INTESTINAL OBSTRUCTION

SBO
LBO

02/05/24 1
 Definition
• Arrest of downward propulsion of intestinal
content

02/05/24 2
 Classification of intestinal
obstruction
• Dynamic intestinal obstruction/mechanical
• Adynamic intestinal obstruction/pseudo-
obstruction
• Complete intestinal obstruction
• Incomplete/partial intestinal obstruction

02/05/24 3
 Classifications…
• According to nature of obstruction: simple intestinal
obstruction vs. strangulated intestinal obstruction
• According to level of obstruction
 SBO: high SBO, low SBO
 LBO
• Onset and course of obstruction: acute vs. chronic

02/05/24 4
 Etiology of intestinal obstruction
(according to its anatomic relationship to the intestinal wall )

• Intraluminal causes (e.g., foreign bodies, gallstones,

faecal impaction or meconium)
• Intramural (e.g., tumors, Crohn’s disease–associated
inflammatory strictures)
• Extrinsic (e.g. strangulated hernia, volvulus,
adhesions or bands)

02/05/24 5
• Small intestinal ileus is the most common form of
intestinal obstruction-----it occurs after most
abdominal operations and is a common response to
acute intra abdominal inflammatory conditions
• Mechanical small bowel obstruction commonly result
from volvulus, intra-abdominal adhesions, hernias, or
cancer
• Mechanical colonic obstruction most often develops in
response to volvulus, carcinoma, diverticulitis.
• Acute colonic pseudo-obstruction occurs most
frequently in the postoperative period or in response
to another acute medical illness

02/05/24 6
• When the bowel is occluded at a single point along
the intestinal tract, simple obstruction is present
• When a segment of bowel is occluded at two points
along its course by a single constrictive lesion that
occludes both the proximal and the distal end of the
intestinal loop as well as traps the bowel’s
mesentery, closed-loop obstruction is present

02/05/24 7
• When the blood supply to a closed-loop segment of
bowel becomes compromised, leading to ischemia
and eventually to bowel wall necrosis, strangulation
and perforation, is present
• The most common causes of simple obstruction are
intra-abdominal adhesions, tumors, and strictures
• The most common causes of closed-loop obstruction
are hernias, band/adhesions, and volvulus

02/05/24 8
 Etiology by age
• Neonates: congenital atresia , mid gut volvulus ,
anorectal malformation ,mechonium ileus and
Hirschsprung`s disease
• Infant: ileocaecal intussusception , Hirschsprung`s
disease and strangulated hernia
• Adult: volvulus, adhesion /band, strangulated hernia.
• Elderly: volvulus, colon carcinoma, adhesion and
strangulated hernia

02/05/24 9
 Pathophysiology of intestinal
obstruction
• Early in the course of an obstruction, intestinal motility and
contractile activity increase in an effort to propel luminal
contents past the obstructing point
• Later in the course of obstruction, the intestine becomes
fatigued and dilates, with contractions becoming less
frequent and less intense
• As the bowel dilates, water and electrolytes accumulate both
intraluminally and in the bowel wall itself----this massive
third-space fluid loss accounts for the dehydration and
hypovolemia

02/05/24 10
 Pathophysiology…
• The metabolic effects of fluid loss depend on the site and
duration of the obstruction
• With a proximal obstruction, dehydration may be
accompanied by hypochloremia, hypokalemia, and metabolic
alkalosis associated with increased vomiting
• Distal obstruction of the small bowel may result in large
quantities of intestinal fluid into the bowel; however,
abnormalities in serum electrolytes are usually less dramatic.
• Oliguria, azotemia, and hemoconcentration can accompany
the dehydration

02/05/24 11
 Pathophysiology…
• Hypotension and shock can ensue
• Other consequences of bowel obstruction include
increased intra-abdominal pressure, decreased venous
return, and elevation of the diaphragm, compromising
ventilation
• These factors can serve to further potentiate the effects
of hypovolemia
• As the intraluminal pressure increases in the bowel, a
decrease in mucosal blood flow can occur
• These alterations are particularly noted in patients with a
closed-loop obstruction in which greater intraluminal
pressures are attained

02/05/24 12
 Pathophysiology…
• A closed-loop obstruction, produced commonly by a twist of
the bowel, can progress to arterial occlusion and ischemia if
left untreated and may potentially lead to bowel perforation
and peritonitis
• Bacteria translocating to mesenteric lymph nodes and even
systemic organs
• However, the overall importance of this bacterial
translocation on the clinical course has not been entirely
defined.

02/05/24 13
 Clinical features
• Cardinal symptoms
 abdominal pain
 abdominal distention
 vomiting
 absolute constipation

02/05/24 14
• The nature of the presentation will be influenced by
the site
• In high SBO, vomiting occurs early and is profuse
with rapid dehydration-----distension is minimal with
little evidence of fluid levels on abdominal
radiography
• In low SBO, pain is predominant with central
distension. Vomiting is delayed. Multiple central fluid
levels are seen on radiography

02/05/24 15
• In LBO,
distension is early and pronounced
pain is mild and vomiting and dehydration are late
 the proximal colon and caecum are distended on
abdominal radiography

02/05/24 16
• The nature of the presentation will also be
influenced by whether the obstruction is acute or
chronic or acute on chronic or subacute
• Acute obstruction usually occurs in SBO, with sudden
onset of severe colicky central abdominal pain, early
vomiting, late distension and constipation

