DISCUSS INTESTINAL OBSTRUCTION

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DISCUSS INTESTINAL OBSTRUCTION:

DISCUSS INTESTINAL OBSTRUCTION PRESENTER : DR AROJU S.A MODERATOR : DR P ABUR DEPARTMENT OF SURGERY ABUTH, SHIKA – ZARIA 12/24/2012

OUTLINE:

OUTLINE INTRODUCTION CLASSIFICATION AETIOLOGY PATHOPHYSIOLOGY CLINICAL PRESENTATION MANAGEMENT COMPLICATIONS PROGNOSIS CONCLUSION 12/24/2012

Introduction:

Introduction Definition Stoppage of the cranio-caudal movement of bowel contents due to narrowing or complete blockage of the bowel lumen. It is one of the commonest surgical emergencies worldwide. 12/24/2012

Introduction:

Introduction It is commoner in the small bowel than the large bowel. It is important to make early and correct diagnosis. Treatment must be prompt & appropriate 12/24/2012

Classification:

Classification Dynamic / Adynamic Acute / Chronic / Acute on chronic High / Low Simple / Strangulated / Close loop Complete / Partial 12/24/2012

Adynamic Ileus:

Adynamic Ileus Paralytic ileus It is due to paralysis of intestinal musculature Characterized by absence of peristalsis & pain 12/24/2012

Dynamic Ileus:

Dynamic Ileus Peristalsis is working against a mechanical obstruction. It may be acute or chronic. Associated with abdominal pain 12/24/2012

Aetiology:

Aetiology 12/24/2012

Aetiology:

Aetiology 1. Extramural i. Strangulated Hernia ii. Adhesions & Bands iii. Volvolus 12/24/2012

Strangulated External Hernia:

Strangulated External Hernia 12/24/2012

Adhesions & Bands:

Adhesions & Bands 12/24/2012

Volvolus:

Volvolus 12/24/2012

Annular pancreas:

Annular pancreas 12/24/2012

Aetiology:

Aetiology 2. Intraluminal i. Ascariasis ii. Gallstone iii. Faecal impaction iv. Foreign bodies 12/24/2012

Gallstone ileus:

Gallstone ileus 12/24/2012

Ascariasis:

Ascariasis 12/24/2012

F.B in GIT:

F.B in GIT 12/24/2012

Aetiology:

Aetiology 3. Intramural i. Atresia ii. Anorectal anomalies iii. Intussusception iv. Aganglionic megacolon v. Tumours vi. Inflammatory lesions 12/24/2012

Intussusception :

Intussusception 12/24/2012

Small & Large bowel tumors:

Small & Large bowel tumors 12/24/2012

Multiple atresia:

Multiple atresia 12/24/2012

Duodenal web:

Duodenal web 12/24/2012

Crohn’s dx & Diverticulitis:

Crohn’s dx & Diverticulitis 12/24/2012

COMMON CAUSES OF INTESTINAL OBSTRUCTION ACCORDING TO AGE:

COMMON CAUSES OF INTESTINAL OBSTRUCTION ACCORDING TO AGE 12/24/2012

Causes of Adynamic Ileus:

Causes of Adynamic Ileus 12/24/2012

Metabolic Causes:

Metabolic Causes Hypokalemia. Hypomagnesemia. Hyponatremia. Ketoacidosis. Uremia. Porphyria. Heavy metal poisoning. 12/24/2012

Medications:

Medications Narcotics. Antipsychotics. Anticholinergics. Ganglionic blockers. Agents used to treat Parkinson’s disease. 12/24/2012

Retroperitoneal process:

Retroperitoneal process Retroperitoneal hematoma. Pancreatitis. Spinal or pelvic fracture. 12/24/2012

Neuropathic disorders:

Neuropathic disorders Diabetes. Multiple sclerosis. Scleroderma. Lupus erythromatosis. Hirshsprung's disease. 12/24/2012

Intra-abdominal surgery:

Intra-abdominal surgery Motility usually returns for the: small bowel within 24 – 48 hrs. gastric within 48 hrs. colonic within 3-5 days. 12/24/2012

Pathophysiology:

Pathophysiology 12/24/2012

Simple Obstruction:

