INTESTINAL OBSTRUCTION

1. INTESTINAL OBSTRUCTION MOSTAFA ABOU ALI PROFESSOR OF SURGERY SUEZ CANAL UNIVERSITY

2. INTESTINAL OBSTRUCTION A. Overview of the Problem - Concept - Common Types - Common Causes B. General Management Guidelines -Clinical Diagnosis - Paraclinical Diagnosis - Treatment

3. CLINICAL QUESTIONS 1. WHAT IS OPERATIONAL CONCEPT OF INTESTINAL OBSTRUCTION? DEFINITION: PROBLEMof the intestinal contents to pass through normally (Problem, motility, inability difficulty, failure) INTESTINAL OBSTRUCTION- SMALL INT. AND LARGE INT. (starting from the duodenum)

4. CLINICAL QUESTIONS 2a. How is intestinal obstruction classified in terms of degree of obstruction? • PARTIALintestinal obstruction • COMPLETEintestinal obstruction

5. CLINICAL QUESTIONS 2b. How is intestinal obstruction classified in terms of its CAUSE? • MECHANICAL • NON MECHANICAL

6. CLINICAL QUESTIONS • CARDINAL SIGNS AND SYMPTOMS: • Presence of the cardinal signs and symptoms of intestinal obstruction plus high-pitched bowel sound

7. CLINICAL QUESTIONS 3a. What are reliable signs and symptoms (more than 90% certainty) that will indicate mechanical intestinal obstruction? • Presence of the cardinal signs and symptoms of intestinal obstruction plus Palpable abdominal mass and/or high- pitched bowel sound

8. Presence of the cardinal signs and symptoms of intestinal obstruction plus high-pitched bowel sound

9. The normal flow of intestinal contents can be blocked by a • Mechanical obstruction or by a • Functional obstruction that occurs because of impaired intestinal motility. An acute abdomen often ensues.

10. Mechanical obstructions are common and have various benign and malignant causes. If not treated expeditiously (usually by surgical removal of the cause), mechanical obstructions can rapidly become lethal.

11. INTESTINAL OBSTRUCTION • Acute obstruction occurs over hours to days and has a rapidly evolving course, whereas • Chronic obstruction may have a slow course with malnutrition, constipation, and other signs of chronic illness.

12. INTESTINAL OBSTRUCTION TYPES • SIMPLE OBSTRUCTION. • STRANGULATING OBSTRUCTION. • Closed loop obstruction. • Intussusceptions. • Perforating obstruction

13. INTESTINAL OBSTRUCTION • Closed loop obstruction. • Intussusceptions. • Perforating obstruction.. The most common area of perforation when the colon is obstructed is the cecum.

14. INTESTINAL OBSTRUCTION CAUSES • INTESTINAL ADHESIONSare the most common cause of obstruction. • Previous surgical exploration • Idiopathic They may be DIFFUSE, involving all peritoneal structures, or SOLITARY, blocking only one area of the intestine.

15. ADHESIVE INTESTINAL OBSTRUCTION

16. ADHESIVE INTESTINAL OBSTRUCTION

17. ADHESIVE INTESTINAL OBSTRUCTION

18. ADHESIVE INTESTINAL OBSTRUCTION

19. ADHESIVE INTESTINAL OBSTRUCTION

20. Herniasare a second very common cause of intestinal obstruction. A segment of intestine migrates through a defect in the abdominal wall (external hernia)or through a mesenteric or omental defect (internal hernia) and becomes blocked by the narrow ring that is present at the peritoneal communication of the hernia.

21. INTESTINAL TUMORS are the third most common cause of obstruction. The most common obstructing tumor is an adenocarcinomas of the colon or rectum. Benign lesions of the small bowel and colon, such as lipoma, can become the leading point of an Intussusception. Other malignant tumors, such as carcinoid or lymphoma, can obstruct the intestinal lumen.

