Intestinal obstruction

By
Idede, Donald Aigbokhan
MBBS(Ilorin)
General Surgery Division,
Department of Surgery,
University of Benin Teaching Hospital.
 OUTLINE
• Definition
• Classification
• Epidemiology
• Aetiology
• Pathophysiology
• Clinical Presentations
• Differential Diagnosis
• Management
• Complications
 Definition
• Intestinal Obstruction is a partial or complete blockage of the
bowel that prevent the contents of the intestine from passing
through.
• Intestinal obstruction is defined as an impediment, blockade,
or arrest of the forward movement of the luminal content of
the bowel.
• It may involve the small intestine (small bowel obstruction),
large intestine (large bowel obstruction), or both.
• It is also one of the common surgical emergencies.
 Classification
Classification

Cause Duration Site Nature

Dynamic Acute High Simple

Adynamic Chronic Low Strangulation

Acute-on-
Closed Loop
chronic
 Based on Cause
• DYNAMIC or Mechanical: peristalsis is working against a
mechanical obstruction
• ADYNAMIC or Paralytic Ileus: there is no mechanical
obstruction; however peristalsis may be absent or
inadequate.
 Based on Duration
• Acute i.e. sudden onset of severe and rapidly evolving
symptoms of obstruction. Pain and vomiting are prominent.
This usually favors the small intestine
• Chronic i.e. there is insidious onset with slowly progressive
symptoms with prominent distension and constipation the
usually favors the large bowel
• Acute-on-chronic i.e. chronic obstruction suddenly becoming
acute by obstruction of already narrow intestinal canal. It
starts in the large intestine but gradually involves the small
intestine, usually in a patient with an incompetent ileocecal
valve.
 Based on Site
This site of obstruction is its position relative to the ampulla of
Vater.

• High- relatively near to the ampulla of Vater- jejunum and

proximal ileum.

• Low- relatively distant to the ampulla of Vater- distal ileum

and colon.
 Based on Nature of Obstruction
• Simple Obstruction- only the bowel lumen is occluded

• Strangulation Obstruction- both the bowel lumen and blood

supply to the segment (mesenteric blood vessel) are
occluded.

• Closed Loop Obstruction- When both the limbs (afferent &

efferent limbs) of the loops are obstructed. A classic form is
seen in presence of malignant stricture of the colon with
competent ileocecal valve.
 Epidemiology
• Accounts for about 1% of all hospitalization
• About 3% of surgical emergencies
• incidence increases with age; the median age at diagnosis is
64
- 1 in 2 000 newborn
- 1 in 5 000 children above 2 years.
• No racial predisposition.
• Affects men and women equally
• Majority of bowel obstruction occur in Africa
 Epidemiology
The most common causes (in order of occurrence) in
developing countries are
• Strangulated hernia,
• Postoperative adhesions,
• Colonic tumor and
• Volvulus
The most common causes in developed countries in order of
occurrence are
• Postoperative adhesions,
• Strangulated hernia, and
• Colonic tumors
 Aetiology
Dynamic (Mechanical) obstruction
- Intraluminal
a. Ascariasis
b. Foreign Bodies
c. Impacted Faeces
d. Pedunculated tumours
- Intramural
e. Atresia
f. Anorectal anomalies
g. Aganglionic megacolon
h. Malignancy
i. Strictures
j. Intussusception
k. Crohn’s disease
- Extramural
l. Adhesions
m. Hernia
n. Volvulus
 Aetiology
Adynamic obstruction.
a. Abdominal causes: peritonitis, abdominal operations,
Retroperitoneal haemorrhage
b. Systemic causes: Electrolyte imbalance (e.g. hypokalaemia,
sodium overload, hypomagnesaemia), sepsis
c. Medications: Narcotics, Antipsychotics, Anticholinergics,
ganglionic blockers
d. Neuropathic disorders: Diabetes, Multiple sclerosis, lupus
erythematosis
 Pathophysiology
Simple Obstruction,
• blockage occur without vascular compromise
• Below the level of obstruction, there is normal peristalsis and
absorption until the contents are either absorbed or passed out.
• Above the level of obstruction, the bowel becomes distended.
Peristaltic activity is lost as the distension increases if the
obstruction is not relieved.
• The distension is results from accumulation of Gas and Fluid.
• Accumulation of fluid increases distension which in turn leads to
secretion of more fluids.
• The degree of distension is also dependent on the site of
obstruction ( Low sites are more distended)
 Pathophysiology

• Distension of the abdomen can also compromise respiration;

