Intestinal obstruction

Intestinal obstruction

Mechanical obstruction

Paralytic Ileus

Paralytic Ileus

After abdominal surgery (laparotomy) Electrolyte imbalances (hypokalemia) Abdominal thrauma Spine fracture Retroperitoneal hemorrhage Ureter distension Acute pancreatitis Ischemia of the intestine Drugs (Narcotics, Psychotropics) Peritonitis (ex. Gangrenous cholecystitis) Diabetic coma Extra abdominal infections (Lung) Sepsis IBD (ulcerative colitis)

Intestinal mechanical obstruction

Pathogenesis

Stenosis Obstruction Compression Invagination Torsion Angulation Strangulation

Intestinal obstruction
Pattern in Africa
80% with gangrenous bowel segments
3% 10% 3%

Adhesions Hernia Small Intest volvolus Intussusception Sigmoid volvolus Ascaris Large bowel tumor

40% 14%

14% 16%

70 % of the patients were below the age of 15 years

Intestinal mechanical obstruction

Large gallstones -- cholecystoenteric fistula gallstone ileus Bezoars (children, mentally retarded, toothless, after gastrectomy) Congenital lesions (atresia, stenosis, duplication) Neoplasms of small bowel peritoneal carcinosis Inflammation (Chrons disease- diverticulitis- BKendometriois) Fecal impaction (bedridden old patient) Meconium Foreign bodies Iatrogenic strictures (intest. Anastomosis o RT)

Etiology

Simple mechanical obstruction

PATHOGENESIS

Accumulation of fluids and gas proximal to the obstruction Distention of the intestine (self perpetuating)

Increase intestinal secretion Losses of water, Na, Cl, K, H Dehydratation, ipokalemia, hypochloremia Metabolic alkalosis

Simple mechanical obstruction

PATHOGENESIS

Circultory changes Low central venous pressure Reduced cardiac output Hypotention Hypovolemic shock

Rapid proliferation of intestinal bacteria Toxiemia

Mechanical obstruction

Paralytic Ileus

Strangulation obstruction
PATHOGENESIS

Ischemia of the bowel Loss of blood and plasma into the strangulated segment Gangrene Perforation Peritonitis Sistemic absorption of toxic materia

Simple Mechanical obstruction

Surgical timing

Strangulation Obstruction

Intestinal obstruction Site Proximal s.b. obstruction

Greather vomitimg and less intestinal distention than distal obstruction

Colon obstruction

Less fluid and electrolyte disturbance Large distension and perforation risk

Intestinal obstruction Clinical aspects

Abdominal pain Vomiting Obstipation Abdominal distention Failure to pass flatus Fever Dehydratation Hypotention hypovolemic shock

Intestinal obstruction Pain

Typical crampy pain in paroxysm at 4 to 5 minute intervals in proximal obstruction Less frequently in distal occlusion After a long period of mechanical obstruction the crampy pain may subside A strangulation should be suspected when continuus severe pain replace crampy pain

Intestinal obstruction Vomiting

Proximal obstruction produce profuse vomiting and little abdominal distension Distal obstruction is less frequent but feculent

BUT

Initial phase byliary aspect Late phase feculent

Intestinal obstruction - Level

HIGH
PAIN VOMITING METEORISM BEGINNING ABDOMINAL DISTENTION GENERAL CONDIT ELECTOLYTES

LOW

Crampy pain in paroxism Less intensity Early, profuse, biliary + Acute Moderate, upper quadrant Early compromission Cl, K, Na rapid loss Late, feculent may be absent +++ Slow, insidious Early, intense preserved Late hydro electrolytic imbalance

Intestinal obstruction Clinical examination

Key points

Palpation abdominal masses can suggest neoplasms, intussusception, abscess Incarcerated hernias may be obscure (obese) Surgical scars can suggest adhesions Abdominal auscultation period of increasing separated by periods of quite bowel sounds (high pitched, tinkling or musical) in mechanical obstruction Rectal examination to seek luminal masses. Blood in the feces suggest mucosal lesion (cancer, intussusception, infarction)

Intestinal obstruction Clinical examination

Patient age and sex

Young children and babies Atresia Volvolus Anal imperforation Meconial ileus Intestinal Duplication Malrotation Intussusception Ascaris infestation Hernia

Adults Hernia Adhesions Neoplasm Inflammation RT Endometriosis Gynecological pathology

Intestinal obstruction Radiological examination

Abdominal direct X ray exhamination Barium enema CT Endoscopy Ecography (very difficult because of the massive presence of gas)

Intestinal obstruction Abdominal direct X ray exhamination

Gas abnormally large quantities of gas in the bowel Multiple gas-fluid levels in the upright or lateral decubitus position

Intestinal obstruction
Abdominal direct X ray exhamination Remember

Multiple gas-fluid levels does not always mean intestinal obstruction Abdominal pain and diarrhea can be found in gastroenteritis (cytomegalovirus infection as well as salmonellosis) expecially if profuse watery for 12 or more hours.

Intestinal obstruction Radiological examination What can we see

Identify the distended tract Small bowel Colon Both plus stomach

Intestinal obstruction Radiological examination Small bowel Gas in the small bowel outlines the valvulae conniventes, which usually occupy the entire trasverse diameter of the bowel image

Intestinal obstruction Radiological examination large bowel Colonic haustral marking occupy only a portion of the transverse diameter of the bowel

Intestinal obstruction Radiological examination Typical the small bowel pattern occupies the more central portion of the abdomen, the colon shadow is on the periphery of the abdominal film or in the pelvis

Intestinal obstruction Radiological examination

During paralytic ileus gaseous distention occurs somewhat uniformly in the stomach, small intestine and colon

Intestinal obstruction Barium Enema

Helpful in distal occlusion may be operative in intussusception

Intestinal obstruction CT scan

Is sensitive for diagnosing complete obstruction of the small bowel and determining the localization and cause of obstruction

Proximal obstruction

Distal obstruction

Intestinal obstruction Laboratory test

Hematocrit WBC Electrolytes PCR (C reactive protein) AST -ALT GGT- LDH

Intestinal obstruction Treatment

Fluid and electrolytes therapy Intestinal decompression (NG tube) Diuresys monitoring Correct surgical timing for relief of obstruction

Intestinal obstruction Timing of operation depends

Duration of obstruction Severity of fluid, electrolyte and acid base abnormalities Opportunity to improve vital organ function Consideration of the risk of strangulation