AJ INTESTINAL OBSTRUCTION 12 NOV 2015

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INTESTINAL OBSTRUCTION:

INTESTINAL OBSTRUCTION PROF:AKMAL JAMAL FCPS;FRCSEd : 12 NOV 2015

INTRODUCTION :

INTRODUCTION Accounts for 5% of all acute surgical admissions. 80% occurs in small bowel 20% occurs in colon Mortality in 3% without strangulation which increases to 30% with strangulation.

Slide 3:

WHAT’S INTESTINAL OBSTRUCTION ?

Definitions :

Definitions Intestinal Obstruction is defined as partial or complete blockage of the bowel that results in the failure of intestinal contents to pass. OR Failure of propulsion of intestinal contents

Objectives of Lecture:

Objectives of Lecture You should be able to address the following questions Is this bowel obstruction or ileus ? Is this a small or large bowel obstruction? Is this proximal or distal obstruction? What is the cause of this obstruction? Is this a complex or simple obstruction?

Objectives of Lecture:

Objectives of Lecture You should be able to address the following questions What investigations are needed? What is the role of other supportive investigations? What is immediate/ intermediate treatment plan? What are the indications for surgery?

Classification:

Classification 1.Cause of obstruction 2.Anatomical site of obstruction 3.Duration of obstruction 4.Extent of obstruction 5.Type of obstruction

1. Cause of obstruction Classified into 2 types:

1. Cause of obstruction Classified into 2 types A.Dynamic or Mechanical Obstruction B.Adynamic or Paralytic Obstruction

Dynamic Obstruction :

Dynamic Obstruction Peristalsis is working against a mechanical obstruction. The obstructing lesion may be: Extramura l Intramural Intraluminal

Cause of obstruction :

Cause of obstruction Peristalsis is absent (Ex. Paralytic ileus ) Peristalsis may be present in a non-propulsive form. (Ex. Pseudo-obstruction) Adynamic

2.Anatomical Site of Obstruction :

2.Anatomical Site of Obstruction Small Bowel Large Bowel

Small Bowel Obstruction :

Small Bowel Obstruction

3.Duration of Obstruction:

3.Duration of Obstruction Acute Obstruction usually occurs in small bowel obstruction Chronic obstruction is usually seen in large bowel obstruction In Acute on Chronic Obstruction there is a short history of distention and vomiting against a background of pain and constipation. Subacute Obstruction implies an incomplete obstruction.

4. Extent of obstruction :

4. Extent of obstruction Partial obstruction Complete obstruction

5. Type of Obstruction:

5. Type of Obstruction Simple mechanical obstruction Bowel lumen is obstructed No vascular compromise Strangulated obstruction Bowel lumen is obstructed Vascular supply is compromised

Causes- Small Bowel Obstruction:

Causes- Small Bowel Obstruction

Outside:

Outside

Extraluminal :

Extraluminal Postoperative adhesions Congenital adhesions Hernia Volvulus

Wall:

Wall

Mural :

Mural Neoplasms lipoma polyps leiyomayoma lymphoma carcimoid carinoma secondary Tumors INFLAMMATORY Crohns TB Stricture Others Intussusception Congenital

LUMEN :

LUMEN GALL STONES BEZOARS WARM s FECES

Luminal:

Luminal F. Body Bezoars Gall stone Food Particles WORMS : A. lumbricoides

Bolus Obstruction. :

Bolus Obstruction. 1. Gallstones : Gallstone Ileus (stones enter the intestine through a fistulous communication between theGB / bile duct and the GI tract) 2. Food : Bolus obstruction may occur after partial or total gastrectomy when unchewed articles can pass directly into small bowel

Bolus Obstruction. :

Bolus Obstruction. Bezoars : Trichobezoars (Hair Balls) Phytobezoar (Fruit/Vegetable Fibre ).

