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Intestinal Obstruction

Intestinal Obstruction. General Surgery, Renhe Hospital, Three Gorges University ， Zhang-Xianlin. Introduction and Definitions. Accounts for 5% of all acute surgical admissions

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Intestinal Obstruction

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  1. Intestinal Obstruction General Surgery, Renhe Hospital, Three Gorges University， Zhang-Xianlin

  2. Introduction and Definitions • Accounts for 5% of all acute surgical admissions • Patients are often extremely ill requiring prompt assessment, resuscitation and intensive monitoring • Obstruction A mechanical blockage arising from a structural abnormality that presents a physical barrier to the progression of gut contents. • Ileus is a paralytic or functional variety of obstruction Obstruction is: Partial or complete Simple or strangulated

  3. 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 x-ray was taken on admission.

  4. What are your objectives? 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? How should I start investigating my patient? What is the role of other supportive investigations? What is my immediate/ intermediate treatment plan? What are the indications for surgery? What are the medico-legal and ethical issues that I should address?

  5. Learning objectives: 1. Know the common causes of BOWEL OBSTRUCTION. 2. Be able to use history, physical examination and simple investigations to reach the most likely diagnosis in a patient with BOWEL OBSTRUCTION. 3.Be able to outline the principles of managenment in a patient with BOWEL OBSTRUCTION

  6. CLASSIFICATION • 1, Mechanical obstruction • obturation obstructoin • intestine compression • lesions in the intestinal wall • 2, Nonmechanical obstruction • dynamic ileus----->including paralytic ileus • 3,blood ileus • According to the blood circulation to the bowel, no impaired or impaired : • simple ileus • strangulation ileus

  7. Gas diffusely through intestine, incl. colon May have large diffuse A/F levels Quiet abdomen No obvious transition point on contrast study Peritoneal exudate if peritonitis Large small intestinal loops, less in colon Definite laddered A/F levels “Tinkling”, quiet= late Obvious transition point on contrast study No peritoneal exudate Adynamic vs Mechanical Ileus Obstruction

  8. Flatus Residual colonic gas above peritoneal reflection /p 6-12h Adhesions 60-80% resolve with non-operative Mx Must show objective improvement, if none by 48h consider OR Complete obstipation No residual colonic gas on AXR SBFT may differentiate early complete from high-grade partial Almost all should be operated on within 24h Partial vs Complete

  9. Lesions Extrinsic to Intestinal Wall • Adhesions (usually postoperative) • Hernia • External (e.g., inguinal, femoral, umbilical, or ventral hernias) • Internal (e.g., congenital defects such as paraduodenal, foramen of Winslow, and diaphragmatic hernias or postoperative secondary to mesenteric defects) • Neoplastic • Carcinomatosis, extraintestinal neoplasm • Intra-abdominal abscess/ diverticulitis • Volvulus (sigmoid, cecal)

  10. Congenital Malrotation Duplications/cysts Traumatic Hematoma Ischemic stricture Infections Tuberculosis Actinomycosis Diverticulitis Neoplastic Primary neoplasms Metastatic neoplasms Inflammatory Crohn's disease Miscellaneous Intussusception Endometriosis Radiation enteropathy/stricture Lesions Intrinsic to Intestinal Wall

  11. Site? Small Bowel vs. Large Bowel • Scenario • prior operations,  in bowel habits • Clinical picture • scars, masses/ hernias, amount of distension/ vomiting • Radiological studies • gas in colon?, volvulus?, transition point, mass • (Almost) always operate on LBO, often treat SBO non-operatively

  12. Common Causes SBO- 1st World

  13. frequency Common Causes of LBO • Colon cancer • Diverticulitis • Volvulus • Hernia Unlike SBO, adhesions very unlikely to produce LBO

  14. Causes of Adynamic Ileus • Following celiotomy • small bowel- 24h, stomach- 48h, colon- 3-5d • Inflammation e.g. appendicitis, pancreatitis • Retroperitoneal disorders e.g. ureter, spine, blood • Thoracic conditions e.g. pneumonia, # ribs • Systemic disorders e.g. sepsis, hyponatremia, hypokalemia, hypomagnesemia • Drugs e.g opiates, Ca-channel blockers, psychotropics

  15. Causes- Small Bowel

  16. Small Bowel Adhesions Accounts for 60-70% of All SBO Results from peritoneal injury, platelet activation and fibrin formation. Associated with starch covered gloves, intraperitoneal sepsis, haemorrhage and wash with irritant solutions iodine and other foreign bodies. As early as 4 weeks post laparotomy. The majority of patients present between 1-5 years Colorectal Surgery 25% Gynaecological 20% Appendectomy 14% 70% of patients had a single band Patients with complex bands are more likely to be readmitted Readmission in surgically treated patients is 35%

  17. Hernia Accounts for 20% of SBO Commonest 1. Femoral hernia 2. ID inguinal 3. Umbilical 4. Others: incisional and internal H. The site of obstruction is the neck of hernia The compromised viscus is with in the sac. Ischaemia occurs initially by venous occlusion, followed by oedema and arterialc ompromise. Attempt to distinguish the difference between: Incaceration Sliding Obstruction Strangulation is noted by: Persistent pain Discolouration Tenderness Constitutional symptoms

