Intestinal Obstruction

Hussam Abdur Rab 07-72

Ilma Savul 07-81

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 peritonism. Bowel
Sounds are hyperactive.

The plain abdominal xray

was taken on admission.
Image courtesy of Ademola Adewale, MD
emedicine.medscape.com/intestinalobstr
uction

Definition
Intestinal Obstruction :
Any obstruction, partial or complete, that
causes hindrance to the passage of the
intestinal contents; most common
symptoms are abdominal pain, vomiting,
and distention.
The block may be complete or incomplete,
may be mechanical or paralytic, and may
Dorland's Pocket 28th Edition Medical
or may not compromise
the vascular
Dictionary

Classification
Intestina
l
Obstruct
ion
Adynami
c

Dynamic

Intralum
inal

Intramur
al

Extramu
ral

Absent
Peristalsi
s

Bailey and Love's Short Practice of Surgery, 25th

Edition, Volume 2

Present
Peristalsi
s

Classification
Speed of onset acute / chronic / acute on

chronic (large bowel obstruction leading

ultimately to small bowel obstruction)
Site high / low
Nature simple / strangulating

Bailey and Love's Short Practice of Surgery, 25th

Edition, Volume 2

Bailey and Love's Short Practice of Surgery, 25th

Edition, Volume 2

Pathophysiology
Distal loop
collapses

Inc
peristalsis
proximally
(colic)

Dilates with
gas and
fluid

Reduced
strength,
flaccidity

Proximal
dilation

Impaired
blood
supply

Mucosal
ulceration
and
perforation

Bowel

obstructio
n

U.S. National Library of Medicine

Clinical Features
Four cardinal symptoms:
1. Colicky abdominal pain
2. Distension
3. Absolute constipation
4. Vomiting

U.S. National Library of Medicine

Clinical Features
Signs :

The patient shows with dehydration due to

copious vomiting, and may be rolling about
with colicky pain.
2. The pulse is elevated but the temp. is
frequently normal.
3. Raised temperature and rapid pulse
suggests strangulation.
4. The abdomen may even be distended and
peristalsis may be visible.
1.

U.S. National Library of Medicine

Examination
Inspection abdominal scar / strangulated

external hernia
Palpation generalized abdominal tenderness /

palpable mass
Auscultation increased / absent bowel sounds
Per Rectal exam fecal impaction
U.S. National Library of Medicine

Risk Factors
Modifiable

Non-Modifiable

GI tract, abdominal
Infants - congenital
surgery
bowel deformities
(atresia,
Hernia
imperforate anus)
Inflammatory
Old age
disease
Family history of
Cancer
colorectal cancer
Foreign bodies (fruit
pits, gallstones,
worms)
Chronic, severe
constipation
U.S. National Library of Medicine
Thrombosis,

Dynamic/Mechanical
A mechanical or dynamic obstruction is when
peristalsis is working against a mechanical
obstruction.
These include Intraluminal, Intramural,
Extramural

Adynamic/Paralytic
In paralytic or adynamic obstruction, peristalsis
may be absent (e.g. Paralytic ileus)
It may be present in a non-propulsive form (e.g.
Mesenteric vascular occlusion or pseudoobstruction).
U.S. National Library of Medicine

Mechanical
Obstruction

Adynamic Ileus

Gas proximal to

obstruction site
Step ladder pattern of
air-fluid levels
Tinkling abdomen
Obvious transition
point on contrast
study
No peritoneal exudate

Gas diffusely through the intestine,

including the colon

May have large air-fluid levels
Quiet abdomen
No obvious transition point on

contrast study
Peritoneal exudate if peritonitis

U.S. National Library of Medicine

Mechanical Obstruction

U.S. National Library of Medicine

Adynamic Ileus

U.S. National Library of Medicine

Dynamic Obstruction

Intralumi
nal

Intramura
l

Extramur
al

Impaction
Foreign
bodies
Bezoars
Gallstones
Parasites

Stricture
Malignancy
Inflammati
on

Bands/adh
esion
Hernia
Volvulus
Intussusce
ptions

U.S. National Library of Medicine

Extramural Causes

Adhesions usually post op

Hernia
External (e.g. inguinal, femoral, umbilical)
Internal (foramen of winslow, hole in the

mesentery, diaphragmatic hernias etc.)