4. Worms: Ascaris lumbricoides may cause low small bowel obstruction particularly in children. :

4. Worms : Ascaris lumbricoides may cause low small bowel obstruction particularly in children.

MOST COMMON CAUSES:

MOST COMMON CAUSES - ADHESIONS & - EXTERNAL HERNIAS (both are more than 75% of cases) CROHN’S, TB, TUMORS, INTUSUSCEPTION. SMALL INTESTINE

Causes- Large Bowel Obstruction:

Causes- Large Bowel Obstruction

Large Bowel Obstruction:

Large Bowel Obstruction

Common Causes of LBO:

Common Causes of LBO Colon cancer-60% Diverticulitis Volvulus Hernia Benign Strictures-ISCHEMIA/RADIATION ADHESIONS are RARE CAUSE OF LBO

Special types of Obstruction:

Special types of Obstruction STRANGULATION INTUSSUSCEPTION VOLVULUS CLOSED LOOP OBSTRUCTION

Slide 31:

Ischemia of the bowel Strangulation obstruction PATHOGENESIS Loss of blood and plasma into the strangulated segment Gangrene Perforation Peritonitis Systemic absorption of toxic material

Causes of strangulation :

Causes of strangulation Ext: Herniae , Adhesions/Bands Volvulus / Intussusceptions Closed-Loop Obstruction Mesenteric Vascular Occlusion/ Infarction

Slide 33:

Causes of strangulation

Clinical features of strangulation:

Clinical features of strangulation Constant pain, severe pain Tenderness with rigidity and peritonism Shock

Slide 35:

Appearance of strangulated intestines

INTUSSUSCEPTION:

It is the invagination of one part of the bowel into the lumen of another INTUSSUSCEPTION 80% of intussusception occur in children under 2 years. In adults , the cause is tumors/polyp/ Meckel Div/ lipoma .

Slide 37:

volvulous

INTUSSUSCEPTION:

INTUSSUSCEPTION VARIETES: ILEO COLIC ILEO-ILEOCOLIC ILEO-ILEAL

Closed-loop obstruction:

Closed-loop obstruction Bowel is obstructed at both the proximal and distal point.. Cause- HERNIA/VOLVULUS COLONIC CANCER Unrelieved, this may result in necrosis and perforation.

Volvulus:

Volvulus A twisting or axial rotation of a portion of bowel about its mesentery. When complete it forms a closed loop of obstruction with resultant ischemia secondary to vascular occlusion.

1) Volvulus Neonatorum :

1) Volvulus Neonatorum Due to arrest gut rotation and narrow mesentery of small bowel and Caecum .

2) Volvulus of Small Intestine :

2) Volvulus of Small Intestine Primary or secondary and usually in the lower ileum Spontaneous or secondary

3) Cecal Volvulus :

3) Cecal Volvulus A clockwise twist · Acute features of obstruction . 25% has tympanic swelling in the midline or left side of the abdomen .

Cecal volvolus:

Cecal volvolus

4) Sigmoid Volvulus :

4) Sigmoid Volvulus An anticlockwise twist . Most Common spontaneous Volvulus in Adults. Chronic constipation is a predisposing factor .

Slide 46:

SIGMOID VOLVULUS “ COFFEE BEAN SIGN” Dilated horse-shoe shaped sigmoid colon due to volvulus .

Adhesions:

Adhesions Most common cause of small bowel obstruction . peritoneal irritation results in fibrin production, which results in adhesions Causes of adhesions Ischemic Areas, Foreign Material, Infection, Inflammatory Conditions, and Radiation Enteritis.

Slide 49:

Adhesions

Slide 50:

Pathogenesis

Patho-physiology I:

Patho-physiology I 8L of isotonic fluid received by the small intestines 7L absorbed 2L enter the large intestine 200 ml excreted in the faeces

Patho-physiology II:

Patho-physiology II Obstruction results in: 1. Initially- increased peristalsis 2. Increased intraluminal pressure by fluid and gas 3. Vomiting 4. Sequestration of fluid into the lumen from the circulation

Patho-physiology II:

Patho-physiology II Obstruction results in: 5.Lymphatic and venous congestion- oedematous tissues 6. Hypovolaemia and electrolyte imbalance 7.Further: localised anoxia, mucosal necrosis and perforation and peritonitis. 8.Bacterial over growth with translocation of bacteria and it’s toxins causing bacteraemia and septicaemia.

Clinical Presentation:

Clinical Presentation Depends on: Site . Level Duration . Underlying pathology. The presence or absence of intestinal ischemia .