02/05/24 17
• Chronic obstruction is usually seen in LBO, with lower
abdominal colic and absolute constipation followed by
distension
• In acute on chronic obstruction there is a short history
of distension and vomiting against a background of
pain and constipation
• Subacute obstruction implies an incomplete
obstruction
• Presentation will be further influenced by whether the
obstruction is simple---in which the blood supply is
intact; OR strangulating/strangulated----the blood
supply is compromised

02/05/24 18
 Physical exam
• The pt with intestinal obstruction may present with
tachycardia and hypotension, demonstrating the
severe dehydration that is present
• Fever suggests the possibility of strangulation
• Abdominal exam demonstrates a distended abdomen,
with the amount of distention some what dependent
on the level of obstruction
• Previous surgical scars should be noted.
• Early in the course of bowel obstruction, peristaltic
waves can be observed, particularly in thin pts, and
auscultation of the abdomen may demonstrate
hyperactive bowel sounds with audible rushes
associated with vigorous peristalsis (i.e., borborygmi)

02/05/24 19
 Physical…
• Late in the obstructive course, minimal or no bowel
sounds are noted
• Mild abdominal tenderness may be present with or
without a palpable mass; however, localized
tenderness, rebound, and guarding suggest peritonitis
and the likelihood of strangulation
• A careful examination must be performed to rule out
incarcerated hernias in the groin, the femoral triangle,
and the obturator foramen.
• A rectal exam should be performed to assess for
intraluminal masses and to examine the stool for
occult blood, which may be an indication of
malignancy, intussusception, or infarction

02/05/24 20
 Strangulation
• “Classic” picture of strangulation-----a constant,
noncrampy abdominal pain, tenderness with
rigidity, fever, tachycardia, low BP, leukocytosis
• In cases of intestinal obstruction in which pain
persists despite conservative Mgt, even in the
absence of the above signs, strangulation should be
diagnosed
• When strangulation occurs in an external hernia, the lump is
tense, tender and irreducible, there is no expansile cough
impulse and it has recently increased in size

02/05/24 21
 Ix
• CBC
• RFT
• Serum electrolytes
• Plain X ray of the abdomen
• Erect CXR
• U/S
• CT scan
• Endoscopy

02/05/24 22
 Radiological features of
obstruction
• SBO X-ray Findings
Small bowel larger than 3 cm in diameter
multiple air and fluid levels
Paucity of gas in the colon
valvulae conniventes
• Obstructed large bowel, except for the caecum,
shows haustral folds, Dilation of the small and/or
large bowel and air fluid levels
• A dilated colon without air in the rectum
• Air in rectum → obstipation, ileus, or partial obstruction

02/05/24 23
 Rx of intestinal obstruction

02/05/24 24
 General Principles of Rx
1. GI drainage
2. Fluid and Electrolyte replacement
3. Relief of Obstruction

02/05/24 25
 Supportive and conservative
• NPO
• NG decompression
• Correction of fluid and electrolytes disorders
• Treatment of infection

02/05/24 26
• Operation :exploration
• Immediate operation indicated in peritonitis,
incarcerated hernia, suspected or confirmed
strangulation, sigmoid volvulus with systemic toxicity
or peritoneal irritation, small bowel volvulus, colonic
volvulus above sigmoid,

02/05/24 27
 Conservative Mgt
• Conservative therapy, in the form of NG
decompression and fluid resuscitation, is
commonly recommended in the initial Rx for
 Partial small bowel obstruction
 Obstruction occurring in the early postoperative
period
 Intestinal obstruction due to Crohn’s disease
 Carcinomatosis
• Reassess the pt every 4 hr

02/05/24 28
• Look for changes in pain, abdominal findings, and
volume and character of NG aspirate
• Repeat abdominal x-rays, and look for changes in gas
distribution, pneumatosis cystoides intestinalis, and
free intraperitoneal air
• Classify pt’s condition as improved, unchanged, or
worse
• Decide whether operative treatment is necessary
and, if so, whether it should be done on urgent or
elective basis.
02/05/24 29
• Indications for Urgent operation
 lack of response to 24–48 hr of nonoperative
therapy
increasing abdominal pain, distention, or
tenderness;
NG aspirate changing from nonfeculent to
feculent;
↑ proximal small bowel distention with ↓ distal
gas

02/05/24 30
 Fluid Resuscitation and Antibiotics
• Pts with intestinal obstruction are usually
dehydrated and depleted of sodium, chloride, and
potassium, requiring aggressive intravenous
replacement with an isotonic saline solution such as
lactated Ringer’s
• Catheterize and follow Urine output
• After the pt has formed adequate urine, potassium
chloride should be added to the infusion if needed

02/05/24 31
• Serial electrolyte measurements, as well as Hct and
white blood cell count, are performed to assess the
adequacy of fluid repletion
• Broad-spectrum antibiotics are given prophylactically
by some based on the reported findings of bacterial
translocation occurring even in simple mechanical
obstructions
• In addition, antibiotics are administered as a
prophylaxis for possible resection or inadvertent
enterotomy at surgery
02/05/24 32
• Nasogastric suction empties the stomach, reducing
the hazard of pulmonary aspiration of vomitus and
minimizing further intestinal distention from
preoperatively swallowed air.
• Resolution of symptoms and discharge without the
need for surgery have been reported in 60% to 85%
of pts with an adhesive simple intestinal obstruction

02/05/24 33