Intestinal Obstruction

By Dr. Asfand
PGR S.U IV
Introduction
 Is a partial or complete blockage of forward
progression of intestinal contents (chyle)
due to mechanical or functional causes
 can occur at any level distal to

the duodenum
 Is a medical emergency (20% of acute

surgical admissions & 5-10 % of acute

abdomen patients)
 Complications include bowel ischemia &

Perforation
Classification
 Mechanical/Functional
 congenital/acquired;
 partial(incomplete or subacute)/complete;
 acute/acute on chronic/or chronic;
 simple/closed loop/strangulated;
 proximal/distal
Etiology
Dynamic (Mechanical) Adynamic (Functional)

 Intraluminal:
Gallstones, Foreign Body,
 Paralytic Ileus
Round worms, impacted ◦ Post Surgery/trauma
faeces, Bezoars, Meconium
ileus
◦ Electrolyte imbalance
◦ Diabetes mellitus (DKA)
◦ Uremia
 Intramural:
TB stricture, IBD, Malignancy
 Drugs – Narcotics,
Anticholinergics
 Mesenteric ischaemia
 Extraluminal:
Bands/Adhesions, Hernia,
 Pseudo-obstruction
Intussusception, Volvulus
 Incidence

80% in small bowel – usually ileum

20% in colon – usually sigmoid colon (70% CA, 30% due to
diverticulosis, volvulus & inflammatory causes)
Strangulated intestinal obstruction
(interference of mesenteric blood supply)

 Direct External compression

◦ Adhesions
◦ Hernia

 Interruption of mesenteric blood flow

◦ Intussussception
◦ Volvulus

 Primary occlusion of mesentric blood vessles :

acute mesentric ischemia

 Closed Loop Obstruction

◦ Hernia
◦ Adhesions
Features of Strangulation

 Continuous severe pain

 Shock indicates underlying ischemia

 Symptoms commence suddenly and recur

regularly

 Local tenderness associated with rigidity

and rebound tenderness ( Blumbergs sign )
Acute colonic pseudo-obstruction

 It is massive colonic dilatation affecting caecum and Rt.

colon with presentation of colonic obstruction without
any mechanical blockage
 It likely results from imbalance of autonomic regulation of
colonic motility with excessive parasympathetic
suppression causing atony to distal colon causing
functional obstruction
 The vast majority of patients are Elderly hospitalized
patients with major TRAUMA; ILLENESS; MAJOR NON-
INTESTINAL SURGERY
(Stress)
Closed Loop Obstruction
 Afferent & Efferent
limbs of bowel are
obstructed

 The rich bacterial

flora w/in the loop
adds to the
production of gases
causing rapid
distension
Closed Loop Obstruction
 Rapid distension inc luminal pressure
Impaired circulation bowel necrosis &
perforation fulminant peritonitis

 Typically seen in colon with competent

ileocaecal valve
 Hernia, Adhesions, Volvulus
Pathophysiology/Features

Severe Colicky
Vigorous High pitched
Abdominal
Bowel Sounds
Contractions pain

Fluid & Gas Further Distention of

accumulates Intestine

Vomiting/
Borborygmi Metabolic
Alkalosis
 Inc contractions & Multiple air fluid
Distention levels

Inc Intra-luminal
Pressure

Defective absorption/ Fluid &

Severe
Electrolyte Shock Death
Inc intestinal secretion Dehydration
Imbalance

Inc venous pressure

Hence venous return impairs

Congestion, Edema --- jeopardizes Dec Bowel

Arterial supply – ischemia & Gangrene Sounds

Perforation Bacterial / toxin Peritonitis/

translocation Bacteremia, Septicemia
Diagnosis
 History
 Physical Examination
 Lab Tests
 Imaging

• X-Ray (Abdomen & Chest)

• Contrast enhanced CT Scan
◦ Barium Studies
◦ U/S
◦ MRI
History
Abdominal pain

Vomiting Cardinal features Distension

Absolute
constipation

 These clinical features and also the clinical course

vary according to the LEVEL & CAUSE of obstruction
 Comparison of clinical aspects
Proximal Distal small Large bowel
small bowel bowel
Severe vomiting Moderate vomiting Late vomiting

