Pathophysiology.

The principal physiologic derangements Of the mechanically

obstructed intestine with intact blood supply are accumulation of fluid
and gas above the point of obstruction and altered bowel motility. which
leads to systemic derangements. Death from intestinal obstruction was
for many years attributed to "toxins" that were absorbed from the
intestine. In 1919 Hartwell and Hoguet were able to prolong the life of
dogs With high intestinal obstruction by daily parenteral administration
of physiologic saline solution, Gamble later demonstrated that the
"toxic" factor in simple mechanical obstruction was the loss of fluid and
electrolytes from the body by vomiting and by sequestration in the
obstructed bowel. Accumulation of large quantities of fluid and gas
within the lumen of the bowel above an obstruction is progressive. The
net movement of a substance across the intestinal mucosa is equal to
the difference between the unidirectional flux from intestinal lumen to
blood (absorption) and the opposite flux from blood to lumen
(secretion), Accumulation Of fluid within the bowel, a negative net
flux, results if the flux from lumen to blood (absorption) is decreased
or if the flux from blood to lumen (secretion) is increased. After 48 ho
of obstruction, the rate of entry of water unto the intestinal lumen
increases as blood 10 lumen flux. The findings for sodium and po!ass-
iurn•• parallel to those Of fltii& Normal fluxes occur in the Of blood
fluxes from lumen to blood are depressed or Abolished Obstnicted ileal
segment. As a result, water, sodium. and chloride (and presumably
other ions) move into the obstructed intéstiiii segment but not Alt of it,
distending it with fluid that proximately the electrolyte composition Of
plasma.Wright and associates studied net in patients With ileostomies.
Closed loops were produced by proximal obstructing balloons inserted
through the ileostomy. Absorption Of a test solution was found to
increase at moderate elevati Wright and associates studied net flux in
ileostomies. Closed loops were produced by proximal and distal
obstructing balloons inserted through the ileostomy. Absorption Of a
test solution was found to increase at moderate elevation, of pressure,
but fell below normal at pressure three or four normal. Conversely.
secretion of fluid into the lumen progressively as pressure rose. They
concluded that i secretion is the primary cause Of fluid loss and
distention In intestinal obstruction, with decreased absorption playing a
role. Prostaglandin release in response to bowel distention thought to
be the mechanism by which secretion into Obstructed loops is
increased. The bowel immediately above the obstruction is the most
affected initially. It becomes distended with fluids and lytes, and
circulation is impaired, With increasing pressure, the fluid is dispersed
Orad until it reaches bowel that is still capable of absorption, When
obstruction has been present for a long time, the proximal portions of
the intestine also their ability to handle fluid and electrolytes, arid
theentire bowel proximal to the obstruction becomes distended. A
second route of fluid and electrolyte loss is into the wall of the involved
bovvel, accounting for the boggy edematous appearance of the bowel
often seen at operation, Some of tis fluid exudes from the serosal
surface of the bowel, resulting in free peritoneal fluid, The extent of
fluid and electrolyte loss into bowel wall and peritoneal cavity depends
on the extent of bowel involved in venous congestion and edema, and
the length Of time before the obstruction is relieved. The most obvious
route of fluid and electrolyte loss is by vomiting or gastrointestinal tube
after treatment is initiated. 'The aggregate Of these losses (1) into the
bowel lurnen, (2)ånto the edematous bowel wall, (3) as free peritoneal
fluid, and (4) by vomiting or nasogastric suction, rapidly depletes the
extracellular fluid space, leading progressively to hemoconcentration.
hypovolemia, renal insufficiency, shock, and death unless treatment is
prompt. Much of the distention of the bowel above a mechanical
obstruction can be accounted for by the fluid sequestered within the
lumen. Intestinal gas also is responsible for distention. The approximate
composition of small intestine gas (Table 22-12) that t e a position is
swallowed air to which small omounts of gases Gases are absorbed
from the intestine at rates that are directly the partial pressure of the
particular gas in the intes- related t I e plasma, and in the air breathed.
In the case of nitro- there is little diffusion, since the partial pressures
of the gas e in intestine, plasma, and air. On the other are virtually the
sam dioxide diffuses very rapidly, because the partial hand, carbon
dioxide is high in the intestine, intermediate pressure of carbon in
plasma, and very low in air. For this reason, though carbon dioxide is
produced in I gaseous distention. Strangulated Obstruction. Occlusion
of the blood supply to a segment of bowel in addition to obstruction of
the lumen usually is referred to as strangulated obstruction. Interference
with the mesenteric blood supply is the most serious complication of
intestinal obstruction. This frequently occurs secondary to ad- hesive
band obstruction, hernia, and volvulus. The accumulation of fluid and
gas in obstructed loops and the altered motility seen in simple
mechanical obstruction are rapidly overshadowed by the consequences
of blockage of ve- nous outflow from the strangulated segment—
extravasation of bloody fluid into the bowel and bowel wall. In addition
to the loss of blood and plasmalike fluid, the gangrenous bowel leaks
toxic materials into the peritoneal cavity. These have been variously
identified as exotoxins or endotoxins, or toxic hemin breakdown
products. The consequences of strangulated obstruction are related to
several factors. The toxic contents are produced by bacteria. In order
for the toxins to have an effect, the mucosa must be disrupted and the
toxins must pass into the circulation. Damage tointestinal vessels
expedites absorption. Symptoms are a mani-festation of the absorbed
toxins. Closed-Loop Obstruction. When both afferent and efferent
limbs of a loop of bowel are obstructed, it is referred to as closed-loop
intestinal obstruction. This is a dangerous form of obstruction because
of the propensity for rapid progression to strangulation of the blood
supply before the usual manifestations of intestinal obstruction become
obvious. Interference with blood supply may occur from the same
mechanism that produced ob-struction of the intestine—e.g., twist of
the bowel on the mes- entery or extrinsic band—or from distention of
the obstructed loop. The secretory pressure in the closed loop rapidly
reaches a level sufficient to interfere with venous return from the loop.
Widespread distention of the intestine usually does not occur, and so
neither does abdominal distention. Colon Obstruction. The effects on
the patient with colon Obstruction usually are less dramatic than the
effects of small .
Laboratory Findings. Intestinal obstruction usually re- sults in losses
of 4 to 8 L of intravascular and extracellular fluid into the small bowel,
with consequent compromise of the cardiovascular system. Elevation
of blood urea nitrogen and creatinine levels, hemoconcentration,
hyponatremia, and hypokalemia are the most common early laboratory
signs. Urinary specific gravity of 1.025 to 1.030 is the rule; proteinuria
or mild acetonuria may be present. Sodium-free water from proteolysis
and catabolism of fat will partially replace the intravascular deficit, but
hyponatremia, hypochloremia, and hypoosmolality will result. Urine
volume gradually increases, though not to normal, with excretion of
potassium, including the potassium freed by cellular catabolism. The
previously noted progressive increase in the hematocrit concentration
is halted or reversed by the ingres sof endogenous water. Acid—base
effects are determined by the nature of the fluid lost. Metabolic acidosis
from the combined effects of dehydration, starvation, ketosis, and loss
of alkaline secretions is most common. Metabolic alkalosis occurs
infrequently, principally because of loss of highly acid gastric juice.
With great distention of the abdomen, the diaphragm may be
sufficiently elevated to embarrass respiration, resulting in carbon
dioxide retention and respiratory acidosis. Simple mechanical
obstruction is accompanied by a modest increase in the number of
leukocytes with some shift to the left. White blood cell counts of 15,000
to 25,000/mm3, and marked polymorphonuclear predominance with
many immature forms, strongly suggest that the obstruction is
strangulated, but this is not a sensitive indicator. Very high white cell
counts, such as 40,000 to 60,000/mm3, suggest primary mesenteric
vascular occlusion. Serum amylase level elevations may occur in
intestinal obstruction, Amylase gains entry to the blood by regurgitation
from the pancreas because of back pressure in the duodenum, or by
DIAGNOSIS

