INTESTINAL OBSTRUCTION

Dr.Bakti H Simanjuntak SpB(K)V

 OVERVIEW:

• CLASSIFICATION
• COMMON CAUSES OF OBSTRUCTION
• CLINICAL FEATURES
• INVESTIGATION
• TREATMENT
INTRODUCTION
Accounts for 5% of all acute surgical admissions
Patients are often extremely ill requiring prompt
assessment, resuscitation and intensive
monitoring
Obstruction
A mechanical blockage arising from a structural abnormality that presents a
physical barrier to the progression of gut contents.

Ileus
is a paralytic or functional variety of obstruction

Obstruction is:
-Partial or complete
-Simple or strangulated
 CLASSIFICATION

DYNAMIC ADYNAMIC
(MECHANICAL)
(FUNCTIONAL)

Peristalsis is working
against a mechanical
obstruction
Result from atony of the
intestine with loss of normal
peristalsis, in the absence of a
mechanical cause.

or it may be present in a
non-propulsive form (e.g.
mesenteric vascular
occlusion or pseudo-
obstruction)
DYNAMIC OBSTRUCTION
(MECHANICAL)
 WHAT’S
INTESTINAL
OBSTRUCTION ?
INTESTINAL OBSTRUCTION
IS:
RESTRICTION TO THE NORMAL PASSAGE OF INTESTINAL
CONTENTS
OR
LUMINAL INTESTINAL CONTENTS CAN’T PASS THROUGH
OR
FAILURE OF PROPULSION OF INTESTINAL CONTENTS
………
 CLASSIFICATION
ACCORDING TO:
- TYPE
- ONSET
- LEVEL
- NATURE
 ACCORDING TO TYPE
INTESTINAL OBSTRUCTION MAY BE CLASSIFIED INTO TWO
TYPES :
1• DYNAMIC OR MECHANICAL WHERE PERISTALSIS IS WORKING
AGAINST A MECHANICAL OBSTRUCTION.

2• ADYNAMIC OR PARALYTIC WHERE THE MECHANICAL ELEMENT IS

ABSENT AND MAY OCCUR IN TWO FORMS:

PERISTALSIS MAY BE ABSENT (PARALYTIC ILEUS) OR

NON-PROPULSIVE FORM (MESENTERIC VASCULAR
OCCLUSION OR PSEUDO OBSTRUCTION).
 ACCORDING TO ONSET

NATURE OF PRESENTATION

ACUTE :SUDDEN SEVERE CENTRAL COLICKY PAIN, CENTRAL

DISTENTION AND EARLY VOMITING WITH LATE
CONSTIPATION(USUALLY SMALL BOWEL)
CHRONIC :LOWER ABD. PAIN WITH CONSTIPATION FOLLOWED BY
DISTENTON OF LONG DURATION (USUALLY LARGE
INTESTINE)
ACUTE ON TOP OF CHRONIC :SHORT HISTORY OF DISTENTION
WITH VOMITING ON LONGER HISTORY OF PAIN & CONSTIPATION
SUBACUTE :INCOMPLETE OR ON & OFF INTESTINAL OBSTRUCTION
 ACCORDING TO LEVEL

HIGH OR LOW

PROXIMAL OR DISTAL

SMALL OR LARGE BOWEL

HIGH (PROXIMAL) OR LOW (DISTAL) SMALL BOWEL

ACCORDING TO NATURE

SIMPLE

COMPLICATED
 ETIOLOGY
IN BOTH TYPES THERE ARE :
CAUSES FROM OUTSIDE THE WALL
(EXTRALUMINAL)
CAUSES FROM THE WALL (INTRAMURAL)
CAUSES IN THE LUMEN (INTRALUMINAL)
 CAUSES OF I.O (DYNAMIC)

Intraluminal Intramural Extramural

• Impaction • Congenital atresia • Bands/ adhesion(40%)
• Foreign bodies • Stricture • Hernia (12%)
• Bezoars • Malignancy(15%) • Volvulus
• Gallstone • Intussusception
• Tumor-benign/malignant
 ETIOLOGY
DYNAMIC(MECHANICAL)FROM THE
WALL
1- TB
2- CROHN’S
3- TUMORS
4-STICTURE
5- CONGENITAL ……… .
.
 ETIOLOGY
MECHANNICAL IN THE
LUMEN
BEZOARS WARMs
1- GALL STONES
2- F.B

3- BEZOARS
FECES
4- WARMS GALL STONES

5- FECES ………..
 ETIOLOGY
MECHANICAL
BANDS

COMPRESSION
EXTRALUMINAL
1- BANDS
2- ADHESIONS
3- ABSCESS
4- HERNIAS
5-COMPRESSION ……..

