ILEUS & BOWEL OBBSTRUCTION

Interruption of the normal passage of bowel contents either due to a functional decrease In peristalsis or mechanical obstruction
Ileus = lack of movement which leads to bowel obstruction, which leads to ileus.

Classification:

Mechanical bowel obstruction

Functional/Adynamic obstruction (Ileus):
Ileus- loss of peristalsis with consequent dilation of intestine in the absence
of an obstructing lesion
Small bowel obstruction Large bowel obstruction

Paralytic: Destructive (pseudo- Sub-classification

• Postoperative obstruction);
(abdominal/pelvic)- develops • Mesenteric ischemia Impairment Cause:
72hrs after abdominal surgery degree Intraluminal (exophytic):
• Sepsis, uraemia, electrolyte
disbalance.
• Total − Tumours, intussusceptions, ascarids, biliary stones,
Partial bezoars, foreign body
• Drugs
• Inflammation, retroperitoneal Extrinsic:
abscess, hemoperitoneum. − Adhesions, herniation, intraabdominal masses,
• Vertebral fractures (spinal endometriosis
trauma) Intramural:
− Atresia, post inflammatory strictures

Clinical course: Bowel vascular compromise:

• Acute/subacute Obturative – lumen is obstructed, mesentery intact
• Chronic − Intraluminal tumor, foreign body etc.
Strangulated- Mesenteric vessels are compromised
− Volvulus, incarcerated hernia
Mixed
− Intussusception (first obturation occurs, then
strangulation), adhesions
 MECHANICAL BOWEL OBSTRUCTION
Etiology Clinic Diagnosis Treatment
Small Bowel • Adhesions (60%)- • Abdominal pain is colicky and occurs early. Lab: Conservative
Obstruction history of surgery • Vomiting occurs early especially in high • ↑ WBC If:
(SBO) • Hernias, obstruction.- • Metabolic acidosis (if recurrent − Partial obstruction
• Stricture (e.g. in o bilious in high obstruction. vomiting)/alkalosis (if bowel OR
Crohn’s) o ‘feculent’ due to bacterial overgrowth. strangulation)
• Tumours (late sign) • Hypokalaemia/hyponatremia − Complete obstruction with no signs
• Abdominal distension may be mild if the • ↑ Htc- if dehydration of ischemia/necrosis
obstruction is very proximal. 1. Fluids & electrolyte
• Constipation occurs late and may be absent. Instrumental 2. Decompression (gastric tube or
• Absent bowel sounds (late) • Abdominal & chest x-ray enteric),
3. Urine catheter (0,5ml/kg/h)
− There may be a history of previous o SB dilation if >3cm, kloiber cups
4. Bowel rest (nil per os)
abdominal surgery, adhesive obstruction, o LB dilation if >6cm
o Ceacal dilation if >9cm 5. Analgesia
pelvic radiotherapy, or of a painful swelling
6. Etiology specific (e.g. for stool
consistent with a strangulated hernia • Abdominal CT with contrast- Gold
impaction: stool evacuation)
standard: obstruction localisation
Large Bowel • Tumours – colorectal • Pain may not be colicky in nature. (do not give contrast in suspected complete
Surgery:
Obstruction • Inflammatory – • Abdominal distension occurs early and is often obstruction or perforation) Exploratory laparotomy
(LBO) diverticulitis, colitis, marked. For LBO:
Crohns. • Constipation occurs earlier. • Laparoscopy- to detect adhesions in
emergency or elective?
• Mechanical – Volvulus, • Vomiting appears late. SBO
Elective Emergency
hernia, obstipation, • Partial obstruction may allow passage of liquid • Barium/ water soluble enema
• Partial
strictures, stool (spurious diarrhoea). − Shows tapering of bowel lumen at • Slow • Total
• Ischaemia − There may be a history of altered bowel obstruction site progress • Acute
• Functional –toxic
megacolon
habit, weight loss, or rectal bleeding − In suspected distal LBO • X-ray: • ↑ CRB, WBC
consistent with colorectal cancer, caecum • X-ray: caecum
− Water soluble enema can be used when
− a history of previous sigmoid volvulus. suspected complete bowl obstruction
< 11 cm ≥12 cm
• X-ray: free air
− Recurrent left iliac fossa (LIF) pain suggests • Peritonitis
diverticular disease. “Bird beak” sign→volvulus, • Colostomy/ileostomy
• Hartmann’s operation (2 stage op.)
Complications: • Subtotal colectomy
1. Large intestine can dilate to 10 cm in • Resection + large bowel lavage +
diameter. “Apple core” sign → tumor anastomosis
2. Peritonitis • Resection + anastomosis •
3. Perforation Endoscopic stent
 SBO VS LBO
Sign SBO LBO
Bowel lumen >3cm >6cm
Ceacal dilation: >9cm
Loops position and number Central, multiple Peripheral, few
Air fluid levels Multiple, short Few, long
Valves Kerkring’s (circular) Haustra (semi-circular)
Air in large intestine - +
Kloiber Cups Jejunum: in LUQ
Ileum: in pelvic region

PARALYTIC ILEUS

Etiology Clinic Diagnosis Treatment

• Postoperative (abdominal/pelvic)-
develops 72hrs after abdominal
surgery
• Sepsis, peritonitis
• Endocrine abnormalities: uraemia,
hypothyroidism
• electrolyte disbalance: hypokalemia
• Drugs
• Inflammation, retroperitoneal
abscess, hemoperitoneum.
• Vertebral fractures (spinal trauma)
• Neuropathy
• Continuous non-colicky diffuse abdominal Lab: Conservative
pain • ↑ WBC- left shift suggesting infection or If: no signs of sepsis
• Nausea, vomiting ischemia
• Abdominal distention • Anemia – due to intraabdominal haemorrhage 1. Fluids & electrolyte
• Constipation • Hypokalaemia/hypomagnesemia 2. Decompression (gastric tube or
• Tenderness if peritonitis enteric),
• Decreased of absent bowel sounds Instrumental: 3. Urine catheter (0,5ml/kg/h)
• X-ray: gaseous distention, gas shadows in 4. Bowel rest (nil per os)
rectum 5. Analgesia
• Abdominal CT: for ddx mechanical obstruction
vs ileus Surgery:
If signs of peritonitis:
− Exploratory laparotomy
− Appendectomy