Slide 55:

CARDINAL Clinical features Abdominal pain Vomiting Constipation Abdominal distention

Site:

Site

PAIN :

PAIN TRUE COLICKY . S ite - Periumbilical (small Bowel Colic) Lower 1/3 of Abdomen (Large Bowel Colic) O nse t--Sudden C haracter - Colicky R adiation - No Radiation. Generally Periumbilical or Suprapubic .

PAIN Associated symptoms-none:

PAIN Associated symptoms-none T iming - Small Bowel colic occurs every 2-20 minutes. Large Bowel Colic occurs about every 30 minutes or more. E xacerbating and Relieving Factors- Corresponds with Peristalsis S everity - Severe.

PAIN:

PAIN Sudden Onset Constant Severe INDICATES STRANGULATION/INFARCTION

VOMITING:

VOMITING Time of onset : Early : High small bowel obstruction Late : Low small bowel obstruction Delayed or absent : Large bowel obstruction

VOMITING:

VOMITING Nature of vomitus Clear gastric : Pyloric obstruction Bilious : High small bowel obstruction Feculent : Low small bowel obstruction or late colonic

DISTENTION :

DISTENTION - The lower the site of obstruction the more bowel distention. “ Higher up” Bowel Obstruction is NOT associated with distension. “ Colon” Obstruction causes the colon to distend around the periphery of the abdomen and might extend into the small bowel if the ileocaecal valve is incompetent .

ABSOLUTE CONSTIPATION :

ABSOLUTE CONSTIPATION - Develops once the block becomes complete and the bowel below is empty, so that neither feces nor flatus are passed. Occurs Early in “lower” Large Bowel Obstruction. Occurs Late in “High” Small Bowel Obstruction.

Late Manifestations:

Late Manifestations Pyrexia Respiratory Distress Dehydration Oliguria Hypovolemic Shock Peritonism Septicemia

GP EXAMINATION:

GP EXAMINATION DEHYDRATION DRY FURRED TONGUE SUNKEN DULL EYES FOETER DRY WRINKLED SKIN

ABD:EXAMINATION:

ABD:EXAMINATION 1) INSPECTION - Look For… Surgical Scars Hernias Distention Visible Peristalsis- STEP LADDER PATTERN

Surgical Scar-ADHESIVE INTESTINAL OBSTRUCTION:

Surgical Scar-ADHESIVE INTESTINAL OBSTRUCTION

ADHESIVE INTESTINAL OBSTRUCTION:

ADHESIVE INTESTINAL OBSTRUCTION

DISTENTION:

DISTENTION

Distention:

Distention

Visible Peristalsis:

Visible Peristalsis

Visible Peristalsis:

Visible Peristalsis

IRREDUCIBLE HERNIA:

IRREDUCIBLE HERNIA

Incarcerated Inguinal Hernia:

Incarcerated Inguinal Hernia

Strangulated Hernia:

Strangulated Hernia

Incarcerated Femoral Hernia causing obstruction:

Incarcerated Femoral Hernia causing obstruction

Para-umblical Hernia.:

Para-umblical Hernia.

Incisional hernia following laparatomy for peritonitis:

Incisional hernia following laparatomy for peritonitis

Skin discolouration over a strangulated incisional hernia:

Skin discolouration over a strangulated incisional hernia

ABD:EXAMINATION:

ABD:EXAMINATION 2) PALPATION – Palpate for… Masses-INFAMMATORY/NEOPLASM Hernias- GROINS/ABD:WALL Tenderness-NOT PRESENT IN SIMPLE OBSTRUCTION Perform Rectal Exam.

EXAMINATION:

EXAMINATION 3) PERCUSSION – Resonance in centre. Dull in flanks

EXAMINATION:

EXAMINATION 4) AUSCULTATION – Bowel Sounds are Initially Loud and frequent→ BORBORYGMI Then as bowel distends the sounds become more resonant and high pitched. →

Clinical Questions :

Clinical Questions 1. What is a operational concept of intestinal obstruction? 2. How is intestinal obstruction classified ? 3. What are reliable signs and symptoms of mechanical intestinal obstruction?

