Intestinal obstruction

INTESTINAL OBSTRUCTION 1. Definition

2. Sites of obstruction
Small bowel
Large bowel
3. Causes of the obstruction
Lesions extrinsic to the bowel wall
Lesions intrinsic to the bowel wall
Intraluminal obturator lesions
4. Types of intestinal obstruction
Mechanical obstruction vs. Adynamic
ileus
Partial vs. Complete
Simple vs. Strangulated
High vs. low
Small bowel vs colon
5. Clinical picture
Radiogical tests
Fluid and electrolyte status
Dr.Yunus Yavuz
6. Treatment of intestinal obstruction

1. Definition
INTERRUPTION IN THE PASSAGE OF
INTESTINAL CONTENTS
Intestinal obstruction
1. Definition
2. Sites of obstruction
Small bowel
Large bowel
3. Causes of the obstruction
Lesions extrinsic to the bowel wall
Lesions intrinsic to the bowel wall
Intraluminal obturator lesions
4. Types of intestinal obstruction
Mechanical obstruction vs. Adynamic
ileus
Partial vs. Complete
Simple vs. Strangulated
High vs. low
Small bowel vs colon
5. Clinical picture
Radiogical tests
Fluid and electrolyte status
6. Treatment of intestinal obstruction

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 2. Sites of obstruction
2.Sites of obstruction
Small Bowel vs. Large Bowel Common Causes of Small Bowel
• Scenario Obstruction (SBO)
– prior operations, change in bowel habits
• Clinical picture 5%
5%

– scars, masses/ hernias, amount of 10%

distension/ vomiting Adhesions
Neoplasms
• Radiological studies Hernias
Crohns
– gas in colon?, volvulus?, transition point, 20% 60%
Miscellaneous
mass
• (Almost) always operate on LBO, often treat
SBO non-operatively

2. Sites of obstruction Intestinal obstruction

Common Causes of Large Bowel Obstruction
1. Definition
(LBO) 2. Sites of obstruction
Small bowel
• Colon cancer 3.
Large bowel
Causes of the obstruction
Lesions extrinsic to the bowel wall
• Diverticulitis Lesions intrinsic to the bowel wall

• Volvulus frequency Intraluminal obturator lesions

4. Types of intestinal obstruction
Mechanical obstruction vs. Adynamic
• Hernia ileus
Partial vs. Complete
Simple vs. Strangulated
High vs low
Small bowel vs colon
Unlike SBO, adhesions very unlikely to 5. Clinical picture
Radiogical tests
produce LBO 5.
Fluid and electrolyte status
Treatment of intestinal obstruction

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 3. Causes of obstruction
3. Causes of obstruction
Lesions Extrinsic to Intestinal Wall
• Adhesions (usually postoperative)
• Hernia
• Outside the wall – External (e.g., inguinal, femoral, umbilical, or
ventral hernias)
• Inside the wall – Internal (e.g., congenital defects such as
paraduodenal, foramen of Winslow, and
diaphragmatic hernias or postoperative secondary
to mesenteric defects)
• Inside the lumen
• Neoplastic
– Carcinomatosis, extraintestinal neoplasm
• Intra-abdominal abscess/ diverticulitis
• Volvulus (sigmoid, cecal)

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 • CT scan through the mid abdomen shows dilated small bowel loops
filled with fluid and decompressed ascending and descending colon.
These are typical CT findings in small bowel obstruction.

• CT scan of the abdomen of a patient with a mechanical bowel

obstruction secondary to an abscess in the right lower quadrant
(arrow). Multiple dilated and fluid-filled loops of small bowel are noted.

• Barium radiograph demonstrates obstruction of the third portion of the

duodenum secondary to superior mesenteric artery compression as a
consequence of burn injury.

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Congenital indirect inguinal hernia

at
at rest
rest upon
upon straining
straining

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 3. Causes of obstruction
Lesions Intrinsic to Intestinal Wall

• Congenital • Neoplastic
– Malrotation – Primary neoplasms
– Duplications/cysts – Metastatic
neoplasms
• Traumatic
– Hematoma • Inflammatory
– Ischemic stricture – Crohn's disease

• Infections • Miscellaneous
– Tuberculosis – Intussusception

– Actinomycosis – Endometriosis

– Diverticulitis – Radiation
enteropathy/stricture

• CT scan of a patient with

Crohn's disease demonstrates
marked thickening of the
bowel (arrows) with a high-
grade partial small bowel
obstruction and dilated
proximal intestine.

