Intestinal obstruction, BOWEL OBSTRUCTION

Intestinal obstruction is a significant or mechanical blockage of intestine that occurs when food or stool can not move through the intestine.
These obstruction may be complete or partial.

1. INTESTINAL OBSTRUCTION PRESENTED BY PANKAJ SINGH RANA NURSE PRACTITIONER IN CRITICAL CARE

2. INTRODUCTTION Intestinal obstruction means blockage of intestinal pathway that prevents the normal flow of products of intestine. It is also known as bowel obstruction.

3. DEFINITION Intestinal obstruction is a significant or mechanical blockage of intestine that occurs when food or stool can not move through the intestine. These obstruction may be complete or partial.

4. CAUSES MECHANICAL CAUSES: An intraluminal obstruction or a mural obstruction from pressure on the intestinal wall occurs e.g.. Tumour & neoplasm, stenosis , hernia, abscess.

5. FUNCTIONAL OBSTRUCTION: The intestinal mass culture can’t propel the contents the bowel. e.g.. Amyloidosis (It is a group of disease in which abnormal protein known as amyloid fibrils builds up in tissue, it cause & change in shape, work & also called organ failure.) - Muscular dystrophy - Endocrine disorder such as diabetes - Neurological disorders

6. CLASSIFICATON ON THE BASIS OF CHANGES & MOVEMENTS Dynamic\ a dynamic ON THE BASIS OF DURATION Subacute & acute chronic ON THE BASIS OF LOCATION Small bowel obstruction & large bowel obstruction

7. ON THE BASIS OF CHANGES & MOVEMENTS DYNAMIC : It occurs when peristalsis is working against a mechanical obstruction.

8. ADYNAMIC : It may occur in two forms: 1. Where peristalsis may be absent. Occurring secondarily to neuromuscular failure in the mesentery. 2.Where peristalsis may be present in non-propulsive form (pseudo-obstruction). * In both form mechanical elements is absent .

9. ON THE BASIS OF NATURE IT IS CALSSIFIED INTO SUBACUTE & ACUTE : It usually occurs in small bowel obstruction with sudden onset of severe colicky central abdominal pain distension & early vomiting & constipation. CHRONIC OBSTRUCTION : Usually seen in large bowel obstruction with lower abdominal colic and absolute constipation, followed by distension .

10. ON THE BASIS OF LOCATION Small bowel obstruction : duodenum, jejunum, and ilium are the part of the small intestine, when the obstruction occur in this part of intestine . High bowel wash : ascending colon, transverse colon, descending colon, cecum , rectum when the obstruction occur in this part of intestine.

11. SMALL BOWEL OBSTRUCTION duodenum, jejunum, and ilium are the part of the small intestine, when the obstruction occur in this part of intestine .

12. CAUSES Adhesion 60% Hernia 20% Neoplasm 5% Volvulus 5%. Others: IBD - gall stone - foreign body – intussusception Atresia Stenosis

13. ADHESION

14. Superior mesenteric artery syndrome: compression of duodenum by superior mesenteric artery in abdominal aorta

15. INTUSSUSCEPTION

16. VOLVLUS

17. LARGE BOWEL OBSTRUCTION Descending colon, sigmoid colon rectum and anal canal is part of large intestine Large bowel obstruction occur when if obstruction in these part of intestine

18. CAUSES Cancer 60%. Diverticular disease 15%. Volvulus 15%. Others: hernia – fecal impaction - IBD. Inflammatory bowel disease Constipation Adhesion Faecaloma extreme form of faecal immobilization Colon atresia- narrowing of colon

19. PATHOPHYSIOLOGY Due to etiological factor Impairment of passage of material through bowel Accumulation of flatus,feaceas and retention of fluid, reduce the fluid absorption and stimulate more gastric secretion

20. PATHOPHYSIOLOGY Distension of proximal intestine with solid fluid and gas With increasing distension, increase intestinal lumen pressure Decrease in venous in increase in capillary pressure

21. Oedema, congestion with decrease capillary pressure Rapture of perforation of intestine Peritonitis

22. CLINICAL MANIFESTATION Initial symptoms is usually crampy pain that is wave like and colicky. Classical symptoms is nausea vomiting and constipation Without treatment abdominal pain may increase as a result of perforation Ischemia Absence of passage of flatus abdominal distension Fever Tachycardia

23. Difference between High & Low intestinal obstruction HIGH LOW BEGINNING Acute Slow, insidious GENERAL CONDITION Early compromission preserved PAIN Crampy pain in paroxism Less intensity VOMITING Early, profuse, biliary Late, feculent may be absent ABDOMINAL DISTENTION Moderate , upper quadrant Early , intense CONSTIPATION + +++ ELECTOLYTES Cl, K, Na rapid loss Late hydro electrolytic imbalance

