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M.C 80 yr Female
ED
Abdominal distension
Progressively worsening
Vomiting
Constipation
Passing flatus
PAST HISTORY
MEDICAL:
Hypertension
SURGICAL:
On Examination
Vitals
Pulse:70/min, Regular
BP: 130/80
Temp: 36.5 C
RR: 15/min
Dehydrated
CNS: GCS 15/15
CVS: S1 + S2 + 0
Chest: Bilateral NVB
Abdominal Exam
Investigations
FBC:
Hb: 12 gm/dl
WCC: 9000
Platelets: 299,000
U&E
K: 4 meq/l
CRP: 17
Lactate: 1.3
Investigations
PFA
Investigations
CT Abdomen / Pelvis
Investigations
Management
Conservative
Intake-Output Record
Wide Bore
Left on free drainage
IV Fluids
Foleys Catheter to aim Urine output > 1ml/kg/hour
Analgesia
Thrombo-Prophylaxis
TEDS
Tinzaparin
Management
Management
Laparoscopy
Management
Converted to Laparotomy
INTESTINAL OBSTRUCTION
Classification
Dynamic
High
Low
Large Bowel
Intra Luminal
Intra Mural
Extra Mural
Adynamic
Dynamic Obstruction
Causes
Intraluminal
Impaction
Foreign bodies
Bezoars
Gall stones
Worms
Dynamic Obstruction
Intramural
Stricture
Malignancy
Dynamic Obstruction
Extramural
Bands
Adhesions
Hernia
Volvulus
Intussusception
Etiology
Adynamic Obstruction
Absent Peristalsis
Paralytic Ileus
Classification of Intestinal
Obstruction
By Surgical Pathology
Simple
Strangulated
By Nature of Presentation
Acute
Subacute
Chronic
Acute on Chronic
Pathophysiology
Simple occlusion
Proximal distension is
because of:
Gas
Nitrogen 90 %
H2S
Fluid collection
Pathophysiology
Pathophysiology
In closed Loop
Obstruction
Pathophysiology
In strangulation
Symptomatology
Pain
First symptom
Colicky in nature
Centered around umbilicus --- Small bowel
Lower abdomen-----Large bowel
With increasing distension, colicky is
replaced by diffuse pain
Severe pain is indicative of strangulation
Does not occur in Paralytic ileus
Symptomatology
Vomiting
Symptomatology
Distension
Symptomatology
Constipation
Richter's Hernia
Gallstone ileus
Mesenteric vascular occlusion
Obstruction associated with pelvic abscess
Partial obstruction (faecal impaction/colonic neoplasm)
where diarrhoea may often occur
Examination
General
Dehydration
Repeated vomiting
Fluid sequestration
Urea and haematocrit rise
Pyrexia
Onset of ischemia
Intestinal obstruction
Inflammation associated with obstructing
diseases
Hypothermia indicates septicemia
Examination
Abdomen
Inspection
Scars
Site of distention
Visible peristalsis
Irreducible swellings
Examination
Palpation
Abdominal mass
Tenderness
Rigidity
Hernial Orifices
Examination
Percussion
Auscultation
Resonance
Hyper-resonant
Silence
DRE
Impacted faeces
Rectal tumor
Blood on finger
Features of Strangulation
Presence of shock
Pain
Symptoms commence suddenly and recur
regularly
Localised tenderness
Rebound tenderness
Rigidity
Raised WCC & CRP
Metabolic acidosis: Rising Lactate & Base
deficit
Investigations
PFA
PFA
CT Abdomen / Pelvis
Management
Principles
Gastrointestinal Drainage
Fluid & Electrolyte replacement
Relieve of Obstruction
Management
Initial management
Pass NG
I/V fluids: Saline or Hartmanns
Catheterise
Antibiotic are not necessary but many
clinicians give because of overgrowth of
the bacteria
Management
Monitor
Pulse
Temp
BP
Respiratory rate
Urine out put
Abdominal girth
Abdominal tenderness
WCC, CRP & Lactate
Conservative Management
Done in
Surgical Management
Surgical Management
Surgical Management
Paralytic ileus
Impacted faeces
Volvulus
No strangulation seen on previous
exploration
Surgical Management
Site of obstruction
Nature of obstruction
Viability of the gut
Surgical Treatment
Viable
Nonviable
No bleeding if mesentery is
pricked
Peritoneum
Shiny
Bowel musculature
Firm
No peristalsis
Causes
Carcinoma
Diverticular disease
Volvulus
Pseudo-obstruction
Types
Acute
Chronic
Full resuscitation
Proximal stoma
Ilio-transverse internal bypass
Left hemicolectomy
Double barreled colostomy (Paul-Mikulicz)
Hartmanns procedure
On table lavage of colon with primary
anastomosis
Primary anastomosis with proximal covering
stoma
Rare Causes
Rare Causes
Rare Causes
Rare Causes
Rare Causes
Rare Causes
Thank You