Resection of the ileum, ileocecal valve, cecum, Barium radiograph demonstrates a

and ascending colon for Crohn's disease of typical "apple-core" lesion (arrows)
the ileum. Intestinal continuity is restored by caused by adenocarcinoma of the
end-to-end anastomosis. small bowel, producing a partial CT scan of abdomen demonstrates a
obstruction with dilated proximal smallbowel neoplasm (arrow).
bowel.

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 Small bowel leiomyosarcoma
(malignant gastrointestinal
stromal tumor) with
hemorrhagic necrosis.

• Large circumferential mucinous adenocarcinoma of the jejunum.

Gross photograph of primary lymphoma
of the ileum shows replacement of
all layers of the bowel wall with tumor.

• Gross pathologic characteristics of carcinoid tumor. A, Carcinoid tumor of the

Small bowel lymphoma presents as perforation and peritonitis. distal ileum demonstrates the intense desmoplastic reaction and fibrosis of
the bowel wall. B, Mesenteric metastases from a carcinoid tumor of the small
bowel.

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• Gross pathologic features of Crohn's disease. A, Serosal surface
demonstrates extensive "fat wrapping" and inflammation. B, Resected
specimen demonstrates marked fibrosis of the intestinal wall, stricture,
and segmental mucosal inflammation.
• Small bowel series in a patient with Crohn's disease demonstrates a
narrowed distal ileum (arrows) secondary to chronic inflammation and
fibrosis.

• Barium study
demonstrates
jejunojejunal
intussusception.

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 3. Causes of obstruction

Intraluminal/ Obturator Lesions

• Gallstone
• Enterolith
• Bezoar
• Foreign body

• Plain abdominal film demonstrates a number of ingested foreign bodies

in a patient presenting with a small bowel obstruction.

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 4. Types of bowel obstruction
Intestinal obstruction
Adynamic Ileus vs Mechanical Obstruction
1. Definition
2. Sites of obstruction
Small bowel
Large bowel • Gas diffusely through • Large small intestinal
3. Causes of the obstruction
Lesions extrinsic to the bowel wall intestine, incl. colon loops, less in colon
Lesions intrinsic to the bowel wall
Intraluminal obturator lesions • May have large diffuse • Definite laddered A/F
4. Types of intestinal obstruction
Mechanical obstruction vs. Adynamic
A/F levels levels
ileus
Partial vs. Complete • Quiet abdomen • “Tinkling”, quiet= late
Simple vs. Strangulated
High vs low • No obvious transition • Obvious transition
Small bowel vs. colon
5. Clinical picture point on contrast study point on contrast study
Radiogical tests
Fluid and electrolyte status
• Peritoneal exudate if • No peritoneal exudate
6. Treatment of intestinal obstruction peritonitis

4. Types of bowel obstruction

Mechanical Obstruction
Causes of Adynamic Ileus

• Following celiotomy
– small bowel- 24h, stomach- 48h, colon- 3-5d
• Inflammation e.g. appendicitis, pancreatitis
• Retroperitoneal disorders e.g. ureter, spine, blood
• Thoracic conditions e.g. pneumonia, # ribs
• Systemic disorders e.g. sepsis, hyponatremia,
hypokalemia, hypomagnesemia
• Drugs e.g opiates, Ca-channel blockers,
psychotropics

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 4. Types of bowel obstruction
Adynamic Ileus Is there strangulation?
• 4 Cardinal Signs
fever, tachycardia, localized
abdominal tenderness, leucocytosis
• 0/4 0% strangulated bowel
• 1/4 7% “ “
• 2-3/4 24% “ “
• 4/4 67% “ “
• process accelerated with closed-loop
obstruction.