ABSCESS
HERNIA
 ETIOLOGY
ADYNAMIC INTESTINAL OBSTRUCTION.
1- PERITONITIS
2- ELECTROLYTES’ IMBALANCE
3- POSTOPERATIVE
4- ISCHEMIA
5- DRUGS
6- RETROPERITONEAL CAUSES...
 CLINCAL PICTURE
HISTORY- INSPECTION- PALPATION-& AUSCULTATION

-ABD. PAIN, DISTENTION, VOMITING ,CONSTIPTION

- DEHYDRATION & LOSS OF SKIN TURGOR

- TACHYCARDIA & HYPOTENTION

- INCREASED OR ABSENT BOWEL SOUNDS

- TENDERNESS ,REBOUND OR GUARDING

- RECTUM SOMETIMES EMPTY


 DETAILS:
MECHANICAL OBSTRUCTION
WHERE PERISTALSIS WORKS
AGAINST OBSTRUCTION
 MOST COMMON CAUSES
SMALL INTESTINE
-ADHESIONS &
- EXTERNAL HERNIAS (BOTH ARE MORE THAN 75% OF CASES)
- CROHN’S, TB, TUMORS, INTUS., CONGENITAL………
LARGE INTESTINE
- TUMORS &
- VOLVULUS (BOTH ARE 90% OF CASES
- DIVERTIDULITIS (RARE)
- ADHESIONS (EXTREMELY RARE IF AT ALL)
 CAUSES ACCORDING TO AGE
BIRTH : ATRESIA, MECONIUM, NE, VOLVULUS,HIRSCHSPRUNG’S

3 WEEKS : PYLORIC STENOSIS

6-9MONTHS : INTUSSUSCEPTION

TEENAGE : APPENDICITIS , MECKEL’S DIVERTICULITIS

YOUNG ADULT : ADHESIONS , HERNIA

ADULT : ADHESIONS , HERNIA, APPENDICITIS, CROHN’S, CARCINOMA

ELDERLY : CARCINOMA, DIVERTICULITIS, SIGMOID VOLVULUS , FECES

 PATHOPHYSIOLOGY
THE OBSTRUCTION COULD BE :
- SIMPLE
- CLOSED LOOP
- STRANGULATED
 PATHOPYSIOLOGY
SIMPLE OBSTRUCTION :
1-ABOVE THE OBSTRUCTION
OBSTRUCTION  PERISTALSIS INCREASES  INTSTINE DILATES 
REDUCTION IN PERISTALTIC STRENGTH  FLACCIDITY AND
PARALYSIS (PROTECTIVE BUT LATE)

2- BELOW THE OBSTRUCTION

NORMAL PERISTALSIS & ABSORBTION  UNTIL IT BECOMES
EMPTY  IT CONTRACTS & BECOMES IMMOBILE
 PATHOPHYSIOLOGY
DISTENTION OF THE INTESTINE IS
CAUSED BY ACCOMULATION OF:

1- GAS gas Distention

fluids
2- FLUIDS fluids
 PATHPYSIOLOGY
GAS IN THE INTESTINE IS DUE TO:

1. SWALLOWED AIR
2. BACTERIAL OVERGROWTH
3. DIFFUSION FROM BLOOD
 PATHOPHYSILOGY
FLUIDS COME FROM :
1. INGESTED FLUIDS
2. SALIVA
3. GASTRIC AND INTESTINAL JUICE
4. BILE & PANCREATIC SECRETIONS
 PATHOPHYSIOLOGY
DEHYDRATION CAUSED BY :