Less distension Central distension Early distension ,

pronounced
Colicky pain Central abdominal pain Less pain

Constipation late Varies in appearance Constipation is early

feature

Severe dehydration Moderate Less dehydration

Specific Points
 Distension - minimal /absent in mesenteric
vascular occlusion
 Fever signifies inflammation in bowel wall /

ischemia / perforation
 Hypothermia -- when septicemia due to

poor pyrogenic response

 Physical Examination
Others Abdominal General

Systemic examination •Abdominal distension and •Vital signs:

If deemed necessary. it’s pattern P, BP, RR, T, Sat
•CNS •Hernial orifices •dehydration
•Vascular •Visible peristalsis •Anaemia, jaundice, LN
•Gynaecological •Tympanitic Abdomen
•Assessment of vomitus if
•Muscuoloskeltal •Cecal distension
possible
•Tenderness, guarding and •Full lung and heart
rebound
examination
•Organomegaly
•Bowel sounds
–High pitched
–Absent
•Rectal examination
visible peristalsis
seen in
obstruction
Lab Tests
 CBC Anemia, Leukocytosis
 Urea/ Creatinine Dehydration
 Serum Electrolytes

 Random Blood Sugar - DM

 Coagulation Screen - DIC
 LFTs - Bilirubin & Alk Phosphatase
 Serum Amylase - non-specific
Radiological Evaluation
Plain X-Ray

Always request:
Supine, Upright, lateral
and CXR
(Obstructive Series)

Diagnostic in 60% of cases

but further evaluation
(CT or barium studies)
may be necessary in rest
of the cases
Findings
 Supine Film:
◦ Gas distended Bowel
Loops

SBO LBO

Supine Film: Gas Distended Bowel Loops

Contd……
 Upright Film

◦ Multiple Air Fluid levels

“Stepladder pattern”

Flat surfaces at the Air Fluid interface

Difference Between Large & Small Bowel
Obstruction
Small Bowel Large bowel
•Central (diameter 2.5cm to 5cm) •Peripheral ( diameter 5cm+)
•Vulvulae conniventes •Presence of haustration
•Presence of solid faeces

vulvulae
conniventes
CXR
 Upright Film:

◦ Gas under the

diaphragm
(perforated viscus)
Other Causes
Claw hand sign

Intussusception Gall stone Ileus IBD

Other causes

Carcinoma (desc left

Paralytic Ileus colon)

Massive Gastric Dilatation

CT Scan
 Useful in patients with Hx of Abd CA &
postsurgical pts
 Role/Advantages:

◦ Level of obstruction
◦ Degree of obstruction & ischemia
◦ Cause : volvulus, hernia, luminal & mural causes
◦ Free fluid & Gas (perforated viscus)
◦ Can detect closed loop obstruction & early
strangulation
SBO - Air Fluid level seen Adhesive Small Bowel Obstruction
Adjunctive Tests
 Sigmoidoscopy (Rigid or flexible)
◦ Performed when on Abd X-Ray large amounts of
colonic air extends down to the rectum
◦ To rule out rectal or distal sigmoid obstruction

 Barium Studies (follow through, Enema)

◦ Performed if there is history of
recurring obstruction or distal partial
colonic obstruction (via sigmoidoscopy)
◦ Gastrografin or Barium Sulphate
◦ Limited use in acute setting
 U/S, fast MRI
◦ They are performed if the clinical profile &
Physical Ex is consistent with Intestinal
Obstruction despite Normal Abdominal
Radiographs
◦ Also capable off detecting the cause of the
obstruction
◦ Not routinely performed
General Management
Keep patient NPO

1. Nasogastric Intubation/Aspiration
 Reduce bowel distension
 Improve pulmonary ventilation
 Reduce risk of subsequent aspiration during
induction of anesthesia and post extubation
• Non-vented Ryle’s tube
• Vented Salem tube
• Bakers Intestinal tube

2. Fluid and electrolyte replacement

3. Parenteral antibiotics
 Broad spectrum antibiotics- Ampicillin, Gentamycin,
Metronidazole, Cephalosporins
 To correct bacterial infection
 Mandatory for all patients undergoing small or large bowel
resection