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 4. Types of bowel obstruction

Partial vs Complete
• Flatus • Complete obstipation
• Residual colonic gas • No residual colonic
above peritoneal gas on AXR
reflection
• Adhesions • SBFT may
• 60-80% resolve with differentiate early
non-operative Mx complete from high-
• Must show objective grade partial
improvement, if • Almost all should be
none by 48h operated on within
consider OR 24h

4. Types of bowel obstruction

Characteristics of proximal and CAUSES OF COLONIC OBSTRUCTION IN
ADULTS
distal small bowel obstruction
Carcinoma (65 %)
Proximal Distal
Diverticulitis (20 %)
Acute onset Less acute onset
Vomiting prominent Less prominent Volvulus (5 %)
Vomiting not feculent Often feculent Others (10 %)
Pain at frequent intervals Less frequent intervals
Distention minimal Noticable

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 CLINICAL MANIFESTATIONS OF
COLORECTAL CANCER

Right Colon Left Colon

Anemia Obstructive symptoms

Weight loss Gross blood in stool
Palpable mass Change in bowel habits
Fatigue Characteristic x-ray
+sigmoidoscopy

Cancer

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 COLONIC OBSTRUCTION
ESSENTIALS OF DIAGNOSIS

• Constipation-obstipation
• Abdominal distention- sometimes tenderness
• Abdominal pain
• Nausea and vomiting (late)
• Characteristic x-ray findings

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 5. Clinical picture
Intestinal obstruction
1. Definition
2. Sites of obstruction
Small bowel
Large bowel • Colicky abdominal pain
3. Causes of the obstruction
Lesions extrinsic to the bowel wall
Lesions intrinsic to the bowel wall
• Abdominal distension
Intraluminal obturator lesions
4. Types of intestinal obstruction • Vomiting
Mechanical obstruction vs. Adynamic ileus
Partial vs. Complete
Simple vs. Strangulated • Decreased passage of stool or flatus
High vs low

5.
Small bowel vs colon
Clinical picture
• Typical radiographic picture
Symptoms and signs
Radiogical tests
– plain AXR, contrast CT, UGI/SBFT,
5. Treatment of intestinal obstruction
enteroclysis

LOSS OF FLUID AND ELECTROLYTES

Pathophysiology IN INTESTINAL OBSTRUCTION

• Hypercontractility--hypocontractility • into the bowel lumen

• Massive third space losses • into the edematous bowel wall
– oliguria, hypotension, hemoconcentration • into the peritoneum
• Electrolyte depletion • vomiting or NG suction
• bowel distension--increased intraluminal
pressure--impedement in venous return-
-arterial insufficiency

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 ↑Secretion
↓ Absorbtion

Nitrogen70%
Oxygen 12%
CO2 8%
Hydrgen 5%
N3 4%

Physical findings:
Tachycardia
Rebound (+)
Muscle guarding Localised tenderness
Fever

Auscultation:
Auscultation High-pitched amphoric rushes
(metallic bowel sounds)

Lab: Hyponatremia, Hypocloremia, ↑ urine osm.

met. asc. Leukocytosis ( 15-25.000/mm3 )

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Intestinal obstruction
Management of Bowel Obstruction
1. Definition
2. Sites of obstruction
Small bowel
Large bowel
3. Causes of the obstruction
Lesions extrinsic to the bowel wall NEVER LET THE SUN RISE OR FALL
Lesions intrinsic to the bowel wall
Intraluminal obturator lesions ON A PATIENT WITH
4. Types of intestinal obstruction BOWEL OBSTRUCTION
Mechanical obstruction vs.
Adynamic ileus
Partial vs. Complete
Simple vs. Strangulated
5. Clinical picture
Radiogical tests
Fluid and electrolyte status
6. Treatment of intestinal obstruction

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 Principles SURGICAL TREATMENT

• Fluid resuscitation • Preoperative preparation⇒ Partial-complete

Malignant –benign
• Electrolyte, acid-base correction Early posoperative

• Close monitoring • Nasogastric suction+CVP+Foley Cath.

– foley, central line • Fluid and electrolyte resuscitation (Ringer
• NGT decompression lactate+ Saline+ K (?)+ ANTIBIOTICS (?)

• Antibiotics controversial • Operative therapy Adhesiolysis, enterotomy,resection,

by-pass, ostomy
• TO OPERATE OR NOT TO OPERATE

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