1. REDUCED INTAKE
2. REDUCED ABSORPTION
3. INCREASED LOSS (VOMITING & SEQUESRATION)
 PATHOPHYSIOLOGY
SYSTEMIC EFFECTS OF OBSTRUCTION :
1. WATER AND ELECTROLYTE LOSSES (LEAD TO HYPOVOLEMIA)
2. TOXIC MATERIALS AND TOXEMIA(LEAD TO SEPSIS)
3. CARDIOPULMONARY DYSFUNCTION(ATELECTASIS)
4. RENAL FAILURE
5. SHOCK AND DEATH
 PATHOPHYSIOLOGY
STRANGULATION LEADS TO IMPAIRED VENOUS
RETURN  INCREASED CONGESTION 
-FREE PERITONEAL FLUID
-EDEMA OF INTESTINAL WALL
-BLOOD IN THE LUMEN
-IMPAIRED ARTERIAL BLOOD SUPPLY
-ISCHEMIA AND GANGRENE
PATHOPHYSIOLOGY :
(1) PROXIMAL SEGMENT
• HYPERPERISTALTIC PHASE
• ANTIPERISTALTIC PHASE
• STAGE OF DILATATION
•FLUID ACCUMULATION
• GAS ACCUMULATION
• INCREASED TENSION
• ISCHEMIA

(2) DISTAL SEGMENT

COLLAPSED
ADYNAMIC OBSTRUCTION CAUSES
EITHER LOCALIZED OR GENERALIZED
SMALL INTESTINE
- POSTOPERATIVE
- INTRA-ABDOMINAL ABSCESS OR PERITONITIS
- MESENTERIC EMBOLISM OR THROMBOSIS

LARGE INTESTINE
- RETROPERITONEAL HEMATOMA
- DRUGS
- HYPOKALEMIA
- IDIOPATHIC
 DIAGNOSIS
HISTORY

CLINICAL EXAMINATION

PARACLINICAL EXAMINATION
 SYMPTOMS & SIGNS
PAIN

DISTENTION

VOMITING

CONSTIPATION AND OBSTIPATION

 THE PAIN
IN SMALL BOWEL OBSTRUCTION IS CENTRAL &
COLICKY

IN LARGE BOWEL OBSTRUCTION IS DULL &

PERIPHERAL

IN STRANGULATION IS CONTINUOUS & SEVERE

 IN PARALYTIC ILEUS IS ABSENT

 THE VOMITING
TIME OF ONSET :
EARLY: HIGH SMALL BOWEL OBSTRUCTION
LATE: LOW SMALL BOWEL OBSTRUCTION
DELAYED OR ABSENT: LARGE BOWEL OBSTRUCTION

NATURE OF VOMITUS
CLEAR GASTRIC: PYLORIC OBSTRUCTION
BILIOUS: HIGH SMALL BOWEL OBSTRUCTION
FECULENT: LOW SMALL BOWEL OBSTRUCTION OR LATE COLONIC
 CONSTIPATION
INCOMPLETE

COMPLETE (OBSTIPATION)
 DISTENTION
HIGH OBSTRUCTION: LITTLE AND CENTRAL
DISTENTION IF AT ALL

 LOW OBSTRUCTION: GREAT DISTENTION

TO THE WHOLE ABDOMEN
 CLINICAL EXMINATION
INSPECTION: DEHYDRATION, DISTENTION, VISIBLE PERISTALSIS,
HERNIAS, SCARS

PALPATION: MASES, TENDERNESS, GUARDING, RIGIDITY, OBSTRUCTED

HERNIA

PERCUTION: TYMPANI, TENDERNESS

AUSCULTATION: FREQUENT, METALIC (HIGH PITCHED), BORBURIGMI,
ABSENT

DIGITAL RECTAL EXAMINATION: IMPACTION, MASSES, BLOOD, EMPTY

RECTUM
 PARACLINICAL EXAM.
 PLAIN ABDOMINAL X-RAY :  ERECT & SUPINE

CT SCAN

CBC

KFT
 LATE MANIFISTETIONS
OLIGURIA.
DEHYDRATION: DRY TONGUE & SKIN,
SUNKEN EYES AND POOR VENOUS FILLING
HYPOVOLEMIC SHOCK
FEVER
RESPIRATORY EMBARRASSMENT
PERITONISM
 RADIOLOGICAL PICTURE
 SMALL BOWEL OBSTRUCTION
- CENTRAL DISTENTION (GAS)
- VALVULAE CONNIVENTES
- “LADDER-LIKE DILATATION”
- SMALL DIAMETER
 LARGE BOWEL OBSTRUCTION
- PERIPHERAL DISTENTION “PICTURE FRAME”
- MORE GROSS DISTENTION
- HAUSTRAL INDENTATION & LARGE DIAMETER
DIAGNOSIS ?