4. Analgesia

5. Blood Transfusion
 FFP or platelet transfusions
 Often needed in critical patients

6. Indwelling Catheter
 Hourly Urine output monitoring
7. CVP For Fluid And Monitoring

 PCWP (pulmonary capillary wedge pressure)

monitoring
 Needed in haemodynamically unstable patients

Follow Up
 IMPROVEMENT  DETERIORATION

Conservative Surgery indicated if no

treatment is carried improvement occurs with in
on. 24-48 hours

Specific Surgery:
Therapy directed at
underlying disease
Surgical Treatment
 Exploratory Laparotomy (emergent in
critically ill patients)
 Wide Midline Incision
 Revision of intestine & detection of level and

cause of obstruction
 Decompression of proximal obstruction
 Assess viability of bowel (peristalsis, colour,

vessel pulsations)
 Removal of obstruction

Operative procedures vary according to cause of

obstruction
Specific Management
Adhesions
 Post operative adhesion obstruction usually
resolves on conservative measures.

 In adhesive obstructed cases, laparoscopic

adhesiolysis (adhesive band lysis) maybe
performed in selected patients or using
open procedure
Congenital atresia/stenosis
 Investigations- Plain X-ray
 Duodenal obstruction- stomach & proximal

duodenum are distended- “double bubble”

 Jejunal & ileal obstruction- air fluid levels

present
Congenital atresia/stenosis
 Treatment:
 Correct electrolyte & fluid deficits
 Duodenal atresia requires

duodenojejuostomy & spliting of the

anastomosis with a feeding tube.
Malrotation & neonatal
volvulus
 Investigation:
 Plain x-ray of the small bowel - gas shows

malrotation & level of obstruction + A/F

levels.
 Barium meal (inv of choice)
Malrotation & neonatal
volvulus
 Treatment:

 The volvulus is reduced, the

transduodenal band (Ladd’s
band) divided, the duodenum
mobilised & the mesentry
freed.
 Appendicectomy is routinely
performed to avoid diagnostic
difficulty with appendicitis in
the future (ladds operation)
 Infarcted bowel necessitates
resection.
Merkel’s diverticulum
 Investigation
 white cell count is raised
 A Merkel’s radioisotope scan will reveal acid

producing gastric mucosa.

Merkel’s diverticulum
 Treatment:
 Excision of the inflammed diverticulum
 Presence of gastric mucosa requires the

resection of the ileal loop containing the

diverticulum to ensure complete excision of
all acid producing mucosa.
Meconium Ileus
 Plain x-ray
 Shows small dilated bowel loops
 Gastrograffin enema (in the absence of

acute obstruction) shows up the meconium

Meconium Ileus
 Treatment:
 Colonic gastrograffin (enema) washouts

may restore patency

 Proximal ileum is anastomosed end to side

to the colon with a distal ileostomy to clear

the obstruction.
 Intussusception

 Investigations:
 Gastrograffin enema (‘claw sign’ of ileocolic

intussusception)
 In adults, a contrast CT scan of the

abdomen or barium enema is confirmatory.

Intussusception
 Rx:
 Reduction of the intussusception by

hydrostatic pressure (in children) – done

w/in 24 hrs
 Surgical reduction by milking out the ISS;

bowel resection if there is gross edema

preventing reduction or vascular
compromise.
 Reduction via laparosopic approach
Volvulus of the bowel
 Investigations:
 Plain x-ray may be diagnostic
 ‘kidney bean-shaped’ shadow in the right

upper zone: Sigmoid volvulus

 ‘kidney bean-shaped’ shadow in the left

lower zone: Caecal volvulus.

Volvulus of the bowel
 Rx:
 Sigmoid volvulus may be relieved at right

sigmoidoscopy – if not then laparotomy &

sigmoidopexy performed
 Emergency laparotomy & resection of the

volvulus for strangulated or recurrent cases.

 Gangrenous bowel is exteriorised &

resected, with the formation of a ‘double

barrel’ colostomy (Paul-Mikulicz procedure).
Intestinal ischaemia
(Acute)
Investigations:
 White cell count: >20×10 /L
9

 Serum amylase: slightly raised (>200IU)

Mesentric angiography

Rx:
 Laparotomy: superior mesentric

embolectomy;
 Resection of areas of non-viable bowel.

‘second look’ laparotomy at 24 hours for

further resection of non-viable bowel.
 Hernia
 In cases of strangulated Inguinal/femoral
hernias the standard groin incision is given
& the weakness repaired using hernioplasty
or herniorrhaphy, with bowel resection if
required.
Thank You