Intestinal Obstruction
Presenter: Chew Ye Ying
Mentor: Dr Neogh
Intestinal Obstruction
• Occur when normal flow of intraluminal
contents is interrupted
• Intestinal obstruction (IO) is a surgical
emergency.
• Can affect any age group.
• Classified into
• Type
• Onset
• Level
According to TYPES
Dynamic → Peristalsis working against
mechanical obstruction
Adynamic → Peristalsis may be absent or
may be present but in non-propulsive way
According to Nature
• Could be
– Partial
– complete
According to LEVEL
• Small bowel
• Large bowel
Closed loop obstruction
• specific type of obstruction in which two points along the
course of a bowel are obstructed at a single location .
• Bowel is obstructed at both proximal and distal points.
• Usually due to adhesions, a twist of the mesentery or internal
herniation.
• Classically seen malignant stricture of colon with a competent
Gangrenous bowel with
ilieocaecal valve. small bowel closed loop
• In large bowel → volvulus obstruction cause by
omental
• In small bowel → small bowel closed loop obstruction
*High risk of strangulation and bowel infarction
ETIOLOGY
Extraluminal
• Congenital bands
• Meckels diverticulum
• Obstructed hernia
• LN compression
• Superior mesenteric
artery syndrome
Mural
• Tumor
• Diverticular stricture
• Intussusception
• Chrons disease
• Atresia
Intraluminal
• Impacted stool
• Gallstone illeus
• Foreign body
• Bezoar
• Roundworm mass
Adynamic ( Functional)
• Paralytic Ileus
• Hirshsprungs disease
• Ogilvie syndrome (Pseudo-obstruction)
• Peritonitis
• Electrolytes imbalance
• Drugs
Etiology according to ages
• Birth: Atresia, Volvulus, Hirschsprungs
• 3 weeks: Pyloric stenosis
• 6-9months : Intussusception
• Teen: Appendicitis, Meckels diverticulitis
• Young Adult: Adhesion, Hernia
• Adult: Adhesion, hernia, Cronh`s , Carcinoma
• Elderly: Carcinoma, Diverticulitis, sigmoid volvulus
PATHOPHYSIOLOGY
Pathophysiology
History
4 cardinal features:
• Abdominal pain
- Colicky in nature
- Intermitten
- Constant sharp pain (complete obstruction)
- Sudden severe pain (volvulus)
• Vomitting
- Initially consists of stomach content then Bile, follow
by feculent matter
- Vomit of altered blood might indicate heamorrahge
or gangrene
• Abdominal distention
- Moderate distention in Ileum
- Marked distension in colon
• Constipation
– Obstipation / Absolute constipation: constipation
to feces and flatus
– Present initially in large bowel obstruction
– Exception: IO with diarrhea (eg. Fecal impaction)
Small Bowel Large Bowel
• Usually presented with • Usually presented with
vomiting first and distention, abdominal pain
dehydration. and obstipation.
• Abdominal pain over • Nausea and vomiting may
periumbilical and cramping not be present early.
in nature with interval of • Abdominal pain over
every 4 – 5 mins. infraunbilical and cramping
with interval of every 20 –
30 mins
Other important history
History of or risk of GI malignancy
Previous abdominal or pelvic surgery
Risk factor for ischemic bowel like atherosclerotic
rheumatic heart disease, heart disease, and previous
stroke
History of foreign body ingestion
Underlying abdominal wall or groin hernia
Medication history
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Signs
• Signs of dehydration.
• Signs of malignancy.