Hernia
DIAGNOSIS ?
Paralytic Ileus
 DIAGNOSIS

Large bowel obstruction

Small bowel obstruction
 DANGEROUS SIGNS
(RED FLAGS)
CONSTANT PAIN
ABSENT BOWEL SOUNDS
TENDERNESS WITH RIGIDITY
LEUKOCYTOSIS
FEVER AND TACHYCARDIA
SHOCK
 MANAGEMENT OF ACUTE CASE (PLAN)
I.V FLUIDS AND ELECTROLYTES RESCUSITATION FOR ALL
N.G TUBE IF REPEATED VOMITING
ANTIBIOTICS FOR ALL
HERNIA  OPERATION
ADHESIONS  CONSERVATIVE FIRST
OBSTRUCTION  REMOVE
VOLVULUS  DEROTATE AND OR OPERATE
MESENTERIC ISCHEMIA  OPERATE
ABSCESS OR PERITONITIS  DRAIN AND TREAT
INTUSSUSCEPTION  PNEUMATIC OR BARIUM REDUCTION OR
OPERATE
 TREATMENT OF ADHESIVE OBSTRUCTION

INITIALLY TREAT CONSERVATIVELY PROVIDED THERE IS NO

SIGNS OF STRANGULATION; SHOULD RARELY CONTINUE
CONSERVATIVE TREATMENT FOR LONGER THAN 72 HOURS
AT OPERATION, DIVIDE ONLY THE CAUSATIVE ADHESION
AND LIMIT DISSECTION
LAPAROSCOPIC ADHESIOLYSIS IN CASES OF CHRONIC
SUBACUTE OBSTRUCTION
 HERNIA
• ACCOUNTS FOR 20% OF SBO
• COMMONEST 1. FEMORAL HERNIA
2. ID INGUINAL
3. UMBILICAL
4. OTHERS: INCISIONAL
• THE SITE OF OBSTRUCTION IS THE NECK OF HERNIA
• THE COMPROMISED VISCUS IS WITH IN THE SAC.
• ISCHAEMIA OCCURS INITIALLY BY VENOUS OCCLUSION, FOLLOWED BY OEDEMA
AND ARTERIALC OMPROMISE.
• ATTEMPT TO DISTINGUISH THE DIFFERENCE BETWEEN:
• INCARCERATION
• SLIDING
• OBSTRUCTION

• STRANGULATION IS NOTED BY:

• PERSISTENT PAIN
• DISCOLOURATION
• TENDERNESS
• CONSTITUTIONAL SYMPTOMS
 VOLVULUS
A TWISTING OR AXIAL ROTATION OF A Features: palpable tympanic lump
PORTION OF BOWEL ABOUT ITS (sausage shape) in the midline or left
side of abdomen.
MESENTERY. WHEN COMPLETE IT FORMS A Constipation, abdominal distension
CLOSED LOOP OBSTRUCTION ISCHEMIA (early & progressive)
CAN BE PRIMARY OR SECONDARY:
 1°: CONGENITAL MALFORMATION OF THE GUT
(E.G: VOLVULUS NEONATORUM, CECAL OR SIGMOID
VOLVULUS)
 2°: MORE COMMON, DUE TO ROTATION OF A PIECE OF
BOWEL AROUND AN ACQUIRED ADHESION OR STOMA

COMMONEST SPONTANEOUS TYPE IN

ADULT IS SIGMOID, CAN BE RELIEVED BY
DECOMPRESSION PER ANUM
SURGERY IS REQUIRED TO PREVENT OR
RELIEVE ISCHAEMIA
 ACUTE INTUSSUSCEPTION
An intussusception is composed
OCCURS WHEN ONE PORTION OF THE of three parts :
GUT BECOMES INVAGINATED WITHIN the entering or inner tube;
AN IMMEDIATELY ADJACENT SEGMENT. the returning or middle tube;
the sheath or outer tube
COMMON IN 1ST YEAR OF LIFE (intussuscipiens).
COMMON AFTER VIRAL ILLNESS
ENLARGEMENT OF PEYER’S PATCHES
ILEOCOLIC IS THE COMMONEST
VARIETY IN CHILD.
COLOCOLIC INTUSSUSCEPTION
COMMONEST IN ADULT
CLASSICALLY, A PREVIOUSLY
HEALTHY INFANT PRESENTS WITH
COLICKY PAIN AND VOMITING (MILK
THEN BILE).
BETWEEN EPISODES THE CHILD
INITIALLY APPEARS WELL.
LATER, THEY MAY PASS A
‘REDCURRANT JELLY’ STOOL.