Clinical Questions :

Clinical Questions 4. What are signs and symptoms of strangulated intestinal obstruction? 5.What are signs and symptoms of partial intestinal obstruction? 6. What are the more common causes of Mechanical Intestinal Obstruction?

INTESTINAL OBSTRUCTION-PART II:

INTESTINAL OBSTRUCTION-PART II PROF:AKMAL JAMAL FCPS;FRCSEd : 19 DEC 2013

Investigations :

Investigations

WHY to INVESTIGATE:

WHY to INVESTIGATE ASSESS GEN:CONDITION CONFIRM DIAGNOSIS ESTABLISH CAUSE

Slide 89:

Intestinal obstruction BLOOD CP-Hematocrit WBC Electrolytes C reactive protein AST -ALT – GGT- LDH UREA/CREATININE Blood Gas ANALYSIS Laboratory test

Slide 90:

Abdominal X ray examination Barium studies/Water soluble contrast X-rays CT Scan Endoscopy Ultrasound (very difficult because of the massive presence of gas) Radiological Investigations

Abdominal -Xrays:

Abdominal - Xrays 1.SUPINE(FLAT) VIEW 2.ERECT VIEW 3.Lateral DECUBITUS View

Normal Gas Pattern:

Normal Gas Pattern Gas in stomach Gas in a few loops of small bowel Gas in rectum or sigmoid

Normal Fluid Levels:

Normal Fluid Levels Stomach Always (except supine film) Small Bowel Two levels possible Large Bowel None normally

Slide 94:

Erect Abdomen Always air/fluid level in stomach A few air/fluid levels in small bowel

Slide 95:

Small Bowel Gas Pattern Centrally located Lie transversly Soft tissue across entire lumen-VALVULAE CONIVENTES-concertina effect Colon Gas Pattern Peripheral Located Caecum -rounded gas shadow,in R I FOSSA Haustral markings Spaced irregularly Donot cross the whole diameter of colon

Slide 96:

Supine or Flat Abdominal Film Dilated Loops of Small Bowel Central location Valvulae conniventes No Air in Colon or Rectum

Erect X-RAY:

Erect X-RAY Small Bowel Obstruction “Step ladder” pattern,. Air-fluid levels .

SMALL BOWEL OBSTRUCTION:

SMALL BOWEL OBSTRUCTION ERECT Note dilated small bowel centrally placed with air/fluid levels / valvulae coniventes Ng tube

X-RAY:

X-RAY Distended Large Bowel Tends to lie peripherally show the Haustrations

Slide 100:

COLON OBSTRUCTION Distension extends to distil descending colon.

OTHER CAUSES of FLUID LEVELS:

OTHER CAUSES of FLUID LEVELS Non obstructive causes 1.Infl bowel diseases 2.Ac: Pancreatitis 3.Peritonitis 4.IA SEPSIS

The Difference between small and large bowel obstruction:

The Difference between small and large bowel obstruction Small Bowel Large bowel Central ( diameter 3 cm max) Vulvulae coniventae Ileum: may appear tubeless Peripheral ( diameter 6 cm max) Presence of haustration

Contrast studies: :

Contrast studies: Indications are controversial . Identify site and often the cause of obstruction . Differentiate between ileus -partial and complete obstruction.

Contrast X-RAY :

Contrast X-RAY Barium Follow-Through Gastrograffin Follow-Through Enteroclysis Barium enema Xrays

Slide 105:

PARTIAL SMALL BOWEL OBSTRUCTION DILATED BOWEL NON DILATED BOWEL OBSTRUCTION * Proximal loops are dilated and distil loops are collapsed indicating an obstruction.