Simple Obstruction Below the obstruction, the bowel exhibits normal peristalsis and absorption until it becomes empty, when it contracts and becomes immobile. 12/24/2012

Simple Obstruction:

Simple Obstruction Above the obstruction, peristalsis is increased to overcome the obstruction, If the obstruction is not relieved the bowel begins to dilate resulting in flaccidity and paralysis. 12/24/2012

Simple Obstruction:

Simple Obstruction The gases are mostly from swallowed air and products of putrefaction & of intestinal contents by bacteria. The fluids are mainly digestive juices 12/24/2012

Simple Obstruction:

Simple Obstruction The fluids accumulate due to loss of the absorbing surface of bowel & disordered fluid & electrolyte transport in the obstructed segment. 12/24/2012

Simple Obstruction:

Simple Obstruction When raised intraluminal pressure is more than venous pressure , there would be venous congestion , oedema of the wall, & mvt of fluid from the plasma into the gut lumen & peritoneal cavity. Death from intestinal obstruction is due to loss of water & electrolytes 12/24/2012

Simple Obstruction:

Simple Obstruction The higher the level of obstruction, the earlier the onset of fluid & electrolytes imbalance. In high obstruction, metabolic acidosis is common because the fluid loss is acid. In low obstruction, metabolic acidosis is likely bcs the sequestered fluid alkaline. 12/24/2012

Strangulation Obstruction:

Strangulation Obstruction When the pressure of the occluding band exceeds the venous pressure Venous engorgement of gut wall Dilatation of intramural lymph channels that carry multiplying bacteria from mucosa surface into systemic circulation. 12/24/2012

Strangulation obstruction:

Strangulation obstruction If the strangulated loop is long, release of the obstruction may cause severe endotoxic shock because of faster absorption of toxins & bacteria from the devitalized gut. Increased venous pressure ► rupture of capillaries ► bleeding into the lumen, wall of the gut & peritoneal cavity. 12/24/2012

Strangulation obstruction:

Strangulation obstruction Necrosis of tissues may be due to Tight occluding band obstruct arterial supply Reflex arterial spasm to venous congestion Thrombosis of intramural & mesenteric veins due to stasis of venous engorgement Hypoxia enhances the growth of anaerobic bacteria 12/24/2012

Closed Loop Obstruction:

Closed Loop Obstruction Afferent & efferent limbs of bowel are obstructed. Typically seen in colonic obstruction with competent iliocaecal valve 12/24/2012

Closed loop obstruction:

Closed loop obstruction The rich bacterial floral adds to the production of gases Rapid distension ► ↑luminal pressure ► circulation impairment ► bowel necrosis & perforation ► fulminant peritonitis. 12/24/2012

Clinical Presentation:

Clinical Presentation 12/24/2012

Clinical presentation:

Clinical presentation The cardinal features of obstruction are pain, vomiting, distension & constipation but clinical presentation varies according to: Site of obstruction . Age of Presentation. Underlying pathology. The presence or absence of ischemia. 12/24/2012

Clinical presentation:

Clinical presentation Abdominal pain 1 st symptom, colicky, intermittent , central in small bowel obstruction, waxes rapidly & wanes slowly, relief in between spasm but persistent pain between spasms of colicky pains. 12/24/2012

Clinical presentation:

Clinical presentation 2. Abdominal distension The lower the site of obstruction the more the distension. It varies inversely as the vomiting. 12/24/2012

Clinical presentation:

Clinical presentation 2. Abdominal distension Central in small bowel obstruction. More in the flanks in colonic obstruction 12/24/2012

Clinical presentation:

Clinical presentation 3. Vomiting Frequency & nature of vomitus depends on the level of obstruction. 12/24/2012

Clinical presentation:

Clinical presentation Pyloric Obstruction W atery and acidic vomitus High Small Bowel Obstruction Bile-Stained vomitus Lower Small Bowel Obstruction Feculent Vomitus Large Bowel Obstruction Uncommon & late symptom. 12/24/2012

Clinical presentation:

Clinical presentation 4 . Absolute constipation Occurs Early in “lower” Large Bowel Obstruction. Occurs Late in “High” Small Bowel Obstruction. 12/24/2012

Examination findings:

Examination findings 12/24/2012

Examination Findings:

Examination Findings Dehydration Common in small bowel obstruction Vomiting and fluid sequestration 12/24/2012

