon and distal iluem Enteroclysis : duodenal intubation , 30-40% barium infusion at 60-90 ml /min Double contrast enteroclysis : followed by infusion of air / methyl cellulose BARIUM


Pros : Views area beyond reach of fibreoptic endoscopes Cons : requires hours of pt prep Difficult to localise pathology that is seen CAPSULE ENDOSCOPY


94-100 % sensitivity >2.5 cm; beak sign; Incomplete obstr : CT + enterocylsis is best High grade : 50 % diff in the calibre of proximal dil and distal collapsed Closed loop: bowel occluded at two points Prominent mesenteric vessels converging towards pt of torsion Strangulation complicates 10% of low grade and 40 % high grade . Thickening of bowel .diffuse vascular engorgement and haziness of mesentry . Poor contrast enhancement or pneumatosis intestinalis represent gangrene . Serrated beak sign: ‘U’ or ‘C’ shaped config of dilated bowel with ends producing beak like narrowing . Ascitis CT


Using water only : negative contrast ; mural lesions very prominent Using dye : positive contrast CT ENTEROCLYSIS


Can detect extra luminal patho and detailed info about the small bowel wall. And does not use ionised radiation MR ENTEROCYLSIS


ADHESIONS: They are not seen in CT Prone to high grade obstr Closed loop appearance in CT is most sensitive sign CAUSES :


Internal hernias always radiological diagn Paraduodenal : cong defect in desc colon ; cluster of small bowel loops in a sac between pancreatic tail and body and stomach Transmesentric : bowel herniates through a defect in the mesentry HERNIAS


Non rotational 0- < 90 counter clockwise before 6 wk Reverse rotational Abn > 90 and < 180 Malrotation with malfixation > 180 and < 270 counter clock wise after 10 weeks MIDGUT VOLVULUS DJ flexure down and to the right Jejunum to right of spine A cockscrew pattern : prox jejunum spiraling downwards in right USG : SMV to the left of SMA Whirlpool sign on doppler


Uncommon in adults X ray : abscece of cecal gas USG : sandwich like appearance Barium enema : claw sign ; coiled spring CT : leading mass INTUSUSCEPTION

TB :

First stage ‘Chicken intestine’; irreg contour Second stage Ulcerations Third stage Hour glass stenosis TB Fleischner sign / inverted umbrella sign: thick ileo cecal valve lips Napkin ring stenosis Goose neck deformity : shortened cecum Steirlins sign: narrowing of term ileum with rapid emptying String sign : narrow stream of barium


LARGE BOWEL OBSTRUCTION X ray : H austral margin Barium enema : CT : Virtual colonoscopy : TYPE 1 A Ileocecal valve competent . Dilated cecum TYPE 1 B Progressin of 1 A to small bowel distention . Dilated cecum. TYPE 2 Incompetent ileo cecal valve. Cecum not dilated. Small bowel dilated .


Elderly , mentally retarded , institutionalized Liver overlap sign Bird of prey sign CAUSES In half cecum twists and inverts so that it occupies LUQ In half twists in axial plane


OGILVIES SYNDROME ADYNAMIC ILEUS Disorder of intestinal motor activity Minimal symptoms Concomitant distended stomach Also called as pseudo obstruction Large bowel obstruction without evidence of mech obstr Due to imbalance in sympathetic innervation Diagnosis of exclusion Marked dilation of entire colon ADYNAMIC OBSTRUCTION


PARTIAL INTESTINAL OBSTRUCTION: Pt has distention and constipation but passing flatus. On the basis of X ray : if air is present in colon Respond to conservative management Oral gastrograffin : instilled through RT ; after 24 hrs if dye in colon then partial obstruction Capsule endoscopy : high chance of retention Breath H 2 : when carbo reach colon anaerobic breakdown USG Ascites : need for Sx Diagnostic and therapeutic lap : MANAGEMENT


INTESTINAL ADHESIONS are treated by surgical lyses of the obstructing bands if the obstruction does not resolve in several days . HERNIAS are treated by a reduction of the contents of the hernia and subsequent repair. The bowel must always be examined for necrosis . INTESTINAL TUMORS are treated by surgical removal . INTRINSIC AND EXTRINSIC lesions treatment depends on the lesion . TREATMENT


PARALYITC ILEUS “ functionally impaired transit of intestinal contents because of decreased activity of GIT in the absence of mechanical obstruction “ Postop SBO needs reoperation Postop ileus is treated conservatively Colonic gas in X ray suggests Ileus RT aspiration : only when vomiting or acute gastric distention Cisapride / mosapride / itapride ; neostigmine ; Alvimopan Prevention : avoid opiates use NSAIDS/ Epidural POSTOPERATIVE ILEUS


Contractions maybe present but are non coordinated and non propulsive In ileus contractions are absent Excessive sympathetic stimulation 88-94 % has an underlying pathology X ray : dilated colon no toxicity Colonoscopy is ideal as its therapeutic 2 mg iv rapid neostigmine Rectal tube : to decompress Sx : decompressing stomas ( cecostomy ) COLONIC PSEUDO OBSTRUCTION


Balloon dilations Colonoscopic incision Intra lesional steroids Colonic stenting Surgical resection Intralesional infliximab : for Crohns Palliation : Nd YAG , Argon ,Stents ,Chemotherapy , Anti TB COLONIC STRICTURES

Indications for Surgery:

Indications 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



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