Slide 106:

SM. BOWEL BARIUM STUDY Note hernia in right lower quadrant

ENTEROCLYSIS:

ENTEROCLYSIS 11/12/2015 Shwartz

Ba Enema: ileocecal intussusception CLAW SIGN :

Ba Enema: ileocecal intussusception CLAW SIGN

Ba Enema SIGMOID VOLVULUS:

Ba Enema SIGMOID VOLVULUS “BEAK SIGN” Barium fills to point of obstruction and twist of sigmoid colon

Slide 110:

Intestinal obstruction Is sensitive for diagnosing complete/incomplete obstruction determining the location cause CT scan

CT, Small bowel obstruction:

CT, Small bowel obstruction

CT, Large bowel obstruction:

CT, Large bowel obstruction

Slide 113:

Ultrasonography Ultrasonography is less costly and less invasive than CT scanning. The sonographic findings of an obstructed bowel include dilated fluid- filled bowel loops. dilated loops show thickened wall thickened valvulae conniventes increased peristalsis

US showing a dilated small bowel (arrow heads) with thickened mucosa :

US showing a dilated small bowel (arrow heads) with thickened mucosa

LAPAROSCOPY:

LAPAROSCOPY

COLONOSCOPY:

COLONOSCOPY

Complications Intestinal Obstruction:

Complications Intestinal Obstruction Dehydration/Electrolyte Imbalance Oliguria Hypovolemic shock, Pyrexia Septicaemia Respiratory embarrassment Peritonitis

Slide 119:

“ Drip and Suck ” Drip - IV Fluids Suck- via Nasogastric Aspiration. Conservative Treatment

Slide 120:

Gastric Aspiration via Nasogastric Tube; This decompress the bowel and remove risk of inhaling gastric contents during anesthesia. .   Treatment

Slide 122:

2. I V Fluid replacement Give normal Saline, Potassium chloride-20 meq or _ Hartmann`s Sol/Ringer-lactate Treatment

What kind of iv fluids ? :

What kind of iv fluids ? 1) Saline 2) Ringers lactate 3) Dextrose 5% 4) Half – and Full strenght Darrow solution 5.Possibly Blood or Plasma if patient is shocked.

How much IV fluids?:

How much IV fluids? The right answer is : DEPENDS ON DEHYDRATION other names: HYPOVOLAEMIA or DEFICIT

How much iv fluid is needed? Rough guidelines for person of 60 kg :

How much iv fluid is needed ? Rough guidelines for person of 60 kg Mildly dehydrated: Signs? - lips and tongue dry - 4 liters iv

How much iv fluid is needed? Rough guidelines for person of 60 kg:

Moderatly dehydrated: Signs ? - also sunken eyes, loss of skin elasticity: - 6 liters iv How much iv fluid is needed ? Rough guidelines for person of 60 kg

How much iv fluid is needed? Rough guidelines for person of 60 kg :

How much iv fluid is needed ? Rough guidelines for person of 60 kg Severily dehydrated: S igns ? - also oliguria/anuria, hypotension, clammy extremities: - 8 liters iv .

Slide 130:

3 . ANALGESICS Narcotics NSAIDS ANTISPASMODICS-NOT USED Treatment

Slide 131:

4. Antibiotic Therapy Started if Strangulation is found or suspected.   Treatment

MONITORING:

MONITORING Foley`s catheter - monitor urine output. Central venous or pulmonary artery catheter monitoring -in shock/heart failure Urea/Electrolytes -twice daily

How long should non-operative management be tried? :

How long should non-operative management be tried? 85-95% of patients with adhesive SBO show marked improvement within 72 hours EAST guidelines 2009: 3-5 days Bologna guidelines 2010: 3 days

Indications for surgery :

Indications for surgery . Generalized or localized peritonitis. Perforation. Obstructed/Strangulated hernia. Palpable mass.(Tumors) Closed loop Failure to improve .

Operative treatment :

Operative treatment Incisions Finding the cause What to do next ? Post operative care

Incisions:

Incisions

SURGICAL APPROACH:

SURGICAL APPROACH MIDLINE LAPAROTOMY INCISION Assesment is directed to: 1.Site of Obstruction 2.Nature of obstruction 3.Viability of bowel

:

HOW to DECOMPRESS? In small bowel by SUCTION? 1) via naso gastric tube and maneuver (C) is the preferred method 2) metal decompressor or 3) urine catheter, large size

Intussusception:

Intussusception

Finding the cause:

Finding the cause Is Gut dead or viable? Signs?