24. COMPLICATION Intestinal perforation Peritonitis due to perforation Sepsis- mostly in which delay in diagnosis or treatment. Intraabdominal abscess. Dehydration Electrolyte disturbance Multiple organ failure(rarely) Death

25. DIAGNOSTIC EVALUATION HISTORY COLLECTION present medical and surgical history past medical and surgical history PHYSICAL EXAMINATION LABORATORY TEST RADIOLOGICAL TEST

26. PHYSICAL EXAMINATION INSPECTION Abdominal Distention , scar, visible peristalsis, PERCUSION Tympani, dullness AUSCULTATION Bowel sounds PALPATION Mass, tenderness, gaurding

27. LABORATORY FINDINGS CBC: Increase PCV (dehydration ) and increase in WBC. KFT: Increase in BUN and creatinine . Lactate concentration-amylase-lactic dehydrogenase useful but not sensitive To rule out necrosis ABG: metabolic alkalosis and respiratory acidosis.

28. RADIOLOGICAL EVALUATION

29. SIGMOIDOSCOPY (FLEXIBLE) it is a minimal invasive endoscopic procedure for large intestine from the rectum through the last part of the colon

30. COLONOSCOPY it is the endoscopic procedure for large intestine and digital part of the small with fibber optic camera on a flexible tube passed through the anus and it provide the visual diagnosis show location of obstruction

31. CT SCAN

32. MEDICAL MANAGEMENT Fluid replacement with aggressive intravenous resuscitation using isotonic saline or ringer lactate is indicate. Antibiotic therapy for gram negative bacteria such as cefazolin and cefotaxime and meropenem Antiemetic for symptomatic relief of nausea and vomiting such as ondansetron Analgesic to relief pain such as morphine, fentanyl and diclofenac.

33. Diuretics to reduce the fluid retention such as furosemide. Stool softener such as duphalac for relief constipation

34. SURGICAL MANAGEMENT Bowel resection ( enterotomy ) - it is a surgical procedure in which a part of bowel is removed, from either small intestine or large intestine. Colostomy Bypass surgery

35. DIETARY MANAGEMENT Clear liquid diet- a Clear liquid diet starting with soups and advancing to half cup to one cup portions. Food allowed on clear liquid diet, fruit juice after 1 to 2 weeks. Low fibber diet- temporarily limiting the amount of fibber for bowel healing

36. Low fibber rich diet such as white bread with outs nuts and seeds White rice, plain white pasta Well cooked vegetables and fruits without skin and seeds Avoid hot spicy and cholesterol rich diet Avoid alcohol Avoid smoking

37. Acute pain related to intestinal obstruction as evidence by patient verbalization. Goal- resolved the pain Intervention- assess level, frequently and type of pain. Provide comfortable position Administer the prescribed medication provide diversional therapy Provide calm environment

38. Imbalance nutrition less than body requirement related to altered nutritional absorption as evidence by aversion to eating Goal : Enhance the nutritional status Intervention: Recommend bed rest before meal Provide oral hygiene Avoid food that cause abdominal cramping Record intake and output Promote patient participation in dietary planning as possible

39. Risk for deficit fluid volume related to vomiting as evidence by skin turgidity Goal : maintain adequate fluid and volume level Intervention: Monitor intake and output Note possible condition that may lead to deficient fluid loss. Monitor vital sign Observe the skin condition Administration preantral fluid

40. Anxiety related to changes in health status as evidence by somatic complaints Goal : Patient feel relaxed Intervention Review physiological factor such as active medical condition Observe and note behaviour Encourage verbalization of feeling

41. A clinical study of intestinal obstruction and its surgical Management in rural population Naveen N, Avijeet Mukherjee , Nataraj Y. S, LingeGowda S. N. The study revealed that Intestinal obstruction is more common in the age group of 30-60 years. Small bowel obstruction is more common than large bowel obstruction. Four cardinal features of intestinal obstruction are pain abdomen, vomiting, distension and constipation. Most common etiological factor is postoperative adhesions followed by abdominal hernia. Malignancy as a cause for obstruction is more common in large bowel than small bowel. Intravenous fluids and electrolytes, gastrointestinal aspiration, antibiotics and timed appropriate surgery are still the mainstay of treatment.

42. CONCLUSION At last in this topic I would like to say intestinal obstruction is a digestive system disorder that may affect the intestinal which are responsible for movement of digestive food particles, faeces, gases. if they are not passed it will strangulate in intestine and cause many problem. It may also cause intestinal perforation that is life threatening condition and if not treated it will cause death.