 What is bowel obstruction?

 It is a mechanical or functional obstruction preventing the normal flow of intestinal

content.
 Surgical emergency
 Mortality of intussusception with treatment is 1-2%, if left untreated, this condition is
unfortunately fatal in 2-5 days. Adhesive intestinal obstruction is followed with high
lethality of 5-7%.

 Classification
It can be classified as mechanical and functional
I. Mechanical: bowel capable of contracting normally or excessivly proximal to a local
site of obstruction
 Occlusive
 Strangulation
 Mixed (instussusception)
II. Functional: peristalsis maybe absent (paralytic ileus), or present in non-propelsive
form (mesenteric vascular occlusion, pseudo-obstruction)
 Spastic ileus
 Paralytic ileus
ALSO WE CAN DIVIDE INTO
For small bowel 80%
1. Extramural
Adhesions - mostly post-operative, 66% adhesion and 10-25% obstruct
Hernia- inguinal in particular
Neoplasm- external mostly
2. Mural
Strictures – crohn’s disease
İntussusception
Meckels diverticulum
3. Intraluminal
Gallstone ileus
Foreign body

For large bowel 20%

1. Extramural
Diverticular disease usually at the sigmoid colon
Volvulus sigmoid colon
2. Mural
Colorectal adenocarcinoma- most common cause of LBO 60%
3. Intraluminal
Fecal impaction
  Stages
1. Stage of disturbance of peristalsis (12-16h)
2. Stage of hemodynamic disorders of the bowel wall and its mesentery (16-36h)
3. Stage of peritonitis (+36)

 Mechanical obstructions
Common causes of small bowel: adhesions and bands following abdominal surgery, external
hernia, intussusceptions, volvulus, neoplasm, obstruction of worms, strictures (IBD).
Common causes of large bowel: large bowel cancer, sigmoid diverticular disease, sigmoid
volvulus.

 Functional obstructions
Common causes of small bowel: paralytic ileus after abdominal surgery, peritonitis,
mesenteric embolism or thrombosis with small bowel infarction, intestinal pseudoobstruction.
Common causes of large bowel: retroperitoneal hematome following lumber fracture or
lumber surgery, idiopathic

 PATHOPHYSIOLOGY
The gastrointestinal tract secretes fluid later absorbs in the colon, when there is an
obstruction this fluid cannot reach the colon and cannot be reabsorbed
As a result there is a fluid loss in intravascular space into the gastrointestinal tract, this leads
to hypovolemia and shock. This abnormal loss of fluid is referred to as “third-spacing”

 CLINICAL FEATURES

1. Crampy pain
2. Vomiting
3. obstipation
4. Abdominal distention
5. Also fever, tachycardia,
Detailed
PAIN
 SBO: cramping/colicky, central
 LBO: spasms, longer lasting, lower abdomen
 The pain will be continous if perforation or strangulation is present
 Absent in paralytic ileus
 Patient finds relief by drowing legs up or fetal position.

VOMITING
 Early in high SBO
 Late in low SBO
 Delayed or absent in LBO
 Character: initially clear and becomes discolored and finally feculent (dark and foul
smiling)

CONSTIPATION
 Early in LBO
 Late in SBO
 Absolute in complete obstruction

ABDOMINAL DISTENTION
 Epigastric or hypogastric in SBO
 Generalized in LBO
A FEW IMPORTANT POINTS about small bowel obstructions:
- Distal bowel obstruction will usually have less emesis
- Nausea and bilious emesis without pain can be common in proximal obstruction
- Obstipation occurs late
- Stinky emesis occurs as a late finding (bacterial overgrowth)
Inspection:
By inspection, need to look scars of previous surgery which can lead to adhesions, visible
peristalsis, swelling in case of hernia, abdominal tenderness, guarding, rebound
tenderness(peritonitis), hyperactive bowel sounds,
Tongue may be dry due to dehydration
Pulse, respiratory rate, blood pressure are usually normal at first. As the patient loses fluid
into the bowel and with vomiting, it can lead to tachycardia and low grade fever.
And overtime patient will have: anxious expression, sunken eyes, dry skin and mucous
membrane

Percussion: tympanic sound

Auscultation: tinkling bowel sound like bubble raising

Pathognomonic signs:
 Wahl's sign: asymmetry of the abdomen, high tympanic sound over the distended bowel.
 Sklyarov’s sign: splashing sounds in the small or large intestine during balloting
palpation of anterior abdominal wall.
 Kywul’s sign: metallic sound over bloated intestinal loop during percussion of plesimer.
 Schlange’s sign: visible peristals.
 Spasokukotsky’s sign: during auscultation “sound of falling drop” above the stretched
intestinal loops.
 Tsege Manteuffel’s sign: when setting the siphon enema all entered the liquid (up to 500
ml) quickly leaves the intestine does not contain impurities of feces and gases). Positive at
sigmoid volvulus

DIAGNOSIS
Blood test:
 Electrolyte imbalances, hypokalemia (in U(urea) and E blood test)
 Metabolic alkalosis due o vomiting stomach acid (in venous blood test)
 Raised lactate which indicate bowel ischemia (venous blood gas or lab sample)
  Leukocytosis- shows ischemia or perforation
 Raised creatitine- may indicate acute kidney injury. Which is a common complication
due to the vomiting and dehydration.

Abdominal x-ray: may see dilated gas-filled loops or air fluid levels which can indicate
obstruction.
Erect chest x-ray: detects air under diaphragm due to intraobdominal perforation
***Contract abdominal CT scan: confirm the diagnosis, site and cause and detects
perforation.

TREATMENT
Conservative:
Spasmolytics, antiemetics
- No suspicion of ischemia or perforation
- Patient needs to be NIL by mouth
- IV fluids for hydrate and correct the electrolyte imbalances
- Nasogastric tube with free drainage

SURGERY
Depends on cause
- Hernia reparation
- Tumor resection
- Resection of blocked region and anastomosis( in patients with colorectal cancer who
may underdo hemicolectomy where half of the colon is removed)
- Stoma (opening of the bowels onto the skin
- Stenting (to reduce symptoms or sometimes done as a bridge to surgery)

DIFFERENTIAL DIAGNOSIS
 Perforated peptic ulcer
 Acute Appendicitis complicated with peritonitis
 Acute Pancreatitis
 Hepatic abscess
 Renal colic
Perforative peptic ulcer
Sharp acute diffuse pain
Absence of hepatic dullness
Rigidity of anterior abdominal wall
On Xray of the abdomen air above the liver
(air sickle)
Acute appendicitis
Constant pain in the right iliac region. Pain
begins around navel and shifts to the lower
right abdomen
Muscular tenderness in the right iliac
region
Single vomiting and diarrhea
Acute pancreatitis
Typically starts as a sudden, severe pain in
the upper abdomen that may radiate to the
back. persistent, gnawing pain.
nausea, vomiting, fever, rapid pulse, and
tenderness in the abdomen.
Acute intestinal obstruction
Periodic acute diffuse pain as wavelike
Constant vomiting and nausea without any
relief
Abdominal distention
On Xray Kloibers cups (airfluid levels)
Splashing sound, increased peristalsis
Acute intestinal obstruction
Periodic acute diffuse pain
Constant vomiting and nausea without any
relief
Abdominal distention
On Xray Kloibers cups
Splashing sound, increased peristalsis
Acute intestinal obstruction
Usually presents with crampy abdominal
pain that comes and goes in waves and
tends to be more generalized.
Abdominal bloating, constipation, inability
to pass gas, vomiting, and sometimes a
visible lump or mass in the abdomen.