Examination Findings:

Examination Findings Pyrexia may indicate: • the onset of ischaemia; • intestinal perforation; • inflammation associated with the obstructing disease. Hypothermia indicates septicaemic shock. 12/24/2012

Inspection:

Inspection Surgical Scars Hernias Distention Visible Peristalsis 12/24/2012

Palpation:

Palpation Masses Hernias Tenderness Perform Rectal Exam. 12/24/2012

Percussion :

Percussion Percuss to hear any Dullness or Resonance related to site of obstruction. 12/24/2012

Auscultation:

Auscultation Bowel Sounds are Initially Loud and frequent→ Then as bowel distends the sounds become more resonant and high pitched→ Eventually becoming Amphoric 12/24/2012

Investigations:

Investigations 12/24/2012

Plain Abdominal X-rays:

Plain Abdominal X-rays usually diagnostic of bowel obstruction in more than 60% of the cases, but further evaluation (possibly by CT or barium ) may be necessary in 20% to 30% of cases. 12/24/2012

X-RAY:

X-RAY 12/24/2012

:

Small Bowel Obstruction with characteristic air-fluid levels . The air rises above the fluid and there is a flat surface at the air-fluid interface. X-RAY 12/24/2012

:

Distended Large bowel tends to lie peripherally and to show the hustrations of the Taenia Coli. X-RAY 12/24/2012

Barium Studies:

Barium Studies are recommended in patients with a history of recurring obstruction or low-grade mechanical obstruction to precisely define the obstructed segment and degree of obstruction. 12/24/2012

Barium meal:

Barium meal Jejunojejunal Intussusception 12/24/2012

CT Scan:

CT Scan CT examination is particularly useful in patients with a history of abdominal malignancy, in postsurgical patients, and in patients who have no history of abdominal surgery and present with symptoms of bowel obstruction. 12/24/2012

CT Scan :

CT Scan Rt colonic tumour 12/24/2012

Other Investigations:

Other Investigations CBC Group & Xmatch blood Urea and Electrolyte RBS. 12/24/2012

Treatment:

Treatment 12/24/2012

Aim of Rx:

Aim of Rx Aim is to relieve obstruction as soon as possible before strangulation occurs or before systemic complications set in. 12/24/2012

Supportive Treatment:

Supportive Treatment Nil per os Fluid and electrolyte Nasogastric aspiration Urethral catheterization Antibiotics Analgesics Correct anaemia 12/24/2012

Conservative treatment:

Conservative treatment Partial obstruction Early post op obstruction Obstruction secondary to Crohn’s disease Recurrent obstruction Open surgery if no improvement after 24hrs 12/24/2012

Operative Treatment:

Operative Treatment Procedure depends on cause of obstruction Non-viable gut must be resected Questionable gut should be checked for viability 12/24/2012

Non-viable bowel:

Non-viable bowel Loss of peristalsis Loss of Sheen Greenish or Black (Not Purple) Loss of Pulsation in supplying vessels 12/24/2012

Specific Rx:

Specific Rx Adhesion obstruction: non operative Strangulated Int. / Ext. hernia: release of obstruction, resection of gangrenous bowel, repair of defect 12/24/2012

Specific Rx:

Specific Rx Intussusception: Hydrostatic / Pneumatic reduction under fluoroscopy. Volvolus: (viable) enema saponis for detorsion (nonviable appropriate resection & anastomosis) 12/24/2012

Specific Rx:

Specific Rx Hirshsprung's- pull through Intestinal atresia- resection + anastomosis Duodenal atresia- duodenoduodenostomy Meconium ileus - resection + anastomosis Pyloric stenosis - pyloromyotomy 12/24/2012

Complications:

Complications Fluid and dyselectrolytaemia Hypovolemic / Endotoxic Shock Peritonitis Adhesion/ Garres’ obstruction Acute Renal Failure Multiple organ 12/24/2012

Prognosis:

Prognosis Type of obstruction Duration of obstruction Cause of obstruction Age of the patient Length of gangrenous bowel 12/24/2012

“Never let the sun rise or set on small-bowel obstruction” :

“Never let the sun rise or set on small-bowel obstruction” THANK YOU FOR YOUR AUDIENCE 12/24/2012

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