Laboratory tests are not generally helpful in the diagnosis or

management of patients with bowel obstruction. Routine blood counts
reveal an elevated hematocrit indicative of intravascular volume
depletion. Leukocytosis is sometimes present, but is often the result of
hemoconcentration and an acute stress response rather than actual
underlying infection. A markedly elevated white blood cell count
should raise the suspicion for strangulation. The blood chemistry may
reveal elevated blood urea nitrogen and creatinine, indicating
hypovolemia with prerenal azotemia. Computed tomography (CT) is
employed increasingly to evaluate patients with suspected bowel
obstruction. The CTscan can often clearly identify dilated proximal and
collapsed distal bowel, a feature that is aided by the administration Of
an oral contrast agent. The precise site and etiology of the 0bstruction
may not be identified by CT, as in the case Of adhesions, although in
some instances an obstructing lesion can be seen. Frager et al.47
compared standard clinical evaluation' including plain radiographs,
with CT in 90 cases of suspected small-bowel obstruction. The correct
diagnosis of complete obstruction was made in only 46% of patients by
clinical plain radiographic findings, whereas CT was found to be 100%
sitive in these cases. CT was also superior in cases of partial small-
bowel obstruction. However, false-positive CT scans were obtained in
6 cases, suggesting that the radiologic teria for small-bowel obstruction
may have been too broad Based upon these and other series in the
literature, CT 4 g has replaced the contrast small-bowel follow-through
in many centers as the primary radiologic tool in suspected mechanical
small-bowel obstruction. There are similar advantages 0 CT in large
bowel obstruction where tumor masses and perlicolic inflammatory
changes can be identified. Abdominal ultrasound has also been touted
for patieåtes with suspected small-bowel obstruction. Ultrasound can
tect fluid-filled, dilated small bowel proximal to collapsed
GENERAL EFFECTS
High obstruction :
1. Circulatory changes are due to loss of fluid and salt in vomiting
and their accumulation in the gut as there is no absorption of fluid
from inside the intestine.
2. As a result of this, there is a lowered blood volume and diminu-
tion of urinary secretion.
3. The salt loss is compensated by the absence of chloride in urine,
passage of salt from corpuscle to plasma and retention of
bicarbonates.
4. In late stages There are (a) Dehydration, (b)
Haemoconcentration, Hypochloraemia, (d) Alkalosis and (e)
Rise of blood urea. The cause of dehydration is loss of large
amount of fluid from the general circulation because they are
con- fined in the lumen of the intestine as well as due to vomiting.

