SMALL INETSTINAL

OBSTRCTIONs
Definition: - Mechanical
blockage which
precludes intestinal
contents from moving
` in the usual oral to
anal progression.

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cont

.
- Intestinal content can not pass
normally to the rectum because
of an interposed extrinsic or
intrinsic block either the small or
large intestine.

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CAUSES OF INTESTINAL
OBSTRCTION
I. Adhesions: a) Post-operative
b) Inflammatory
c) Radiation
II. Hernias: a) External (inguinal,
femoral
etc)
b) Internal

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Cont.

III.Malignancy: a) Primary tumor

b) Secondary
(metastatic)
IV. Intussusceptions
V. Volvulus
VI. Ischemia
VII. Fecal impaction

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Cont.

VII. Miscellaneous: - stricture-TB

- Radiation
- Diverticulitis
- Crohn’s disease
- Foreign body
- Gall bladder stone.

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Pathophysiology

 OBSTRUCTION - Increase of
intestinal motility and contractile
activity to overcome the
obstruction.
 Later-Intestinal fatigue and
dilatation leading in to decrease
of contraction frequency.

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Cont.
 Bowel dilates - Increase
accumulation of water and
electrolyte inside the lumen and wall
(interstitium) of intestine (THIRD
SPACE LOSS) _ Dehydration and
hypovolemia.
 Proximal obstruction= Dehydration
is accompanied by
hypochloremia,hypokalemia and
metabolic acidosis (loss of water, Na+,
,
Cl- H+,K+) due to frequent vomiting.

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Cont.

 Distal obstruction= Large

quantities of fluid into the bowel-
HYPOTENSION AND SHOCK.

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Clinical manifestations
 Cardinal symptoms
- Colicky abdominal pain
- Nausea and vomiting
- Abdominal distension
- Failure to pass flatus and
feces
-These symptoms vary with the
site and duration of obstruction
and whether complete or partial
obstruction. 9
Physical Examination
 General appearance
 Vital signs (Temp,BP and Pulse rate)
 Abdomen:-Inspection=Distended
abdomen
= Visible peristalsis
- Percussion =Hypertympanitic
- Palpation = Tenderness
- Auscultation = Hyperactive
-PR!! bowel sounds.
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Investigations
 Radiological studies:
A) PLAIN ABDOMINAL X-RAY
-Dilated loop of intestine
- Multiple air-fluid levels
- Foreign bodies
- Gallstones (radiopaque)

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Cont.

b) CT scan:_ Sensitive in
complete obstruction.
_ Location and cause of
obstruction ( tumors,
abscess, inflammatory
disease).

_ Strangulation ( Ischemia)
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Cont.

c) Barium meal and follow through

- Level of obstruction
- Type of obstruction (partial or

complete).
- Some causes
(Intussusceptions).
d) US (pregnancy)
e) MRI less useful.
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DIAGNOSIS
 THE DIAGNOSTIC
EVALUATION OF ANY
OBSTRUCTION SHOULD HAVE
THE FOLLOWING GOALS.
a) Distinguishing the
mechanical obstruction from
Ileus.
b) Determining the Etiology of
the obstruction.
C) Discriminating partial from
complete obstruction.
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Cont.

d) Discriminating simple from

strangulating. Thus
the diagnosis is based on:
_ Thorough history and
physical examination.
_ Investigations

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MANAGEMENT

 GENERAL MEASURES:
a) Correction of fluid and
electrolyte imbalance.
b) Antibiotics (Broad spectrum).
c) Nasogastric tube.
d) Urethral catheter.

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Cont.

 SPECIFIC MEASURES:
a) Operative
b) none operative

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LARGE BOWEL OBSTRUCTION

 Classification:
a) Dynamic (mechanical)
b( Adynamic (Pseudo-
obstruction)
a) Mechanical Obstruction:
_ Blockage of the large
bowel( luminal,mural, or
extramural).
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CAUSES:
- Cancer
- Volvulus
- Foreign body
- Intussusceptions
- Diverticulitis
-Crohn’s disease
- Tuberculosis etc

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Clinical manifestation

 Sign and symptoms depend on

cause, location and duration of
obstruction.
 CARDINAL SYMPTOMS
_ Failure to pass stool and flatus
_ Abdominal distention
_ Crampy (colicky) abdominal
pain
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Physical examination

 General appearance and vital signs.

 Abdomen:
_ Inspection:- Grossly distended
_ Palpation:- Tender (mild- severe)
_ Percussion:- Hypertympanitic
_ Auscultation:-Hyperactive /abscent
bowel sounds
 PR

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Investigations

 Plain abdominal x-ray

 CT scan
 Barium enema (smooth bird’s
peak)
MANAGEMENT
- Decompression
- Correction of fluid and
electrolyte imbalance.
- Definitive treatment.
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b) Pseudo-obstruction (Adynamic)
(Paralytic Ileus)
 Absence of intestinal contractility
associated with absent intestinal
motility.
SOME CAUSES
I.INTRA-ABDOMINAL
- Inflammation, infection
E.g. appendicitis,
cholecystitis,pancreatitis
- Peritonitis:- Bacterial (perforated
intestine) chemical (bile, pancreatic
juice
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Cont.

and acid gastric juice.

- Wound dehiscence
- Mesenteric vascular disorder
- Blunt trauma
- Distended bladder

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II. RETROPERITONEAL:

- Infection: Pyelonephritis,
abscess
- Ureteric stone obstruction
- Vertebral fracture : Lumbar,
thoracic.
- Pelvic fracture
- Central nervous system,
trauma tumor.
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III. SYSTEMIC

- Electrolyte disorder
- Uremia
- Lead poisoning
- Septicemia
- Pneumonia (lower lobe)
- Diabetic keto-acidosis
- Mengitis

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Pathogenesis

One mechanism thought to play

a role in the pathogenesis is
sympathetic over- activity
overriding the parasympathetic
system.
This theory was supported by:
a) The success in treating the
syndrome with neostigmine, a
parasympathetic agent.
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Cont.

b) Immediate resolution of the

syndrome after administration of
an epidural anesthetic that
provides sympathetic blockade.

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Reading materials

 Oxford, Textbook of surgery

 Sabiston, Textbook of surgery
 Schwartz, principles of surgery
 Chackelford’s, Surgery of
Alimentary tract

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THANK YOU!!

Questions

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