Red currant jelly stools

 CLINICAL FEATURES
HIGH SMALL BOWEL OBSTRUCTION CARDINAL
FEATURES:
VOMITING OCCURS EARLY AND IS PROFUSE WITH RAPID
DEHYDRATION.
Colicky pain
Vomiting
DISTENSION IS MINIMAL WITH LITTLE EVIDENCE OF FLUID
LEVELS ON ABDOMINAL RADIOGRAPHY
Abd distention
Constipation
LOW SMALL BOWEL OBSTRUCTION
PAIN IS PREDOMINANT WITH CENTRAL DISTENSION.
VOMITING IS DELAYED. OTHER FEATURES:
MULTIPLE CENTRAL FLUID LEVELS ARE SEEN ON Dehydration
RADIOGRAPHY Hypokalaemia
Pyrexia
LARGE BOWEL OBSTRUCTION Abd tenderness
DISTENSION IS EARLY AND PRONOUNCED.
PAIN IS MILD AND VOMITING AND DEHYDRATION ARE LATE.
THE PROXIMAL COLON AND CAECUM ARE DISTENDED ON
ABDOMINAL RADIOGRAPHY
 PHYSICAL EXAMINATION
INSPECTION
ABDOMINAL DISTENTION, SCARS, VISIBLE
PERISTALSIS.
PALPATION
MASS, TENDERNESS, GUARDING
PERCUSSION
TYMPHANIC, DULLNESS
AUSCULTATION
BOWEL SOUND ARE HIGH PITCH AND INCREASE IN
 INVESTIGATIONS:
• LAB:
• FBC (LEUKOCYTOSIS, ANAEMIA, HEMATOCRIT, PLATELETS)
• CLOTTING PROFILE
• ARTERIAL BLOOD GASSES
• U& CRT, NA, K, AMYLASE, LFT AND GLUCOSE, LDH
• GROUP AND SAVE (X-MATCH IF NEEDED)
• OPTIONAL (ESR, CRP, HEPATITIS PROFILE)

• RADIOLOGICAL:
• PLAIN ABDOMINAL XRAYS
• USS ( FREE FLUID, MASSES, MUCOSAL FOLDS, PATTERN OF PARISTALSIS, DOPPLER OF
MESENTERIC VASULATURE, SOLID ORGANS)
• OTHER ADVANCED STUDIES (CT, MRI, CONTRAST STUDIES)

Fluid levels with gas above;
‘stepladder pattern’. Ileal
obstruction by adhesions; patient
erect.
 Figure 3. Lateral decubitus view of
the abdomen, showing air-fluid levels
 Supine radiograph from a patient with consistent with intestinal obstruction
complete small bowel obstruction (arrows).
shows distended small bowel loops in
the central abdomen with prominent
valvulae conniventes (small white
arrow)
THE DIFFERENCE BETWEEN SMALL AND
LARGE BOWEL OBSTRUCTION
Small Bowel Large bowel
•Central ( diameter 3 cm max) •Peripheral ( diameter 6 cm max)
•Vulvulae coniventae •Presence of haustration
•Ileum: may appear tubeless
 ROLE OF CT
• USED WITH IV CONTRAST, ORAL AND RECTAL CONTRAST
(TRIPLE CONTRAST).

• ABLE TO DEMONSTRATE ABNORMALITY IN THE BOWEL

WALL, MESENTERY, MESENTERIC VESSELS AND
PERITONEUM.

• IT CAN DEFINE:
• THE LEVEL OF OBSTRUCTION
• THE DEGREE OF OBSTRUCTION
• THE CAUSE: VOLVULUS, HERNIA, LUMINAL AND MURAL
CAUSES
• THE DEGREE OF ISCHAEMIA
• FREE FLUID AND GAS
• FIGURE: AXIAL COMPUTED TOMOGRAPHY SCAN SHOWING DILATED,
CONTRAST-FILLED LOOPS OF BOWEL ON THE PATIENT’S LEFT
• ENSURE: PATIENT VITALLY STABLE WITH NO RENAL (YELLOW ARROWS), WITH DECOMPRESSED DISTAL SMALL BOWEL ON
THE PATIENT’S RIGHT (RED ARROWS). THE CAUSE OF OBSTRUCTION,
FAILURE AND NO PREVIOUS ALERGY TO IODINE
AN INCARCERATED UMBILICAL HERNIA, CAN ALSO BE SEEN (GREEN
ARROW), WITH PROXIMALLY DILATED BOWEL ENTERING THE HERNIA
AND DECOMPRESSED BOWEL EXITING THE HERNIA.