  18. Other causes Intussusception Gall stone Ileus IBD

  19. Sigmoid Volvulus Colonic Obstruction

  20. Large Bowel Obstruction Aetiology: 1. Carcinoma: The commonest cause, 18% of colonic ca. present with obstruction 2. Benign stricture: Due to Diverticular disease, Ischemia, Inflammatory bowel disease. 3. Volvulus: 1. Sigmoid Volvulus: Results from long redundant, faecaly loaded colon with a narrow pedicle 2. Caecal Volvulus 4. Hernia. 5. Congenital : Hirschusbrung, anal stenosis and agenesis

  21. PATHOPHYSIOLOGY

  22. Patho-physiology I 8L of isotonic fluid received by the small intestines (saliva, stomach, duodenum, pancreas and hepatobiliary ) 7L absorbed 2L enter the large intestine and 200 ml excreted in the faeces Air in the bowel results from swallowed air ( O2 & N2) and bacterial fermentation in the colon ( H2, Methane & CO2), 600 ml of flatus is released Enteric bacteria consist of coliforms, anaerobes and strep.faecalis. Normal intestinal mucosa has a significant immune role • Distension results from gas and/ or fluid and can exert hydrostatic pressure. • In case of BO Bacterial overgrowth can be rapid • If mucosal barrier is breached it may result in translocation of bacteria and toxins resulting in bactaeremia, septaecemia and toxaemia.

  23. Local Effects of Obstruction • 1, peristalsis->hyperperistalsis->abnormal peristalsis • 2,secretion increase and absorption decrease • 3, accumulation of fluids and electrolytes • 4, distension of intestinal lumen • 5, edema of the bowel wall ->anoxemia->necrosis

  24. Systemic Effects of Obstruction • 1, water and electrolyte losses • 2, toxic materials and toxemia • 3, cardiopulmonary dysfunction • 4, shock

  25. Closed-loop Obstruction • 1.It is dangerous form because of the propensity for rapid progression to strangulaton of the blood supply • 2, the secretory pressure in the closed loop quite rapidly reaches a level sufficient to interfere with venous return from the loop.

  26. Colon Obstruction • 1, usually not strangulation • 2, fluid and electrolyte sequestration progresses more slowly

  27. CLINICAL FEATURES • 1, Abdominal pain • 2, Vomiting • 3, Obstipation • 4, Distention

  28. Physical Examination • 1, Inspection : state of nutrition , behavior ,skin color , and turgor and warmth of the skin • 2, Palpation : demonstrating the sites of the distress, then localizing the anatomic areas of possible abnormality. • 3, Auscultation : simple one ----noisy and is heard as rushes. During attacks of colic ,the sounds become loud ,high-pitched and metallic . • 4, Digital examination of the rectum

  29. Laboratory Examination • 1, complete blood count • 2, serum electrolytes and amylase determination • 3, arterial blood gas analysis • 4, urine specific gravity test

  30. Radiologic Examination • X-ray is the most important diagnostic procedure. Intestinal gas often is found. Not so often. Sometimes can display the intestinal loop.

  31. Radiological Evaluation Normal Scout Always request: Supine, Erect and CXR Gas pattern: Gastric, Colonic and 1-2 small bowel Fluid Levels: Gastric 1-2 small bowel Check gasses in 4 areas: Caecal Hepatobiliary Free gas under diaphragm Rectum Look for calcification Look for soft tissue masses, psoas shadow Look for fecal pattern

  32. The Difference between small and large bowel obstruction

  33. Role of CT Used with iv contrast, oral and rectal contrast (triple contrast). Able to demonstrate abnormality in the bowel wall, mesentery, mesenteric vessels and peritoneum. It can define the level of obstruction The degree of obstruction The cause: volvulus, hernia, luminal and mural causes The degree of ischaemia Free fluid and gas Ensure: patient vitally stable with no renal failure and no previous alergy to iodine

  34. Role of barium gastrografin studies As: follow through, enema Limited use in the acute setting Gastrografin is used in acute abdomen but is diluted Useful in recurrent and chronic obstruction May able to define the level and mural causes. Can be used to distinguish adynamic and mechanical obstruction Barium should not be used in a patient with peritonitis

  35. How to initially investigate your patient Lab: CBC (leukocytosis, anaemia, hematocrit, platelets) Clotting profile Arterial blood gasses U& Crt, Na, K, Amylase, LFT and glucose, LDH Group and save (x-match if needed) Optional (ESR, CRP, Hepatitis profile Radilogical: Plain xrays USS ( free fluid, masses, mucosal folds, pattern of paristalsis, Doppler of mesenteric vasulature, solid organs) Other advanced studies (CT, MRI, Contrast studies……senior decision) ECG and other investigations for co-morbid factors

  36. Mechanical Obstruction

  37. Adynamic Ileus

  38. DIAGNOSIS • 1, Whether obstruction : according to clinical manifestation ,we can know. • 2, Mechanical or dynamic one . • 3, Simple or strangulated one.

  39. Understanding the clinical findings

  40. Clinical Findings1. History Persistent pain may be a sign of strangulation Relative and absolute constipation

  41. Clinical Findings2. Examination

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