acidosis or respiratory failure may set in.
• Dehydration and electrolyte imbalance can occur. This is due to:
- Reduced oral intake.
- Defective intestinal absorption
- Losses due to vomiting.
- Sequestration in the bowel lumen.
- Transudation of fluid into intestinal lumen.
Note: The higher the site of obstruction the earlier the onset of
fluid and electrolyte imbalance.
 Pathophysiology
Strangulation obstruction,
• Both the bowel and blood supply is occluded.
• In addition to the effects of simple obstruction, obstruction of
the blood supply has profound consequence.
• Venous obstruction occurs first, followed by arterial occlusion
resulting in rapid ischemia of the bowel wall.
• The ischemic bowel becomes edematous and infarcts, leading to
gangrene and perforation
• Infarction and gangrene can occur in as little as 6hrs.
• As the viability of the bowel is compromised, there is
translocation and systemic exposure to anaerobic organism and
endotoxins occurs.
 Pathophysiology
Closed Looped Obstruction,
- Occurs when two points along the course of a bowel are
obstructed at a single location thus forming a closed loop.
- Usually due to adhesions, a twist of the mesentry or internal
herniation.
- Distension is confined in this closed loop.
- Obstruction to the blood supply occur either from the same
mechanism which caused the obstruction or by twist of the
bowel on the mesentry.
 Clinical Presentation
There are 4 cardinal clinical symptoms
1. Pain
2. Vomiting
3. Distension
4. Constipation
 Clinical Presentation
PAIN
• It is the first symptom
• It is occurs suddenly and it is usually severe
• Colicky in nature and centred on the umbilicus( small bowel
obstruction) or hypogastric (large bowel obstruction)
• Pain coincides with peristaltic activity
• As distension increases, the colicky pain becomes mild and
more diffused constant pain.
• In strangulated obstruction, there is development of a
continuous severe pain.
 Clinical Presentation
Vomiting
• The interval and frequency is dependent on the site of
obstruction
• The more distal the obstruction, the longer the interval
between the onset of the symptom and the appearance of
nausea and vomiting.
• As the obstruction progresses, the character of the vomitus
changes.
 Clinical Presentation
DISTENTION
• The degree of distension is dependent on the site of
obstruction and it is greater when the obstruction is at a distal
site.
• Visible Peristalsis may be present. This can sometimes be
provoked by flicking the abdominal wall and on auscultation,
reveals an increased high pitched bowel sounds.
 Clinical Presentation
CONSTIPATION
• Refers to failure to pass flatus and stool
• It could be absolute(i.e. neither flatus nor faeces is passed) or
relative(i.e. flatus is passed).
• Absolute constipation is a sign of complete intestinal
obstruction.
• Some patient may pass flatus or faeces after the onset of
obstruction as a result of evacuation of distal bowel content
 Clinical Presentation
Others include:
5. Abdominal tenderness
6. General signs of dehydration, shock, electrolyte imbalance-
e.g. sunken eyes, dry tongue, dry inelastic skin, rapid pulse,
low B.P and mental confusion
7. Pyrexia
8. Infrequent urination
9. Fatigue
10. Bloating
 Differential Diagnosis
• Acute appendicitis
• Acute pancreatitis
• Typhoid perforation
• Perforated peptic ulcer
• Salpingitis
• Severe constipation e.t.c
 MANAGEMENT
Physical Examination
• Inspection
- Shape of abdomen, movt. Of abdominal wall, visible peristalsis, scar, striae,
prominent vein, umbilicus
• Palpation
- masses, tenderness, guarding, hernial orifices
• Percussion
- Dullness or resonance related to site of obstruction
- Tympanic node will be present.
- Tenderness on slight percussion suggest strangulation
• Auscultation
- Bowel sound are initially loud and frequent
- Then as bowel distends, the sound becomes more resonant and high pitched
- In strangulation, bowel sound is completely absent
 MANAGEMENT
Rectal Examination
• Presence of mass within or outside the lumen will give a clue
to diagnosis
• Presence or absence of faeces should be noted. Absence
means the obstruction is higher up. If faeces is present, it
should be studied for presence of occult blood which lined
mucosal lesion e.g. in cancer, intussusception or infarction.
 MANAGEMENT
Investigations
• CBC
- increased PCV, increased WBC
• Serum Urea and electrolyte
- dehydration will be reflected in raised serum urea and creatinine
• Serum Amylase
- A non specific test
- may be raised in cases of small intestinal obstruction
• ABG
- metabolic alkalosis and respiratory acidosis
 MANAGEMENT
Investigations
• AXR
- Gas fluid level are important criteria in diagnosis of intestinal obstruction
- When gas and fluid collect, they produce a characteristic pattern called
“air-fluid level”
- Air rises above the fluid and there is a flat surface at the “air-fluid”
interface
- In most cases, AXR has the following features in most cases:
1. ileated loops of small bowel proximal to the obstruction
2. predominantly central dilated loops
3. dilatation of loops >3cm
4. valvulae conniventes are visible
 MANAGEMENT
Investigations
• Barium Studies
- recommended in patients with history of recurring obstruction.
- identify site and often cause of obstruction; also differentiate
between partial and complete obstruction.
- should not be used in patients with peritonitis
• CT Scan
- useful in patient with history of abdominal malignancy, post
surgical Patient, in Patient with no history of abdominal surgery
and present with symptoms of bowel obstruction.
- It has the highest accuracy in diagnosis of intestinal obstruction
 MANAGEMENT
Treatment
1. General Measures:
a. correction of fluid, electrolyte and metabolic imbalance
b. nasogastric Decompression
c. sedation
d. Antibiotics to combact infection
2. Conservative Management
- Previous surgery
- Incomplete obstruction
- Advanced malignancy
3. Operative Treatment
- Generalized or localized peritonitis
- Perforation
- Strangulated hernia
- Closed loop
- Failure to improve on conservative management.
 COMPLICATIONS
• Electrolyte imbalance
• Sepsis
• Jaundice
• Gangrene of bowel
• Perforation of intestine
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