Operative Findings; Small bowel gangrene:

Operative Findings; Small bowel gangrene

SURGICAL PROCEDURES:

SURGICAL PROCEDURES ADHESOLYSIS ENTEROTOMY RESECTION of MASSES INTESTINAL BYPASS STOMA FORMATION

ADHESOLYSIS:

ADHESOLYSIS

ADHESIVE INTESTINAL OBSTRUCTION:

ADHESIVE INTESTINAL OBSTRUCTION

ADHESIVE INTESTINAL OBSTRUCTION:

ADHESIVE INTESTINAL OBSTRUCTION

Slide 149:

1). Lysis of adhesion

Slide 150:

Small bowel obstruction This operation was for a complete small bowel obstruction in a patient whose only prior abdominal operation was an open appendicectomy .

Can adhesions be prevented? :

Can adhesions be prevented? Hyaluronic acid Carboxymethylcellulose Icodextrin 4% solution

Slide 152:

Enterotomy

Enterotomy :

Enterotomy

Slide 154:

small intestine disease Bypass procedure for nonresectable lesions.

INTESTINAL RESECTION& ANASTOMOSIS:

INTESTINAL RESECTION& ANASTOMOSIS

Enterectomy for nonresectable lesions:

Enterectomy for nonresectable lesions

Slide 160:

2015/11/12 small intestine disease 160 Enterostomy

COLOSTOMY :

COLOSTOMY Purposes ( 1 ) to decompress an obstructed colon ( 2 ) to divert the fecal stream ( 3 ) to serve as the point of evacuation of stool ( 4 ) to protect a distal anastomosis following resection

Slide 162:

types of colostomies A loop colostomy

Slide 163:

End colostomy

ADYNAMIC OBSTRUCTION:

ADYNAMIC OBSTRUCTION

Paralytic Obstruction of Intestine :

Paralytic Obstruction of Intestine Definition: A failure of transmission of peristaltic wave secondary to neuromuscular failure This will leads to signs of intestinal obstruction Distension , Absent bowel sounds Constipation, but NO Pain .

Classification of Adynamic Obstruction:

Classification of Adynamic Obstruction Paralytic Ileus –small bowel Pseudo-Obstruction-large bowel Acute Mesenteric Ischemia

Paralytic ileus :

Paralytic ileus CAUSES Post operative : - Self limiting, Lasts for 24-72 Hours -No bowel sounds -No passage of flatus IA Infection : Peritonitis

Paralytic Ileus Gas filled loops /multiple fluids level:

Paralytic Ileus Gas filled loops /multiple fluids level

Paralytic ileus :

Paralytic ileus CAUSES 3 . Reflex ileus : F racture of the spine or ribs Retroperitoneal hemorrhage Metabolic : Hypokalemia , DM, Uraemia

Paralytic ileus :

Paralytic ileus CAUSES 5. Drugs : Spasmolytic Drugs , Parkinson Drugs, Atropine,Antidepressants 6.Neurological Diseases- Stroke/SA HEMORRHAGE

Management:

Management General principles Remove the cause Relieve GI distension by decompression Monitoring fluid and electrolyte balance

Slide 172:

Medication Suppositories and Enemas Use of prokinetic agents Metoclopramide , a dopaminergic antagonist Rectal cisapride ( Propulsid ), a serotonin agonist Erythromycin, a motilin receptor agonist Administration of neostigmine ,

Pseudo-Obstruction of COLON:

Pseudo-Obstruction of COLON Obstruction of the colon, in the absence of a mechanical cause or acute intra-abdominal disease. It is associated with a variety of syndromes where there is an underlying neuropathy and/or myopathy .

Colonic pseudo-obstruction:

Colonic pseudo-obstruction Acute form: The acute form is known as Ogilvie syndrome

Colonic pseudo-obstruction:

Colonic pseudo-obstruction Abdominal radiographs show evidence of colonic obstruction with marked caecal distension being a common feature Perforation is a common complication.

Plain Abdominal Radiograph-Ogilvie Syndrome   :

Plain Abdominal Radiograph-Ogilvie Syndrome  

Colonic pseudo-obstruction:

Colonic pseudo-obstruction TREAMENT Colonoscopic Decompression Laparotomy –CAECOSTOMY Subtotal Colectomy and Ileorectal anastomosis .

Slide 178:

Thank you

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