Volvulus sigmoid / cecal
Intussusception -

British Medical Journal 2005

Adhesions

British Health Journal 2002

British Health Journal 2002

British Health Journal 2002

CASE SCENARIO
A 75-year old Caucasian male presented to the emergency
department with severe abdominal distension and mild
dyspnea. His medical history was significant for diabetes
mellitus, coronary artery disease, and a myocardial
infarction. He had undergone bilateral inguinal hernia
repairs. The patient also admitted with a history of chronic
constipation for which he often self-medicated. He has not
had a bowel movement for ten days.
Physical examination revealed a thin elderly gentleman with
a massively distended abdomen; it was tympanic to
percussion with minimal bowel sounds and visibly dilated
loops of bowel. The abdomen was non-tender and there
were no signs of peritonitis. Digital rectal examination
revealed an empty rectal vault and no intraluminal masses.
Abdominal radiographs were obtained and showed massively
distended large bowel
British Health Journal 2002

Volvulus

The Washington Manual of Medical Therapeutics, 32nd edition

Caecal
Caecal volvulus
volvulus

Clockwise rotation
Females
Acute presentation
Partial or complete

Barium enema shows

absence of barium in
caecum and bird beak
deformity

Sigmoid
Sigmoid volvulus
volvulus

Anticlockwise rotation
Predisposing
factors:
Ch. constipation, high
residue diet
Radiograph shows
dialated bowel loop
running diagonally
right to left, with 2
fluid levels.

The Washington Manual of Medical Therapeutics, 32nd

edition

Cecal Volvulus
Beak-like transition
The dilated cecum is located in the left upper
quadrant.
Also notice the collapsed descending colon
British Health Journal 2002
posterior to the
dilated cecum (curved arrow)

CASE SCENARIO
A 51-year-old white woman with no significant past medical
history presented to the emergency department (ED) with a
2-day history of progressive nausea, vomiting, watery
diarrhea, and subsequent right lower quadrant abdominal
pain. The pain was dull, aching, not related to food intake,
and not exacerbated with exercise. She took daily
multivitamins and denied a family history of colon cancer or
inflammatory bowel disease (IBD). The patient had undergone
an open appendectomy about 14 years ago.
Her vital signs on admission to the ED were stable. The physical
exam was remarkable for right lower quadrant tenderness
with mild guarding; there was no rebound tenderness. A mass
was palpable in the left upper quadrant. Results of laboratory
studies were within the normal range, including complete
blood count, chemistry panel with liver function tests, and
urinalysis.
CT scan was done.

Image courtesy of Ademola Adewale, MD

emedicine.medscape.com/intestinalobstruction

Intussusception
The telescoping of one part of
the bowel into another
The blood supply is cut off by
direct pressure of the outer
layer and by stretching of its
supplying mesentery if
untreated it will lead to
gangrene

World Journal of Surgery

Colo-colic intussusception showing claw sign

World Journal of Surgery

World Journal of Surgery

Intraluminal Causes

Gallstones
Impaction ( food / stercolith )
Foreign body
Bezoars
Worms

Bailey and Love's Short Practice of Surgery, 25th

Edition, Volume 2

CASE SCENARIO
A 74-year-old woman presented to the emergency
department with a three day history of vomiting,
distension, constipation, and abdominal pain. Laboratory
tests revealed elevated levels of blood urea nitrogen
(182 mg/dl; normal, 15-43) and creatinine (1.90 mg/dl;
normal 0.6-1.1). Plain abdominal x-ray film showed a
dilated small intestine in the left upper quadrant. The
patient was admitted to the internal medicine ward with
a diagnosis of acute renal failure with abdominal pain.
Abdominal sonographic examination was performed one
day after admission. Findings included increased
gallbladder wall thickness with tiny mural gas shadowing
collapsed wall appearance, pericholecystic fluid
collection, and increased echo in the gallbladder fossa.
The small intestine was dilated and the valvula
conniventes were visible.

