DISCUSS INTESTINAL OBSTRUCTION (2)

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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

OUTLINE:

OUTLINE INTRODUCTION CLASSIFICATION AETIOLOGY PATHOPHYSIOLOGY CLINICAL PRESENTATION MANAGEMENT COMPLICATIONS PROGNOSIS CONCLUSION

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.

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

Classification:

Classification Dynamic / Adynamic Acute / Chronic / Acute on chronic High / Low Small bowel / Large bowel Simple / Strangulated / Close loop Complete / Partial

Aetiology:

Aetiology 1. Extramural i. Strangulated Hernia ii. Adhesions & Bands iii. Volvolus iv. Neoplasm v. Intra-abdominal abscess

Aetiology:

Aetiology Hernia Volvolus Volvolus

Aetiology:

Aetiology Bands Adhesions

Aetiology:

Aetiology 2. Intraluminal i. Ascariasis ii. Gallstone iii. Faecal impaction iv. Foreign bodies

Aetiology:

Aetiology Gallstone F.B in GIT

Aetiology:

Aetiology Ascariasis

Aetiology:

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

Aetiology:

Aetiology Intussusception Multiple atresia

Aetiology :

Aetiology Small bowel tumour Large bowel tumors

Aetiology:

Aetiology Diverticulitis Crohn’s dx

Neonatal Intestinal obstruction:

Neonatal Intestinal obstruction Intestinal atresia & stenosis Midgut Malrotation Meconium ileus & meconium plug Hirshsprung’s disease Anorectal malformation

Causes of Adynamic Ileus:

Causes of Adynamic Ileus

Metabolic Causes:

Metabolic Causes Hypokalemia. Hypomagnesemia. Hyponatremia. Ketoacidosis. Uremia. Porphyria

Medications:

Medications Narcotics. Antipsychotics. Anticholinergics. Ganglionic blockers. Agents used to treat Parkinson’s disease.

Retroperitoneal process:

Retroperitoneal process Retroperitoneal hematoma. Pancreatitis. Spinal or pelvic fracture.

Neuropathic disorders:

Neuropathic disorders Diabetes. Multiple sclerosis. Scleroderma. Lupus erythromatosis. Hirshsprung's disease.

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.

Simple Obstruction:

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

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.

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

Simple Obstruction:

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

Simple Obstruction:

Simple Obstruction Intraluminal pressure >> venous pressure ► venous congestion ► oedema of the wall ► mvt of fluid from the plasma into the gut lumen & peritoneal cavity. Death from simple intestinal obstruction is due to loss of water & electrolytes

Simple Obstruction:

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

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 mesenteric veins due to stasis of venous engorgement Hypoxia enhances the growth of anaerobic bacteria

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 mesenteric veins due to stasis of venous engorgement Hypoxia enhances the growth of anaerobic bacteria

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.

Closed Loop Obstruction:

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

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.

Clinical Presentation:

Clinical Presentation

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.

Clinical presentation:

Clinical presentation 1. Abdominal pain 1 st symptom, colicky, intermittent , central in small bowel obstruction, waxes rapidly & wanes slowly. There is relief in between spasm except in strangulation.

Clinical presentation:

Clinical presentation 2. Abdominal distension The lower the site of obstruction the more the distension. Central in small bowel obstruction. More in the flanks in colonic obstruction

Clinical presentation:

Clinical presentation 3. Vomiting Frequency & nature of vomitus depends on the level of obstruction.

Clinical presentation:

Clinical presentation High Small Bowel Obstruction Bile-Stained vomitus Lower Small Bowel Obstruction Feculent Vomitus Large Bowel Obstruction Uncommon & late symptom.

Clinical presentation:

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

Examination findings:

Examination findings

Examination Findings:

Examination Findings Dehydration Vomiting and fluid sequestration ↑PR, ↓BP, Urine – scanty & concentrated

Examination Findings:

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

Inspection:

Inspection Surgical Scars Hernias Distention Visible Peristalsis

Palpation:

Palpation Tenderness Masses Hernias iv. A rectal examination to assess for intraluminal masses and to examine the stool for occult blood, which may be an indication of malignancy, intussusception, or infarction.

Percussion & Auscultation :

Percussion & Auscultation Dullness or resonance related to site of obstruction. Bowel Sounds are initially loud and frequent→ Then as bowel distends the sounds become more resonant and high pitched→ Eventually becoming Amphoric

Investigations:

Investigations

Plain Abdominal X-rays:

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

X-RAY:

X-RAY

:

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

:

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

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.

Barium enema:

Barium enema ‘Claw’ sign of iliac intussusception. The barium in the intussusception is seen as a claw around a negative shadow of the intussusception

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.

CT Scan :

CT Scan Lt colonic tumour

Other Investigations:

Other Investigations FBC Group & Xmatch blood Urea and Electrolyte RBS.

Treatment:

Treatment

Aim of Rx:

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

Supportive Treatment:

Supportive Treatment Nil per os IVF Nasogastric aspiration Urethral catheterization Antibiotics Analgesics Correct anaemia

Conservative treatment:

Conservative treatment Partial obstruction Early post op obstruction Obstruction 2º Crohn’s disease Recurrent obstruction Open surgery if there is no improvement after 24hrs.

Operative Treatment:

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

Non-viable bowel:

Non-viable bowel Loss of peristalsis Flabby & dull Greenish or Black Loss of Pulsation in the mesenteric vessels Venous thrombosis may be seen

Specific Rx:

Specific Rx Adhesion obstruction: non operative or operative if no improvement. Strangulated hernia: release of obstruction, resection of gangrenous bowel, repair of defect

Specific Rx:

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

Specific Rx:

Specific Rx Hirshsprung's- pull through Intestinal atresia- resection + anastomosis Meconium ileus - resection + anastomosis

Complications:

Complications Fluid and dyselectrolytaemia Hypovolemic / Endotoxic Shock Peritonitis Acute Renal Failure Multiple organ

Prognosis:

Prognosis Type of obstruction Duration of obstruction Cause of obstruction Age of the patient Length of gangrenous bowel Preoperative IVF & electrolytes correction Co-morbidities

Conclusion:

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

Thank you for listening:

Thank you for listening

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