Source: Jackson, PG. & Raiji M., Evaluation and Management of Intestinal Obstruction, January 2011, American Academy of Family Physicians (AAFP), 83: 2 (160-
ROLE OF BARIUM GASTROGRAFIN
STUDIES
Barium should not be used in
a patient with peritonitis

• AS: FOLLOW THROUGH, ENEMA

• LIMITED USE IN THE ACUTE SETTING
• GASTROGRAFIN IS USED IN ACUTE ABDOMEN
BUT IS DILUTED
• USEFUL IN RECURRENT AND CHRONIC
OBSTRUCTION
• MAY ABLE TO DEFINE THE LEVEL AND MURAL
CAUSES.
• CAN BE USED TO DISTINGUISH ADYNAMIC
AND MECHANICAL OBSTRUCTION
Source: Jackson, PG. & Raiji M., Evaluation and Management of Intestinal Obstruction, January 2011, American Academy of Family Physicians (AAFP), 83: 2 (160-
Source: Jackson, PG. & Raiji M., Evaluation and Management of Intestinal Obstruction, January 2011, American Academy of Family Physicians (AAFP), 83: 2 (160-
 TREATMENT OF INTESTINAL OBSTRUCTION
• SUPPORTIVE
1. RESUSCITATION
2. RYLE TUBE FREE FLOW WITH 4 HOURLY ASPIRATION
-DECOMPRESSION OF PROXIMAL TO THE OBSTRUCTION, REDUCE SUBSEQUENT ASPIRATION
DURING INDUCTION OF ANESTHESIA AND POST EXTUBATION.
3. IV DRIP NORMAL SALINE / HARTMANN (SODIUM & WATER LOSS DURING IO)
4. BROAD SPECTRUM ANTIBIOTIC (NOT MANDATORY BUT NEED IN ALL PATIENT UNDERGOING
SURGERY.
• SURGICAL
IND: OBSTRUCTED / STRANGULATED EXTERNAL HERNIA, INTERNAL
INTESTINAL STRANGULATION AND ACUTE OBSTRUCTION
1. MIDLINE INCISION USUALLY LOOK ON CAECUM
2. OPERATIVE DECOMPRESSION
3. LOOK AT VIABILITY OF INTESTINE
4. LARGE BOWEL OBSTRUCTION: COLOSTOMY
 INDICATIONS FOR SURGERY
• ABSOLUTE
• GENERALISED PERITONITIS
• LOCALISED PERITONITIS
• VISCERAL PERFORATION
• IRREDUCIBLE HERNIA

• RELATIVE
• PALPABLE MASS LESION
• 'VIRGIN' ABDOMEN
• FAILURE TO IMPROVE

• TRIAL OF CONSERVATISM
• INCOMPLETE OBSTRUCTION
• PREVIOUS SURGERY
• ADVANCED MALIGNANCY
• DIAGNOSTIC DOUBT - POSSIBLE ILEUS

Source: http: Surgical Tutor.co.uk

 MANAGEMENT FOR LARGE BOWEL
OBSTRUCTION
All patients require
•Adequate resuscitation
•Prophylactic antibiotics
•Consenting and marking for potential stoma formation

•At operation
•Full laparotomy should be performed
•Liver should be palpated for metastases
•Colon should be inspected for synchronous tumours

•Appropriate operations include:

•Right sided lesions – right hemicolectomy
•Transverse colonic lesion – extended right hemicolectomy
•Left sided lesions – various options
Source: http: Surgical Tutor.co.uk
Three-staged procedure
• Defunctioning colostomy
• Resection and anastomosis
• Closure of colostomy

Two-staged procedure
• Hartmann’s procedure
• Closure of colostomy

One-stage procedure
• Resection, on-table lavage and primary anastomosis
• Three stage procedure will involve 3 operations!
• Associated with prolonged total hospital stay
• Transverse loop colostomy can be difficult to manage
• With two-staged procedure only 60% of stomas are ever reversed
• With one-stage procedure stoma is avoided
• Anastomotic leak rate of less than 4% have been reported
• Irrespective of option total perioperative mortality is about 10%

Source: http: Surgical Tutor.co.uk

 COMPLICATIONS ASSOCIATED WITH
INTESTINAL OBSTRUCTION REPAIR
• INCLUDE EXCESSIVE BLEEDING
• INFECTION
• FORMATION OF ABSCESSES (POCKETS OF PUS)
• LEAKAGE OF STOOL FROM AN ANASTOMOSIS
• ADHESION FORMATION
• PARALYTIC ILEUS (TEMPORARY PARALYSIS OF THE INTESTINES)
• REOCCURRENCE OF THE OBSTRUCTION.