ZUHN, Surgical Ward

Gall Stones
Secondary to

erosion of a large
gallstone through
the gall bladder into
the duodenum.
Mostly 60cm
proximal to the
ileocecal valve.
Diagnostic air fluid
level in the biliary
tree.
Bailey and Love's Short Practice of Surgery, 25th
Edition, Volume 2

Foreign Bodies

National Health Service, UK

Bezoars
Trychobezoar
undigested masses of hair balls
Could be due to hair chewing
May be associated with an underlying

psychiatric disorder
Phytobezoar
Due to high fruit/vegetable fiber intake
Inadequate chewing
Previous gastric surgery
Hypocholorhydria
Loss of gastric pump function
Bailey and Love's Short Practice of Surgery, 25th
Edition, Volume 2

Worms
Ascaris Lumbricoides

may be the causative

agent
If worms are not seen in
the stool or vomitus the
diagnosis may be
indicated by
eosinophilia or the sight
of worms within gasfilled small bowel loops
on a plain radiograph.
Occasionally,
perforation and
peritonitis may occur.
Bailey and Love's Short Practice of Surgery, 25th
Edition, Volume 2
Image courtesy of JOHN BAVOSI/SCIENCE PHOTO
LIBRARY

Intramural Causes

Inflammation Crohns
Disease

National Health Service, UK

Gross pathologic features of Crohns disease.

A, Serosal surface demonstrates extensive fat wrapping and
inflammation.
B, Resected specimen demonstrates marked fibrosis of the intestinal
wall, stricture, and segmental mucosal inflammation.
C, Small bowel series in a patient with Crohns disease demonstrates a
narrowed distal lumen (arrows)
secondary
National Health
Service,to
UKchronic inflammation and

Adenocarcinoma

Barium radiograph
demonstrates a typical
apple-core lesion (arrows)
caused by adenocarcinoma of
the small bowel, producing a

CT scan of abdomen demonstrates a

small bowel neoplasm (arrow).

National Health Service, UK

Large circumferential mucinous

adenocarcinoma of the jejunum.

Small bowel lymphoma presents as

perforation and peritonitis.

National Health Service, UK

National Health Service, UK

Intestinal Obstruction and

Compromised Vascularity

The obstructed intestine may be

Strangulated, or
Non-strangulated

Strangulation will show Hemodynamic

Instability and Peritoneal Sign.

Features suggesting strangulation :

Toxic appearance, rapid pulse + elevated

temperature
Colicky pain continuous as peritonitis
develops
Marked tenderness and abnormal rigidity
Bowel sounds reduced
Raised WBC. Mostly neutrophils

Partial and Complete

Obstruction
Partial
Passage of
Flatus
Presence of
bowel
movements
Abdominal
distention

Complete
Presence of
cardinal
signs of
intestinal
obstruction
Collapsed
rectal valve

Small and Large Bowel

Obstruction
Small Bowel
Obstruction

Large Bowel
Obstruction

Acute onset
Vomiting
prominent
Vomitous not
feculent
Pain at frequent
intervals
Minimal
Distention

Less acute onset

Vomiting less
prominent
Feculent
vomiting if
present
Pain at less
frequent
intervals
Noticable

Closed loop obstructions

Occurs when the bowel is obstructed at

both the proximal and distal points

Usually this is due to adhesions, a twist of
the mesentery or internal herniation
In the small bowel, the risk of strangulation

and bowel infarction is high with a

mortality rate of 10-35%

Closed Loop Obstruction

CT presentation depends on two things

Length of the bowel segment that forms
the closed loop
Orientation of the loop in relation to the
imaging plane.

U or C shaped loops of bowel. Point of obstruction has a

beak-like appearance.

Have You Been Paying

Attention
67 year old otherwise healthy woman presents

to the ED with a chief complaint of abdominal

pain, nausea and vomiting for five Days
The pain is crampy, diffuse and worsening with
time; she denies any fevers, sweats, chills
or hematemesis. Her last flatus and bowel
movement were five days ago.
No medical problems, she takes no
medications. She had an appendecomy 15
years ago.

