Intestinal Obstruction

Yohannes T.
2014 G.C.
Outline
Definition
Classifications
Pathophysiology
Clinical manifestations
Physical Examination
Investigations
Management
Definition

Intestinal obstruction is defined as partial or

complete blockage of the bowel that results in the
failure of intestinal contents to pass
 Classification
According to
1-The mechanism of obstruction :
Dynamic: peristalsis is working
against a mechanical obstruction
which may be:
intraluminal - gallstone ileus, round
worm mass, foreign body,...

Intramural - stricture, tumors,...

extramural - volvulus , intussuception,

hernia,...
 Dynamic obstruction
Intraluminal Intramural Extraluminal

Gallstones Strictures Adhesions

Food bolus Hernia

Malignancy
Volvulus
Bezoars
Intussuption

Worms
 Adynamic: peristalsis may be absent or it
may be present in non propulsive form like in
pseudo-obstruction
2 - Onset :
acute
chronic
3 - Site :
small bowel obstruction
large bowel obstruction
4 - Simple or Strangulated
Pathophysiology

Components of intestinal obstruction:

1 - obstruction point
2 - proximal segment
3 - distal segment
 the proximal segment :
initially increased peristalsis
later decrease in peristalsis + distension
distension is due to :
1 - gas
2 - fluids

the distal segment :

initially normal peristalsis
later immobile + contracts
 Closed loop obstruction

occurs when the bowel is

obstructed at both the
proximal and distal point

if unrelieved it may result

in necrosis and perforation
 Strangulation
Is impairment of blood supply
to the bowel
Signs of strangulation
severe continuous pain
tenderness with rigidity
Shock
Fever
tachycardia after resuscitation
raised WBC
 Causes of strangulation

external - hernial orifices

- adhesions / bands
interrupted blood flow - volvulus
- intussusception
increased intraluminal pressure
- closed loop obstruction
primary - mesenteric infarction
 Cardinal manifestation
1 - Pain:
sudden severe colicky
small bowel : central
large bowel : lower abdomen
2 - Vomiting:
in higher obstruction it occurs
early and is profuse
its nature depends on the
level of the obstruction
3 - Constipation :
absolute (no feces nor flatus)
or partial (only flatus is passed)
early in large bowel obstruction
but late in small bowel

4 - Distension:
the lower the site of obstruction
the more bowel there is available
to distend
Other manifestations
1 - Dehydration
2 - Electrolyte imbalance e.g. hypokalemia
3 - Fever
4 - symptoms and signs of peritonitis

Clinical features vary according to:

site of the obstruction
onset and duration of the obstruction
underlying pathology
presence / absence of strangulation
Physical examination
Vital signs - tachycardia, hypotension,
fever
Abdominal examination
Inspection:
abdominal distension, scars, visible
peristalsis, hernial orifices
Palpation:
mass, tenderness and guarding
Percussion:
hypertympanic
Auscultation:
high pitch and increased or absent
bowel sound
Investigations
CBC, Blood group & Rh, serum
electrolyte

X-Ray:
small bowel obstruction appear
with multiple air-fluid levels as
stepladder pattern
volvulae conniventae
o distended large bowel tends to lie peripherally
and to show the Haustrations
 Ultrasound :
for intussusception
and describe nature of
a mass

CT scan :
usefull to detect :
lesions, tumors,...
Management of Intestinal Obstruction
General management of intestinal obstruction:
GI drainage - NG-tube
fluid and electrolyte replacement
relief of obstruction- e.g. rectal tube
surgical Rx is necessary for most cases of IO

Indications for early surgical intervention:

obstructed or strangulated external hernia
internal intestinal strangulation
Adhesions

most common cause of intestinal

obstruction
difficult to differentiate it from
paralytic ileus in early
postoperative period
most common postoperatively
after appendectomy and
gynecological procedures
 Causes :
ischemic areas
foreign material
infection
inflammatory conditions
radiation enteritis

Types of adhesions:
Early (fibrinous): may disappear in days 15
Late (Fibrous): usually happen after 07 days
 Prevention of adhesions:
good surgical technique
washing of the peritoneal cavity with saline to
remove clots
minimising contact with gauze
covering anastomoses and raw peritoneal surfaces

Management
Early NG-tube insertion, resuscitation,...
Late usually surgery (release of obstructing band)
Volvulus
twisting or axial rotation of a portion of bowel
about its mesentry
Primary : occurs secondary to congenital malrotation of
the gut, abnormal mesenteric attachments or congenital
bands
Secondary: more common than primary, occurs due to
rotation of a piece of bowel around an acquired
adhesion or stoma
Volvulus is less common in small bowel than in
large bowel
 Large bowel rotation may occur in two sites:
Cecum
clock-wise twist
Sigmoid
anticlockwise twist
more common
Dx: plain radiograph shows massive colonic
distension
Mx: decompression, resection and anastomosis
Adynamic

Paralytic ileus

Acute mesenteric ischemia

 Paralytic ileus

a state in which there is failure of transmission of

peristaltic waves

Types:
postoperative: self limiting within 24-72 hours.
Infection
metabolic
reflex ileus
 Presentaion:
abdominal distension
effortless vomiting.
on P/E tympanic abdomen, no return of bowel
sounds on auscultation

Management: preventive
N/G suction and restriction of oral intake.
maintenance of electrolyte imbalance.
specific Rx the primary cause must be
removed.
if Ileus is prolonged, a laparotomy should be done.
Acute mesenteric ischemia:
the superior mesenteric vessels are the visceral vessels
most likely to be affected by embolization and thrombosis,
which is more common.
occlusion at the origin of the SMA is almost invariably the
result of thrombosis
embolisation occurs usually at the origin of middle colic
artery.
Sources of embolization of (SMA):
Lt atrial fibrilation
mural MI
atheromatous plaque from aortic aneurysm.
mitral valve vegetation associated with endocarditis
 Clinical features:
sudden severe abdominal pain out of proportion to
physical findings
persistent vomiting
abdominal tenderness at the beginning, and lately there
will be rigidity
Investigation:
Leucocytosis with high percentage of neutrophil
PT, PTT, INR, Doppler ultrasound, angiography
Management:
full resuscitation and embolectomy
revascularization of SMA in early diagnosed embolic
cases
References
Bailey and Loves: Short Practice of
Surgery, 25th ed

Swartzs: Principles of Surgery,9th ed

Sabiston: Text Book of Surgery, 18th ed

Maingot`s: Abdominal Operations, 8th ed