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Intestinal Obstruction CME CYY
Intestinal Obstruction CME CYY
Intraluminal
• Impacted stool
• Gallstone illeus
• Foreign body
• Bezoar
• Roundworm mass
Adynamic ( Functional)
• Paralytic Ileus
• Hirshsprungs disease
• Ogilvie syndrome (Pseudo-obstruction)
• Peritonitis
• Electrolytes imbalance
• Drugs
Etiology according to ages
• Birth: Atresia, Volvulus, Hirschsprungs
• 3 weeks: Pyloric stenosis
• 6-9months : Intussusception
• Teen: Appendicitis, Meckels diverticulitis
• Young Adult: Adhesion, Hernia
• Adult: Adhesion, hernia, Cronh`s , Carcinoma
• Elderly: Carcinoma, Diverticulitis, sigmoid volvulus
PATHOPHYSIOLOGY
Pathophysiology
History
4 cardinal features:
• Abdominal pain
- Colicky in nature
- Intermitten
- Constant sharp pain (complete obstruction)
- Sudden severe pain (volvulus)
• Vomitting
- Initially consists of stomach content then Bile, follow
by feculent matter
- Vomit of altered blood might indicate heamorrahge
or gangrene
• Abdominal distention
- Moderate distention in Ileum
- Marked distension in colon
• Constipation
– Obstipation / Absolute constipation: constipation
to feces and flatus
– Present initially in large bowel obstruction
– Exception: IO with diarrhea (eg. Fecal impaction)
Small Bowel Large Bowel
• Usually presented with • Usually presented with
vomiting first and distention, abdominal pain
dehydration. and obstipation.
• Abdominal pain over • Nausea and vomiting may
periumbilical and cramping not be present early.
in nature with interval of • Abdominal pain over
every 4 – 5 mins. infraunbilical and cramping
with interval of every 20 –
30 mins
Other important history
History of or risk of GI malignancy
Medication history
Copyrights apply
Signs
• Signs of dehydration.
• Signs of malignancy.
• Abdominal findings:
– Distention / Tenderness
– Step peristalsis in terminal illeal obstruction
– Right → left colonic peristalsis in left sided colonic
obstruction
– Signs of peritonitis if with gut perforation
– Percussion : Tympanic note
– Auscultation: Hyperactive (borborygmi) initially, sluggish or
absent later
– Examined for hernia orfices
– PR : rectum empty in small bowel obstruction, masses,
impaction
Investigation
Blood Investigation
• FBC
– ↓Hb might indicate underlying malignancy
– ↑ TWC might indicates infection / sepsis /perforation
– ↑HCT might indicated dehydration
• ABG
– Acidosis (bowel ischemia)
– Alkalosis (vomiting)
• RP
– Dehydration (↑ urea) and vomittng (derange K⁺)
• Chest X-ray
– Air under diaphragm indicate perforated bowel
• Virgin abdomen
When decide for conservation
management?
• Early post operative obstruction
• Inflammatory bowel disease
• Gallstone illeus.
(Endoscopic fragmentation of stone can be attempt)
• Infectious bowel disease
(TB colon , however delayed diagnosis might need
surgery)
• Colonic diverticular disease
(Antibiotic may reduce peridiverticular inflmmation
thus relieve obstruction)
SUMMARY
Causes of Intestinal Obstruction
Extrinsic lesion
ETIOLOGY RISK FACTOR
Adhesion Prior surgery, diverticulitis, Crohn
disease, peritonitis (eg. Tuberculous
peritonitis)
Hernia (congenital,acquired) Abdominal wall/ inguinal/ femoral/
diaphragmatic hernia
Volvulus Chronic constipation, congenital
abnormal mesenteric attachment