T 36.6 po; BP 100/50; HR 66; RR 22; 100%

on RA
Abdomen: moderately distended, no

incisions, diffusely tympanitic, no masses

or organomegaly, non-tender without
peritoneal signs.
Na- 128 K- 4.6 Cl- 91 CO2- 25 BUN- 46 Cr-

0.9 Glu- 111 WBC- 5.9 Hct- 37.3 plts- 283

amylase- 46 lactate- 1.1

bowel wall edema, collapsed colon

small bowel feces sign present

POINTS TO BE DISCUSSED
What is the cause of the patients intestinal

obstruction?
Is the obstruction strangulating or non-

strangulating?
Can any tests differentiate patients whose non-

strangulating obstruction will resolve with time?

How long should non-operative management be

tried?

To study pattern of acute intestinal obstruction in

a teaching institute: is there a change in
underlying etiology.

Published in Saudi Journal of

Gasteroenterology. October 2010.

Dept of Surgery, Liaquat University of
Medical and Health Sciences, Jamshoro,
Pakistan.
Duration June 2004- June 2009.
Total of 229 patients with clinical or
radiological evidence of acute intestinal
obstruction.

Conclusion
Common Etiologies

Percentages

Post op Adhesion

41%

Abdominal TB

25%

Obstructed/strangulated Hernia

18%

Abdominal TB is emerging common cause

of bowel obstruction and there was an
obvious change in the pattern of etiology
of acute intestinal obstruction.

What is the cause of the

patients intestinal obstruction?
UNIVERSITY OF CALIFORNIA,SAN

FRANSISCO
An update from the Postgraduate Course in
General Surgery on Management of
Small Bowel Obstruction.
March 20-23, 2011.

CONCLUSION
ETIOLOGY

PERCENTAGE

ADHESIONS

60%

CANCER

20%

HERNIAS

10%

IN AMERICA MALIGNANCY ACCOUNTS FOR

MOST CASES OF OBSTRUCTED BOWEL
AFTER ADHESIONS WHILE IN UK
STRANGULATED HERNIAS HAVE A HIGHER

Can any tests differentiate patients

whose non-strangulating obstruction
will resolve non-operatively?
OLD: CLINICAL PRESENTATION
Complete

obstruction = absence of significant flatus or stool for 12 hours

and no colonic gas seen on KUB.
Complete obstruction = 20% success rate with non-operative treatment
20-40% risk of strangulation
Partial obstruction = 80% success rate with non-operative treatment low
risk of strangulation (3-6%)

NEW: ORAL WATER SOLUBLE CONTRAST

Instill

50-150cc of gastrograffin (water-soluble contrast) orally or via NGT.

Obtain abdominal plain films at 4, 8, and/or 24 hours

Presence

of gastrograffin in the colon at 8 hours predicts non-operative

resolution with 95% sensitivity and 99% specificity
University of San Francisco, California.

How long should non-operative

management be tried?
85-95% of patients with adhesive SBO who are

destined to recover without surgery will show

marked improvement within 72 hours.
Bologna Guidelines for Diagnosis and

Management of Adhesive Small Bowel

Obstruction (ASBO): 2010 Evidence-Based
Guidelines of the World Society of
Emergency Surgery : 3 days
EAST GUIDELINES : 3-5 days

MANAGEMENT

Management
Investigations
Treatment

BAILEY & LOVES SHORT PRACTICE OF SURGERY 25TH

EDITION

Investigations
Blood Monitoring
Abdominal X-ray
Water Soluble Contrast Study
Abdominal CT

FIFE PALLIATIVE CARE GUIDELINES APRIL

2010

Blood Monitoring
Blood Urea
Nitrogen
Level
Creatinine
level
Complete
Blood Count

Serum
Potassium
Lactate
Dehydrogena
se Tests

Increased
Hematocr
it
WBC

Dehydration

Increased

Strangulatio
n

GENERAL SURGERY LECTURE NOTES 12TH EDITION, MEDSCAPE

Abdominal X-Ray
Supine Abdominal Films
Erect Abdominal Films

BAILEY & LOVES SHORT PRACTICE OF SURGERY 25TH

EDITION

Jejunum:
Valvulae
Conniventes;
Completely pass
across the width of
the bowel
Regularly Spaced

Giving a
LADDER
EFFECT of
Dilated Loops.

