Intestinal obstruction

Intestinal obstruction and it's management

1. Intestinal Obstruction Presented by: Anish Dhakal (Aryan)

2. Causes

3. Pathophysiology of dynamics bowel obstruction Bowel obstruction Distal End Proximal End: gas, fluid Normal Peristalsis Absorption until it becomes empty Collapsed Increased peristalsis Bowel dilates peristaltic strength Flaccidity and paralysis

4. C ardinal clinical features of acute bowel obstruction Pain D istension Vomiting & Absolute constipation Others Dehydration Hypokalemia (due to strangulation) Pyrexia Tenderness Small bowel obstruction – high or low; •large bowel obstruction

5. Nature of presentation Simple obstruction Blood supply intact Strangulating/ strangulated Direct interference to blood flow By hernial rings or intraperitoneal adhesions/bands Clinical features vary according to Location of obstruction duration of obstruction Underlying pathology Presence or absence of intestinal ischaemia

6. Straight segments that are generally central and lie transversely. No gas is seen in the colon Jejunum Valvulae conniventes Ileum the distal ileum featureless Large bowel Haustral folds, Caecum Rounded gas shadow in the right iliac fossa

7. Principal of Treatment of acute intestinal obstruction There are three main measures: Gastrointestinal drainage via NG tube Fluid and electrolyte replacement Relief of obstruction

8. Supportive Treatment Nasogastric decompression Fluid and electrolyte replacement Analgesics Antibiotics Urine output monitoring Vital Monitoring

9. Surgical Treatment Indications for early surgery Obstructed or strangulated external hernia Internal intestinal strangulation Acute obstruction Principles are to manage : the segment at the site of obstruction the distended proximal bowel the underlying cause of obstruction

10. Surgical Treatment Un-known obstruction site Midline incision for adequate exposure Operative decompression (proper exposure) Reduces pressure on abdominal wound Reduces pain Improving diaphragmatic movement Surgical procedures Depends on etiology Division of adhesions, Excision, bypass or proximal decompression

11. Checking Viability of Involved Gut after Relief of Obstruction Viable Non-viable Circulation Dark colour becomes lighter Mesentery bleeds if pricked Dark colour remains No bleeding if mesentery is pricked Peritoneum Shiny Dull and lusterless Intestinal Musculature Firm Pressure rings may or may not disappear Peristalsis may be observed Flabby, thin and friable Pressure rings persist No peristalsis

12. Management of acute large bowel obstruction Resuscitation Midline incision Distension of the caecum  confirmation of large bowel involvement Removeable lesion Eg . In caecum, ascending colon, hepatic flexure or proximal transverse colon Emergency right hemicolectomy

13. Management Lesion irremovable Colostomy or ileosotomy (incompetent ileocaecal valve) Ileotransverse bypass Caecal perforation: Emergency caecostomy Obstructive lesion at the splenic flexure :extended right hemicolestomy Obstructive lesion at left colon or rectosigmoid junction: left hemicolectomy

14. Chronic large bowel obstruction Organic causes Functional causes Clinical features : constipation( 1 st symptoms) Investigation : DRE, water-soluble enema, CT scan, endoscopy Functional cause management  colonoscopic decompression and conservative management Organic cause management  laparotomy or stent

15. Constriction of a tubular structure of the body that prevents function or impedes circulation: Constant pain , Tenderness with rigidity, Shock Strangulation ( Surgical emergency )

16. Bowel Obstruction by Adhesions Common cause of intestinal obstruction where abdominal operation are common Peritoneal irritation Local fibrin production Adhesion between apposed surfaces May become vascularized and replaced by mature fibrous tissue Types Early fibrinous adhesions Late mature fibrous tissue Usually involve small bowel Causes

17. Factors that may limit adhesion formation include: Good surgical technique Washing of the peritoneal cavity with saline to remove clots, etc. Minimising contact with gauze Covering anastomosis and raw peritoneal surfaces Treatment of adhesive obstruction ■ Initially conservative treatment no longer than 72 hours ■ At operation, divide only the causative adhesion(s) and limit dissection ■ Repair serosal tears; invaginate (or resect) areas of doubtful viability ■ Laparoscopic adhesiolysis

18. Intussusception One portion of gut invaginated within immediately adjacent segment Proximal to distal Common in children (5-10 month) Clinical feature : Episodes of screaming & drawing up legs During attacks  pale Between episodes listless Vomit with time conspicuous & bile stained “red currant jelly” stool