LOW obstruction :
The changes due to fluid and chloridc loss are less marked and death
may thus be delayed. In strangulation, apart from the factors mentioned
above, the death is contributed by loss of blood volume from the
strangulated bowel especially, when it is a long loop. Later additional
factors like peritonitis, septicaemic shock, etc, complicate the existing
situation.
Symptoms
A. Pain at first colicky around the umbilicus, later spread all over
the abdomen. In late stage it may be continuous.
 B. Vomiting is constant (higher the obstruction, more is the volume)
At first it is bilious and but in late stage it is very offensive and
faecal in colour (faecal vomiting).
C. Absolute constipation (no flatus, no faeces) lt is one of the most
characteristic symptoms but even after the onset of obstruction
some-times the contents of the lower bowel is evacuated bv one
motion.
D. Intense thirst and the patient demands water frequeuuz.
E. Distension More marked in large bowel obstruction.

Findings
A. Distension

I. In lower small gut obstruction, the central part of abdomen is

distended first.
II. In large gut obstruction, the distension is more marked on the
flanks and epigastrium.
III. Distension gradually increases and in late stages whole abdomen
bloats up as a whole.

Causes of distension :
(a) Gas from
I. Swallowed air (70%).
II. Diffusion from blood in the congested capillaries
(20%).
 III. Products of bacterial activity and also of digestion
(10%).This consists of 9 parts of Nitrogen and 1 part
of hydrogen sulphide as oxygen is soon absorbed.
(b) Liquid from excretion of water and electrolytes into the lumen
where absorption stops following obstruction.
(c) Toxic paralysis of bowel is mainly due to the endotoxins of the
gram negative bacilli liberated in the lumen of the strangulated
bowel and later its entry into the peritoneal cavity following
perforation

B. Tenderness and rigidity are present. At first they are localised, later
spread all over the abdomen.

C. peristaltic sound are increased with metallic tinkling note except in

the late stage when it is absent.

N.B. There are three types of bowel sounds :

a. Normal 1010 pitched typo lasting for a second occurring
every 20 seconds or so.
b. Prolonged and frequently occurring high pitched sounds of
dynamic obstruction.
c. High pitched tinkling nota occurring every 10-30 seconds
is characteristic of paralytic ileus and due to overflow of
fluid from one distended loop to another during respiratory
move
D. Swelling or lump—may be felt either abdominally or rectally in
strangulated hernia or intussus- ception, respectively.

E. Shock More in strangulation.

F. Two enema test An enema is given and after to 1 hour another is

given. Negative result of the second enema is an important feature.

G. X-ray
i. Distended small gut with mul- tiple fluid levels which is
characteristic is better shown in erect position.

ii. Large gut obstruction peripherally placed gas shadow showing

haustrations. It has been observed that it takes a minimum period
of half an hour, six hours and twentyfour hours for the gas, fluid
and solid respectively to pass through the length of the intestine.
In an intestinal obstruction it normally takes about six hours
before fluid levels are observed in a straight skiagram.

Simple obstruction and strangulation :

i. In strangulation—rebound tenderness is present and rigidity is

marked.

ii. Pain and shock are more in strangulation.

iii. If patient's general condition does not improve within three to
four hours with gastro-duodenal suction and i.v. therapy, in all
probability it is a strangulation. Treatment But It is nearly always
operative. before operation is undertaken, patient is treated with
continuous gastro-duodenal suction and I.V. drip. If it is a case
Of simple obstruction, the operation can deferred and sometimes
it may not be necessary. But in strangulation, operation is