Distal Ileum:
Featureless
BAILEY & LOVES SHORT PRACTICE OF SURGERY 25TH

A rounded gas shadow

in the Right Iliac Fossa

Distended
Caecum,
Obstruction at
Caecum

BAILEY & LOVES SHORT PRACTICE OF SURGERY 25TH

Haustral Folds:
Irregularly spaced
Do not cross the
whole diameter of
the bowel

Large Bowel
Obstruction,
except for caecum
BAILEY & LOVES SHORT PRACTICE OF SURGERY 25TH

Small Bowel
Obstruction
Air- Fluid levels
In Intestinal
Obstruction: Fluid
levels appear later
then gas shadows

Low Colonic
Obstruction

Number of Fluid levels

is directly proportional
to the degree of
obstruction
Does not usually
give rise to small
bowel fluid levels
unless advanced

May give rise

to small bowel
High Colonic
fluid levels in
Obstruction
presence of
incompetent
ileocaecal
valve
BAILEY & LOVES SHORT PRACTICE OF SURGERY 25TH

Characteristic
pattern of "air-fluid
levels due to
collection of both
fluid and gas in the
intestine

American Accreditation HealthCare Commission

Paralytic Ileus: Diffuse

appearance of gas
throughout the small and
large bowel

GENERAL SURGERY LECTURE NOTES 12TH

Water Soluble Contrast Study

Clarify the
presence of
obstruction

Diagnostic
Importance of
Contrast Study in
Intestinal
Obstruction

Help clarify
whether
ischemic
changes are
occurring

Whether
obstruction is
partial or
complete

Identify the
possible
cause of
obstruction

Gastrografin
water-soluble
iodinated
radiopaque
contrast medium
usually used

Contrast Radiography and Intestinal Obstruction

Ann Surg. 2002 July; 236(1): 78.

Why use Gastrografin?

Sparingly absorbed
from the intact
gastrointestinal tract
Therefore permits
gastrointestinal
opacification and
delineation

Non watersoluble agents

are not
feasible or are
potentially
dangerous

Enhances image and

distinguishes normal
loops of bowel and
areas of pathology
DRUGS.COM: DRUGS INFORMATION

Water-soluble
hyper osmotic
solutions
Solution tends to
draw fluid into
the lumen of the
intestine and
increase motility.
May also
diminish
bowel wall
edema
Promote earlier
and more
frequent
resolution of
bowel

Gastrografin study in a
patient with constipation
reveals colonic obstruction at
the recto sigmoid level.
Radiograph courtesy of
Charles McCabe, MD.

MEDSCAPE

Contrast study
demonstrates colonic
obstruction at the level of
the splenic flexure, in this
case due to carcinoma.
Radiograph courtesy of
Charles McCabe, MD.

Abdominal CT
When clinical and radiographic findings are

not conclusive
Distinguishes extrinsic causes e.g.
adhesions and hernia) from intrinsic causes
e.g. neoplasms and Crohn diseases
Distinguishes ileus and mechanical small
bowel obstruction in postoperative patients

MEDSCAPE

Distended, fluid-filled
loops of small bowel
with air-fluid levels

CT Scan: partial small

bowel obstruction.

Air in a decompressed
descending colon (large
black arrow) is
indicative of partial
obstruction.
MEDSCAPE

Treatment
1. Gastric Aspiration
2. Intra-venous Fluid Replacement
3. Relief of Obstruction
4. Medical Treatment