Source: http://www.surgeryencyclopedia.com/Fi-La/Intestinal-Obstruction-Repair.html
 PARALYTIC ILEUS

A STATE IN WHICH THERE IS A FAILURE OF TRANSMISSION OF

PERISTALTIC WAVES 2° TO NEUROMUSCULAR FAILURE ( IN
AUERBACH’S AND MEISSNER’S PLEXUSES)
STASIS  LEADS TO ACCUMULATION OF FLUID AND GAS WITHIN
BOWEL A/W DISTENSION, VOMITING, ABSENCE OF BOWEL SOUND
AND ABSOLUTE CONSTIPATION
VARIETIES FACTORS: POSTOPERATIVE, INFECTION, REFLEX ILEUS
AND METABOLIC
RADIOLOGICAL: GAS FILLED LOOPS OF INTESTINES WITH MULTIPLE
FLUID LEVELS
MANAGEMENT:
ESSENCE OF TREATMENT PREVENTION WITH USE OF
NASOGASTRIC SUCTION AND RESTRICTION OF ORAL INTAKE
UNTIL BOWEL SOUND AND PASSAGE OF FLATUS RETURN
MAINTAIN ELECTROLYTE BALANCE
SPECIFIC TREATMENT:
• REMOVED PRIMARY CAUSE
• DECOMPRESSED GI DISTENSION
• IF PROLONG PARALYTIC ILEUS , CONSIDER LAPAROTOMY EXCLUDE
HIDDEN CAUSE AND FACILITATE BOWEL DECOMPRESSION
 PSEUDO-OBSTRUCTION
OBSTRUCTION USUALLY COLON- OCCUR IN THE
ABSENCE OF MECHANICAL CAUSE OR ACUTE
INTRA-ABDOMINAL DISEASE.
ASSOCIATED WITH A VARIETY OF SYNDROMES IN
WHICH THERE IS UNDERLYING NEUROPATHY
AND/OR A RANGE OF OTHER FACTORS
IDIOPATHIC SEPTICAEMIA
Metabolic Retroperitoneal irritation
Severe trauma at lumbar area Drugs
Shock Secondary GI involvement
Small intestinal pseudo-obstruction
This condition may be primary (i.e. idiopathic
or associated with
familial visceral myopathy) or secondary.
The clinical picture consists of recurrent
subacute obstruction.
 The diagnosis is made by the exclusion of a
mechanical cause.
Treatment consists of
initial correction of any underlying disorder.
Metoclopramide and
erythromycin may be of use.
Colonic pseudo-obstruction (Ogilvie’s
syndrome, )
This may occur in an acute or a chronic form.
presents as acute large bowel
obstruction.
Abdominal radiographs show evidence of
colonic obstruction, with marked caecal
distension being a common
feature.
AXR shows colonic obstruction with marked
caecal distension
Confirmation of absence mechanical cause by
colonoscopy or single contrast water soluble
barium enema or CT.
Once confirmed, treated by colonoscopic
decompression
 ACUTE MESENTERIC OCCLUSION
• ACUTE ISCHEMIC OF MESENTERIC VESSEL. COMMONLY SMA
• CAUSES: AF, MURAL THROMBOSIS, ATHEROMATOUS PLAQUE FROM AORTIC ANEURYSM AND
VALAVE VEGETATION FROM ENDOCARDITIS
• FEATURES: -SUDDEN ONSET OF SEVERE ABD. PAIN IN PT WITH AF AND ATHEROSCLEROSIS
-PERSISTENT VOMITING AND DEFECATION THEN PASSAGE OF ALTERED BLOOD
-HYPOVOLUMIC SHOCK
• INVESTIGATIONS: - NEUTROPHIL LEUKOCYTOSIS
- ABD XRAY: ABSENCE OF GAS IN THICKENED SMALL INTESTINES
• TREATMENT: - ANTI-COAGULANT
- EMBOLECTOMY
- REVASCULARIZATION
- COLECTOMY
THANK
YOU