19. Barium enema  ileocolic intussception (claw sign) Abdominal ultrasound scan Doughnut appearance of concentric rings in transverse section CT scan Target or s a usage shaped soft tissue mass with layering effect Imaging in intussusception

20. Resuscitation with IV fluids Broad spectrum antibiotics Naso gastric drainage Non operative reduction - barium or air enema but C/I if the sign of perforation or peritonitis and shock. Surgery When non-operative reduction failed or contraindicated After resuscitation transverse right sided abdominal incision Reduction  Compressing the most distal part of intussusception towards its origin Irreducible/infracted/pathological lead point  resection and primary anastomosis Managements

21. Volvulus I s a t wisting or axial rotation of a portion of bowel about its mesentery . T he rotation causes obstruction to the lumen (>180˚ torsion) and if tight enough causes vascular occlusion in the mesentery (>360˚) When complete  closed loop of obstructio n ischemia occurs due to vascular occlusion Primary or secondary volvulus

22. Clinical features of volvulus Volvulus of small intestine Usually occurs in the lower ileum Caecal volvulus Usually clockwise twist, palpable tympanic swelling in the midline or left line of abdomen Females > males Sigmoid volvulus Abdominal distension Early & progressive sign associated with hiccough and retching Constipation absolute

23. Ceacal volvulus Radiography  small bowel dilatation Absence of gas in distal colon Barium enema  to confirm diagnosis Absence of barium in caecum & bird beak deformity Sigmoid volvulus Plain radiography massive colonic distension Classic appearance Dilated loop of bowel running diagonally across abdomen from right to left Imaging in volvulus

24. Volvulus neonatorium Abdominal radiograph Evidence of duodenal obstruction Later intestinal strangulation progress abdomen relatively gasless Reduce volvulus at operation [decompression using needle] Caecopexy (fixation of caecum to right iliac fossa) Caecostomy If ischaemic or gangrenous caecum  right hemicolectomy

25. A. Management of Caecal Volvulus Reduce volvulus at operation [decompression using needle] Caecopexy (fixation of caecum to right iliac fossa) Caecostomy If ischaemic or gangrenous caecum  right hemicolectomy

26. Management of Sigmoid Volvulus Flexible sigmoidoscopy or rigid sigmoidoscopy and insertion of flatus tube Success  distension reduces and we can resuscitate and do elective procedure Failure  laparotomy  untwisting of loop and per anum decompression Fixation of sigmoid colon to the posterior abdominal wall Resection If gangrenous  Paul Mikulicz procedure Alternative: Hartman’s procedure with subsequent re- anastamosis

27. Adynamic Obstruction: Paralytic ileus Pseudo-obstruction Paralytic ileus Neuromuscular failure ( Averbach’s -- myenteric & Meissner’s -- submuscosal ) Failure of transmission of peristaltic waves Stasis leading to fluid and gas accumulation within bowel Distension, vomiting, absence of bowel sounds & absolute constipation

28. Types Postoperative Self-limiting (24-72 hrs) Infection Intra-abdominal sepsis Reflex ileus After fracture of spine or ribs Metabolic Uraemia and hypokalemia If 72 hours after laparotomy: No return of bowel sounds on auscultation No passage of flatus Abdominal distension more marked and tympanic In absence of gastric aspiration  effortless vomiting Clinical features

29. Management Nasogastric suction and restriction of oral intake until bowel sounds return and passage of flatus Gastrointestinal distension relieved by decompression Electrolyte and fluid balance Primary cause should be removed If prolonged and life-threatening  laparotomy  to exclude hidden cause and facilitate bowel decompression

30. Pseudo-obstruction Usually of the colon, that occurs in the absence of mechanical cause or acute intra-abdominal disease Factors associated with pseudo-obstruction ■ Metabolic ■ Severe trauma ■ Shock ■ Retroperitoneal irritation ■ Drugs Tricyclic antidepressants ■ Secondary gastrointestinal involvement

31. Small Intestine Pseudo -Obstruction Primary (idiopathic) or secondary Treatment Correction of underlying cause Colonic Pseudo-Obstruction Abdominal X-Ray: Marked caecal distension Treatment Colonoscopic decompression Colonoscopy and placement of flatus tube if recurrence Tube caecostomy when colonscopy fails or is unavailable Subtotal colectomy and ileorectal anastomosis

32. Reference Bailey & Love’s Short Practice of Surgery , 26 th Edition