GENERAL SURGERY LECTURE NOTES 12TH

1. Gastric Aspiration
Nasogastric Suction
Decompresses the bowel
Risk of inhalation of gastric contents

reduced during Anesthesia

BAILEY & LOVES SHORT PRACTICE OF SURGERY 25TH

EDITION

2. Intra-venous Fluid Replacement

If
patient
shocked
Hartmanns
Solution

Normal
Saline

Plasma
Expander
s

GENERAL SURGERY LECTURE NOTES 12TH

3. Relief of Obstruction
Strangulation

Early Surgical
Intervention
Acute Obstruction

Radiological evidence
of obstruction but no
pain or tenderness

Conservative
Management for up
to 72 hours in hope
of spontaneous
resolution

BAILEY & LOVES SHORT PRACTICE OF SURGERY 25TH

General Principles of Surgical

Intervention
Small Bowel Obstruction
Large Bowel Obstruction Proximal to

Splenic Flexure
Left Sided Large Bowel Obstruction

GENERAL SURGERY LECTURE NOTES 12TH

Small Bowel Obstruction

Resected

Because of
Excellent
Blood
Supply

Primary
Anastomosis
Performed

GENERAL SURGERY LECTURE NOTES 12TH

Large Bowel
Proximal to
Splenic Flexure

Resection of
obstruction by
Primary
Ileocolic
Anastomosis

Distal Segment

Exteriorizing
the ends of
Colon as
Temporary
Colostomy:
Loop
Colostomy

Hartmanns
Procedure: If
distal end of
Colon does not
reach the
surface

Poorer Blood Supply of

the Large Bowel and
Intra Luminal Bacteria
GENERAL SURGERY LECTURE NOTES 12TH

For Primary Colo-Colonic

Anastomosis

Proximal Bowel is First

Lavaged by a
catheter passed
through the appendix
stump

Defunctioning Loop
Ileostomy performed
at the same time:
Minimize the
complication of
anastomotic lea

GENERAL SURGERY LECTURE NOTES 12TH

SURGICAL
INTERVENTI
ON

Adequate exposure is
best achieved by
midline incision

Identification and
Assessment of
Caecum: Best Initial
Maneuver

COLLAPSED

DILATED

Lesion is in Small
Bowel

Indicates Large
Bowel Obstruction

BAILEY & LOVES SHORT PRACTICE OF SURGERY 25TH

Operative Decompression
Potential Risk of
septic
complication from
spillage
Dilation of bowel
loops prevents
exposure

Viability of the
bowel is being
compromised

BAILEY & LOVES SHORT PRACTICE OF SURGERY 25TH

Viable and Non-Viable

Loss of
Peristalsis

Loss of normal
sheen: Dull
and Flabby

Dark Color:
Greenish or
black bowel

GENERAL SURGERY LECTURE NOTES 12TH

Loss of
arterial
pulsation in
the
supplying
mesentary

If Doubt About Viability

Bowel wrapped in
hot packs for 10
minutes with
increased
oxygenation and
reassessed

Multiple Ischemic
Areas

Second look
laparatomy at 2448 hours may be
required

BAILEY & LOVES SHORT PRACTICE OF SURGERY 25TH

Types Of Surgical Procedure

Enterolysis
By Pass Surgery or Proximal Decompression
Gastric or Rectal stenting
Gastrostomy

FIFE PALLIATIVE CARE GUIDELINES APRIL

Conservative Management
Intravenous
Fluid

Naso gastric
Aspiration

Psychological
Support
Exclude other causes
of Nausea, Vomiting,
Constipation,
Abdominal distention,
Intestinal colic and
treat accordingly

FIFE PALLIATIVE CARE GUIDELINES

Attempt to remove the obturating faces by

enema to prepare bowel for an elective

operation in chronic obstruction of large
bowel
When period of careful observation is
indicated
Paralytic Ileus is treated conservatively in
the absence of any evidence of mechanical
obstruction or infection

GENERAL SURGERY LECTURE NOTES 12TH

4. Medical Treatment
Antibiotic Therapy
For Pain
For Intestinal Colic
For Vomiting
For Large Volume Vomits

FIFE PALLIATIVE CARE GUIDELINES APRIL

Antibiotic Therapy
Broad- Spectrum Antibiotic including:
o Amoxicillin
o Metronidazole
o Gentamicin
o Cephalosporins

MEDSCAPE

Pain
Opioid Analgesic: Continuous pain due to

tumor and/ or nerve infiltration

Morphine 15mg sc/24 hours
Diamorphine 10mg sc/24 hours
Oxycodone 10mg sc/24 hours

FIFE PALLIATIVE CARE GUIDELINES APRIL

Intestinal Colic
Use Anti-spasmodic
Hyoscine Butyl bromide 60-120mg sc/24

hours

FIFE PALLIATIVE CARE GUIDELINES APRIL 2010

Vomiting
Mechanical
Obstruction

Peristaltic Failure

Cyclizine 150mg sc/24 hours

Metoclopramide 30mg-100mg sc/24

hours

Levomepromazine 6.25mg-25mg

sc/24 hours
Ondansetron 8-16mg sc/24 hours

Care with prokinetics:

o

May cause bowel perforation

May exacerbate colic and vomiting

FIFE PALLIATIVE CARE GUIDELINES

Large Volume Vomits

Octreotide 200-800mcg sc/24 hours
Hyoscine Butylbromide
If still persists; NG Tube may be indicated

FIFE PALLIATIVE CARE GUIDELINES

RECENT ADVANCEMENTS &

RECOMMENDATIONS

Paper #1

Topic: Role of water soluble contrast agents in

assigning patients to a non-operative course in
adhesive small bowel obstruction.

