Intestinal_Obstruction and it's severity

Intestinal obstruction and it's symptoms

1. Intestinal Obstruction

2. ‹#› Abdomen- Bowel sound Present- Mechanical obstruction Not present- Adynamic obstruction (no gas under diaphragm) Perforation (gas under diaphragm)

3. ‹#› Objectives Pathophysiology – dynamic, adynamic Cardinal features – history, examination Causes – small, large gut obstruction Indications – contraindications for conservative Mx

4. ‹#› Obstruction Dynamic – peristalsis, mechanical obstruction Adynamic- paralytic ileus, non propulsive Mesenteric vascular obstruction or, pseudo obstruction

5. ‹#› Dynamic Obstruction Pain, distention, vomiting, absolute constipation Two- small gut – high , low Large gut Acute , chronic, acute on chronic or, sub-acute Simple – intact vascularity Strangulated – compromised vascularity

6. ‹#› Intestinal obstruction: Causes

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8. ‹#› Causes –Dynamic obstruction Intra-luminal –impaction, FB, Bezoars, gallstones Intramural- strictures, malignancy Extra-luminal- bands/adhesions, hernia, volvulus, intussusception

9. ‹#› Adynamic obstruction-causes Paralytic ileus Mesenteric vascular occlusion Pseudo obstruction

10. ‹#› Pathophysiology Proximal gut dilates- altered motility Below the obstruction – normal motility, immobile Proximal – increased peristalsis, dilates, reduced peristalsis, flaccid Gas- bacteria. Aerobic/anaerobic, 90% N2 Fluid- dig. Juices ,

11. ‹#› Pathophysiology Dehydration and electrolyte imbalance Reduced intake Defective absorption Vomiting Sequestration in gut

12. ‹#› Strangulation Blood supply compromised Venous return first affected, arterial Hemorrhagic infarction Translocation and systemic exposure to microbes/ toxins Morbidity/ mortality- age, extent, Peripheral vascular failure

13. ‹#› Closed loop obstruction Strangulation Distention Necrosis perforation

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16. ‹#› Acute Intestinal Obstruction-CP Location, age of obstruction, pathology, ischemia Pain Vomiting Distension Constipation Dehydration, Hypokalemia, fever, abdomen tenderness

17. ‹#› Pain – severe, colicky, umbilical, lower abdomen Increases with peristalsis, later reduces Severe pain - strangulation

18. ‹#› Vomiting High obstruction- violent Low obstruction- slow onset nausea/vomit Gradually digestive food changes to feculent material

19. ‹#› Distension Greater if distal obstruction Visible peristalsis Peristalsis delayed in colonic obstruction Absent in Mesenteric vascular obstruction

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21. ‹#› Constipation Absolute Relative Absent in – Richter’s hernia, gallstone, MVO, Pelvic abscess, partial obstruction

22. ‹#› Dehydration Vomiting, fluid sequestration Dry skin, poor venous filling, sunken eyes, oliguria Raised blood urea, Hb, - secondary polycythemia

23. ‹#› Hypokalemia K, amylase, LDH – strangulation, raised TLC or, leucopenia Fever – indicates – ischemia, perforation, inflammation Hypothermia – septic shock

24. ‹#› Abdomen tenderness Localized – ischemia Peritonitis – infarction or, perforation

25. ‹#› Strangulation Diagnosis is clinical Features of obstruction Persistent pain, Shock, local tenderness Non-responsive to conservative Mx Hernia strangulation – tender, irreducible, absent cough impulse, recent increase in size

26. ‹#› Radiology Supine/ erect plain abdomen films Small gut- central, transverse, no gas-colon Jejunum - valvulae connivantes Ileum - featureless Cecum - round gas in RIF Large gut- haustral folds

27. ‹#› Supine

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29. ‹#› Sigmoid volvulus Dilated, no haustral pattern Small gut- air and fluid levels More the fluid levels, more distal the lesion

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31. ‹#› Inv: Plain x ray- impacted foreign body Fluid levels – non obstructing conditions – inflammatory bowel disease, acute pancreatitis, abdominal sepsis

32. ‹#› Treatment 3 measures Intestinal drainage Fluid and electrolyte replacement Relief of obstruction

33. ‹#› Surgical Mx Mx of segment at the site of obstruction The distended proximal bowel Underlying cause of obstruction

34. ‹#› Supportive NG tube drainage Na , water replacement Antibiotics

35. ‹#› Large gut Ca or diverticular disease Contrast study – pseudo-obstruction Caecal perforation- caecostomy, ileostomy

36. ‹#› Adhesions/bands Commonest Fibrin – adhesions-fibrinous, fibrous Appendectomy , gynaecological op. Bands- congenital, bacterial peritonitis, greater omentum causing band Mx- conservative – 72 hrs –lap adhesiolysis

37. ‹#› Special obstructions Int. hernia – foramen of Winslow, hole in the mesentery, hole in transverse colon, defects in broad ligament, cong diaphragmatic hernia, paraduodenal fossae, intraperitoneal fossae Mx- release the ring, reduction of hernia

38. ‹#› Enteric strictures TB, Crohn’s, Ca, lymphomas, stricturoplasty Bolus obstruction – food, gall stone, trichobezoars, phytobezoars, stercoliths, worms

39. ‹#› Ac Intussusception Proximal gut enters distal gut Adults – lead point, polyp, submucosal lipoma, tumor, Colo-colic – adults Pathology- inner tube, outer tube, returning of middle tube Strangulating obstruction- ileoileal, ileocaecal, ileocolic

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41. ‹#› Clinical picture Severe attacks of pain – lasts few minutes Later - red currant jelly stool Exam –between episodes-50-60% sausage shaped lump – empty RIF –Sign de Dance P/R – blood stained finger Later vomit, distension

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43. ‹#› Radiology Plain film – absent caecal gas Ba enema- claw sign CT scan Mx- Hydrostatic reduction with enema Operative reduction Recurrent – 5%- anchorage of ileum to ascending colon

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46. ‹#› Differential diagnosis Acute enterocolitis Henoch Schoenlein perpura Rectal prolapse

47. ‹#› Volvulus Axial rotation of bowel at its mesentery Congenital or secondary Small intestine, caecum, sigmoid-common Small gut- spontaneous, vegetable consumption – untwist Caecal – clockwise- females- lap . Untwist, resection if gangrene

48. ‹#› Sigmoid Anticlockwise Bands, overloaded colon, large mesocolon, narrow pelvic mesocolic attachment

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52. ‹#› Treatment Flexible sigmoidoscopy/ rigid Laparotomy- untwisting Viable – fixing to retroperitoneum Resection – Paul Mickulikz- gangrene Sigmoid colectomy/ Hartmann’s procedure later re-anastomosis

53. ‹#› Compound volvulus Rare, ile-osigmoid knotting Gangrene Laparotomy - Decompression, resection and anastomosis

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55. ‹#› Thanks