• Abdominal findings:
– Distention / Tenderness
– Step peristalsis in terminal illeal obstruction
– Right → left colonic peristalsis in left sided colonic
obstruction
– Signs of peritonitis if with gut perforation
– Percussion : Tympanic note
– Auscultation: Hyperactive (borborygmi) initially, sluggish or
absent later
– Examined for hernia orfices
– PR : rectum empty in small bowel obstruction, masses,
impaction
Investigation
Blood Investigation
• FBC
– ↓Hb might indicate underlying malignancy
– ↑ TWC might indicates infection / sepsis /perforation
– ↑HCT might indicated dehydration
• ABG
– Acidosis (bowel ischemia)
– Alkalosis (vomiting)
• RP
– Dehydration (↑ urea) and vomittng (derange K⁺)
• GSH/ Coagulation profile / LFT / amylase / LDH (if indicated)
Imaging
• Abdominal X-ray
– Erect: air fluid levels
– Supine: look for small / large bowel dilatation
• Chest X-ray
– Air under diaphragm indicate perforated bowel
• CECT abdominal pelvis (more sensitve and may identified the
cause )
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Red Flag Sings
• Constant Pain
• Absent bowel sound
• Tenderness with rigidity
• Leukocytosis
• Fever and tachycardia
• Shock
Acute Management
1. Keep NBM
2. Insert Ryle’s tube and for free flow also 4hrly asp
3. Cover with antibiotics (broad spectrum)
4. Strict input and output charting
5. V/S monitoring
6. Fluids resuscitation
7. Exploratory laparotomy
If obstruction due to adhesion and no feature of
peritonism, conservative management up to
72hours with regular clinical reviews.
When to decide for surgical
intervention?
• Suspected to have complicated bowel
obstruction like:
– closed loop obstruction,
– bowel ischemia, necrosis, perforation or
– complete obstruction.
• Virgin abdomen
When decide for conservation
management?
• Early post operative obstruction
• Inflammatory bowel disease
• Gallstone illeus.
(Endoscopic fragmentation of stone can be attempt)
• Infectious bowel disease
(TB colon , however delayed diagnosis might need
surgery)
• Colonic diverticular disease
(Antibiotic may reduce peridiverticular inflmmation
thus relieve obstruction)
SUMMARY
Causes of Intestinal Obstruction
Extrinsic lesion
ETIOLOGY RISK FACTOR
Adhesion Prior surgery, diverticulitis, Crohn
disease, peritonitis (eg. Tuberculous
peritonitis)
Hernia (congenital,acquired) Abdominal wall/ inguinal/ femoral/
diaphragmatic hernia
Volvulus Chronic constipation, congenital
abnormal mesenteric attachment
Peritoneal carcinomatosis Ovarian cancer, colon cancer, gastric
cancer
Superior mesenteric artery syndrome Rapid weight loss
Intrinsic lesions
Etiology Risk Factor
Congenital malformation, atresia -
Adenocarcinoma Hereditary colorectal cancer, (eg.
HNPCC, FAP, Puetz-jeghers) , IBD
Metastatic disease Underlying cancer
Anastomotic stricture Prior intestinal surgery
Inflammatory stricture Crohn disease, diverticular disease
Ischemic stricture PAD, aortic surgery
Radiation enteritis/ stricture Prior abdominal or pelvic irradiation
Intraluminal
Etiology Risk factor
Intussusception Small bowel tumor
Gallstone Cholecystitis
Foreign Body Psychiatric disturbance, PEG tube,
Jejunal tube
Parasites Ascaris lumbricoides, strongloides
stercoralis
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References
• Daniel Dante Yeh, Liliana Bordeianou. (2017, Jun). Overview of mechanical
colorectal obstruction. Retrieved Oct 2018, from Uptodate: [Link]
uptodate-com. /overview-of-mechanical-colorectal-obstruction
• Liliana Bordeianou, Daniel Dante Yeh. (2017, NOV). Epidemiology, clinical
features, and diagnosis of mechanical small bowel obstruction in adults.
Retrieved OCT 2018, from Uptodate: [Link]
/epidemiology-clinical-features-and-diagnosis-of-mechanical-small-bowel-
obstruction-in-adults
• Liliana Bordeianou, Daniel Dante Yeh, . (2017, May). Overview of
management of mechanical small bowel obstruction in adults. Retrieved Oct
2018, from Uptodate: [Link] /overview-of-
management-of-mechanical-small-bowel-obstruction-in-adults
• N S Williams, CJK Bulstrode et al. (2013). Bailey & Love's Short Practice of
Surgery. (26th, Ed.) Pheonix: CRC Press (Taylor & Francis Group).
• Thankyou.