Authors: Wadani HA, Al Awad NI, Hassan

KA, Zakaria HM; Abdulmohsen Al Mulhim A,

Alaqeel FO
Place: Department of Surgery, King Fahd
Hospital of the University, College of
Medicine, Dammam University, Kingdom of
Saudi Arabia.
Date: November 2011
Objective: Adhesive SBO is a common
surgical emergency mostly due to postoperative adhesions. This study aims to
determine the role of gastrografin (water


Method: Prospective study. Patients with clinical

signs of postoperative adhesive SBO who met the

inclusion criteria were admitted. After intravenous
hydration, nasogastric tube insertion and
complete suctioning of the gastric fluid, 100 ml of
gastrografin was given and plain abdominal
radiography was taken. If contrast reached colon
in 24 hours, they were considered to have partial
SBO and started oral intake. If gastrografin failed
to reach the colon in 24 hours and the patient did
not improve in the following 24 hours, laparotomy
was performed.

Results: Conservative treatment was

successful in 91% cases and 9% required

operation
Conclusion: Oral gastrografin helps in the

management of patients with postoperative

adhesive SBO.

Paper #2

Topic: Small bowel obstructionwho needs an operation? A

multivariate prediction model.
Authors: Zielinski MD, Eiken PW, Bannon MP,

Heller SF, Lohse CM, Huebner M, Sarr MG.

Place: Division of Trauma, Critical Care, and
General Surgery, Mary Brigh 2-810, St. Mary's
Hospital, Mayo Clinic, USA.
Date: May 2010
Objective: Aim was to identify preoperative
risk factors associated with strangulating SBO
and to develop a model to predict the need for
operative intervention in the presence of an
SBO. Our hypothesis was that free
intraperitoneal fluid on computed tomography

Methods: Reviewed 100 consecutive

patients with SBO, all had undergone CT

reviewed by a radiologist blinded to
outcome. The need for operative
management was confirmed retrospectively
by four surgeons based on operative
findings and the patient's clinical course.
Patients were divided into two groups:
o Group 1: required operative management
o Group 2: did not

Conclusion: Clinical, laboratory, and

radiographic factors should all be considered

when making a decision about treatment of
SBO. The four clinical features-intraperitoneal
free fluid, mesenteric edema, lack of the
"small bowel feces sign," history of vomitingare predictive of requiring operative
intervention during the patient's hospital stay
and should be factored strongly into the
decision-making process of operative versus
nonoperative treatment

Paper #3

TOPIC: Surgical relief of small bowel obstruction by

migrated biliary stent: extraction without enterotomy.

AUTHORS: Garg K, Zagzag J, Khaykis I, Liang H

DATE: 2011 Apr-Jun
PLACE: New York University Lagone Medical

Center, 530 1st Ave, New York, NY 10016, USA

OBJECTIVE: Distal stent migration is a wellknown complication following insertion of biliary
stents. Most such cases can be managed
expectantly, because the stents pass through
the gastrointestinal tract. However, small bowel
obstruction as a result of the stent mandates
surgical intervention.

METHODS: We report the case of a patient

who had distal stent migration causing a

small bowel obstruction. We successfully
retrieved the stent without an enterotomy,
by using a combination of laparoscopy,
endoscopy, and fluoroscopy. Our unique
technique greatly decreased the risk of
bacterial peritonitis in this patient with
decompensated cirrhosis and associated
ascites, which in this patient population
results in a high mortality

CONCLUSION: Retrieval of biliary stents in

cases of small bowel obstruction without

perforation may be successfully performed
without enterotomy or bowel resection. A
similar approach may be applied to other
foreign bodies dislodged in the small bowel.

THANK YOU