22. SEGMOID CARCINOMA

23. OTHER INTRINSIC LESIONSwithin the bowel wall or the lumen can cause acute obstruction. CONGENITAL LESIONS: webs, malrotations, and atresias INFLAMMATORY LESIONS: Crohn's disease, diverticulitis, ulcerative colitis, and infections such as tuberculosis LUMINAL FOREIGN BODIES: bezoars, parasites, and gallstones RADIATION INJURY, othertrauma, orendometriosis • OTHER EXTRINSIC LESIONS, such as large intra-abdominal tumors or abscesses, can compress the intestinal lumen.

24. NEONATAL INTESTINAL OBSTRUCTION • Atresias • Hirschsprung’s Disease • Malrotations • Volvulus • Intussusception • Incarcerated Hernia • Perforated appendix

25. PERFORATED APPENDIX PRESENTED WITH INTESTINAL OBSTRUCTION

26. PERFORATED APPENDIX • Suspect in children 3-5 years old with history suggestive of appendicitis • “Bowel obstruction” in a 3-5 year old without obvious etiology is perforated appendix until proven otherwise • Fever > 101.5 (38.8Cْ), WBC > 20 with bands, diffuse abdominal pain, guarding.

27. Incarcerated Inguinal Hernia

28. INTUSSUSCEPTION • Inversion of the bowel upon itself secondary to a leading point • Juvenile Intussusception most often idiopathic • Also secondary to Meckel"s diverticulum • Presents 6 months to 2 years of age • As early as 1 month

29. INTUSSUSCEPTION • Acute painful episodes followed by periods of lethargy • When incarcerated progress to continuous lethargy • May or may not have “currant-jelly” stool • But often stool is heme positive • Rule out with a left lateral Decubitus film

30. Bad Intussusception

31. Intussusception

32. VOLVULUS • Malrotation most common condition resulting in Midgut Volvulus • Can have Volvulus with normal rotation • Omphalomesenteric remnant • Internal hernia • Duplication • Adhesive small bowel obstruction

33. MALROTATION • Most often presents during the first few months of life • Infant with acute onset of bilious emesis • May be diagnosed on UGI for other reasons • Malrotation is a surgical urgency due to the possibility of Volvulus • VOLVULUS IS A SURGICAL EMERGENCY

34. MALROTATION Normal

35. HIRSCHSPRUNG’S DISEASE (CONGENITAL MEGACOLON) • Male to Female = 9 : 1 • Delayed passage of meconium. • Progressive abdominal distention. • Colonic obstruction which needs urgent colostomy • Chronic constipation. • Poor growth and development. • P/R examination--- painless, gush stool or empty rectum.

36. Hirschsprung's Disease (Congenital Megacolon)

37. Hirschsprung’s Disease

38. Barium Enema

39. TreatmentColostomy

40. Imperforate Anus: Anal atresia

41. ATRESIAS • Esophageal:aspirate feeds immediately, OG tube won’t pass (non-bilious, but still bad) • Duodenal:bilious vomiting immediately, “double bubble” on KUB with absence of distal gas. • Jejunal:usually present 1st 24 hours, large dilated proximal loop or loops

42. ATRESIAS • Ileal: may take 24-48 hours before bilious emesis • Colonic: rare, may present with bilious emesis after 2-3 days • Anal: should be diagnosed at birth, often a perineal fistula is labeled normal

43. JEJUNAL ATRESIA

44. INTESTINAL OBSTRUCTION TREATMENT • INTESTINAL ADHESIONS are treated by surgical lyses of the obstructing bands if the obstruction does not resolve in several days. • HERNIAS are treated by a reduction of the contents of the hernia and subsequent repair. The bowel must always be examined for necrosis. • INTESTINAL TUMORS are treated by surgical removal. • TREATMENT OF INTRINSIC AND EXTRINSIC lesions depend on the lesion.

45. FUNCTIONAL OBSTRUCTIONSare blockages in the intestinal flow that result from impaired motility (paralyticoradynamic ileus). • Direct irritation of the intestine - Extra peritoneal causes, such as retroperitoneal hematoma or nerve root compression. Retroperitoneal dissections, such as a nephrectomy or sympathectomy, can cause a prolonged ileus.