Small Bowel Obstruction

By

Dr. Rafik Hanna

What is SBO?
Interruption

of the normal flow of

intestinal contents.

Causes

Extrinsic; most frequent

-Post-operative adhesions 75%
-Hernias

Intrinsic;

-Tumors; usually metastatic colorectal

carcinoma
-Intussusceptions, volvulus, crohndisease,
gallstones(gallstone ileus)

Epidemiology

15% of abdominal surgeries;

-Will require readmission for SBO within 2
years after the operation

50 70% of admitted SBO patients;

- Will Require surgery

Epidemiology

Risk of recurrence;
Over the next 10 years;
- About 30% for operatively treated pts
-About 50% for non-operatively treated pts

Overall mortality;
- 5% if no strangulation
- As much as 37% if strangulation

Pathophysiology of SBO

Obstruction leads to dilatation of of the stomach

and small intestine proximal to the obstruction
with decompression of the distal small bowel
and colon

Accumulation of swallowed air and gas from

bacterial fermentation will cause more dilatation.

This will lead to intestinal wall edema with loss

of normal absorptive function of the intestine.

Pathophysiology

This results in dehydration with concomitant

electrolyte disturbances, oliguria, tachycardia,
hypotension & azotemia

Progressive bowel wall edema & increasing

intraluminal pressure may compromise perfusion
and so can result in strangulation which ends in
necrosis and eventually perforation.

History
Symptoms;
-Nausia, vomiting
-Abdominal distension
-Abdominal pain;Paroxysmal every 5 min,
periumbilical, crampy

*If pain progress to be constant or focal,

strangulation should be thought of
+/- No bowel movement & inability to pass flatus

History
Past

medical history;

-Previous abdominal surgery

Upper or lower abdominal surgery
Large bowel resection
Appendectomy
Previous surgery for obstruction
Other pelvic surgeries

-Crohns disease

-Intra-abdominal malignancy

Physical examination

General Examination;
-For strangulation; Fever, tachycardia
-For dehydration; oliguria, dry mucous
membranes, hypotension

Abdominal Examination;
-Inspection; distension, hernias, surgical scars
-Auscultation; high pitched or hypoactive
-Percussion; tympani, tenderness

Physical examination
-Palpation;-Localized tenderness, rebound,
guarding , rigidity
-Abdominal mass ;
tumor,volvulus,abscess

DRE;

-Empty rectum
-Rectal mass
-Gross or occult blood

Investigations
Lab;

-Serum lytes, urea, creatinine, hematocrite

-Leucocytosis with leftward shift
-Metabolic acidosis or alkalosis
-Serum lactate; sensitive, non specific for strangulation

Investigations
Radiologic

diagnosis

3 views abdominal x-rays;

-Distended loops of small bowel
-Multiple air-fluid levels
-Free air
-Air in the colon or rectum

Radiologic diagnosis

CT scan
-If plain x-ray is not diagnostic
-With oral and IV contrast
-Discrepancy in the caliber of proximal
and distal small bowel with a point of
transition
-Useful in location of the obstruction, detection
of the cause and possible strangulation
-In most cases no obvious source of
obstruction is seen!?

Radiologic diagnosis
Small

bowel series;

-Done if Ct scan is not diagnostic

-Gold standard for determining whether
an obstruction is partial or complete

Radiologic diagnosis
Abdominal

US;

-more sensitive and specific than plain films

-But not as accurate as CT scan
-Plain films; 50% sensitivity & 75% specificity
-Abd US; 83% sensitivity &100% specificity
-CT scan; 93% sensitivity &100% specificity

Radiologic diagnosis
Level of obstruction

Cause of obstruction

Plain films

60%

7%

Abd US

70%

23%

CT scan

93%

87%

Treatment of SBO
Never

let the sun rise or set

on a SBO
SBO should be observed for no longer
than 12 to 24 hours; if no improvement is
shown, patient should be brought to
surgery to prevent strangulation

Treatment of SBO
Most important to determine;
-Complete or partial?
-Strangulation?
-Then of secondary importance;
-Location ?
-Cause?

Non operative management

Requires that strangulation be ruled out

It is more likely to be successful in patients
with partial obstruction
In recurrent adhesive obstruction, early
postoperative obstruction, metastatic
intaabdomoina malignancy

Non operative management

NPO
IV fluids; crystalloid solution
NG tube;prevents further bowel distension
Foleys catheter; to monitor urine output

Operative management

In approximately - of patients
Indications;
-Complete obstruction
-Suspected strangulation
-No improvement on non operative management
for 12-24 hours
-Closed loop obstruction
-Mesenteric ischemia