Intestinal obstruction is one of the most important part of long case in surgery ward

it is due to blockage of flowing of GI contents

1. Intestinal obstruction Dr. Endale T. ( MD) Wachamo University September , 2025

2. Outlines Introduction Causes of obstruction Pathophysiology Clinical Features Diagnosis General management References

3. Introduction Intestinal obstruction is defined as obstruction of the passage of the intestine for its contents Early recognition and aggressive treatment are crucial in preventing irreversible ischemia and transmural necrosis and thereby in decreasing mortality In 80% occurs in the small bowel, while in 20 % of cases it occurs in the large intestine

4. Small bowel obstruction Common causes in industrialized counties In E thiopia – different study show primary small bowel volvulus is the most common

5. CONT…. SBO : Industrialized countries 5 B.Kotiso et al.(2007)

6. cont … Classification Dynamic vs adynamic Strangulated vs non-strangulated Proximal , intermediate , distal Closed loop vs open-loop obstruction A cute—hours , subacute —days, chronic—weeks, or acute on chronic I ntraluminal , intramural, extramural

7. CONT…

8. Pathophysiology of intestinal obstruction 8 Bacterial translocation =>sepsis

9. Diagnosis Should focus on Distinguish mechanical obstruction from ileus Determine the etiology of the obstruction Discriminate partial from complete obstruction Discriminate simple from strangulating obstruction. History Colicky abdominal pain Nausea & vomiting – frequent , high volume Abdominal distention Failure to pass flatus and feces/obstipation

10. CONT…. Physical Examination V/s Abdominal distention Previous surgical scars should be noted. Peristaltic waves can be observed Hernias sites Bowel sounds Abdominal tenderness. Recta l examination

11. CONT… Radiologic and Laboratory Examinations Lab. Investigations – CBC , electrolyte Plain radiographs usually confirm 60% Site & cause

12. CONT… 12 Triads : Dilated bowel loop Air-fluid level Paucity of air distally central dilated bowel , plicae circularis , multiple air fluid level

13. CONT… CT-scan provide more clinically relevant information. Sensitivity and specificity >94% if bowel obstruction is present localize the obstructive site degree of obstruction closed-loop obstruction Local and regional Mets Limitation :low sensitivity for Partial obstruction(<50%) 13 Complications Ischemia Thickened intestinal walls and poor flow of contrast media into a section of bowel Necrosis and perforation pneumatosis intestinalis pneumoperitoneum , and mesenteric fat stranding suggest

14. CONT…. Ultrasound Criteria fluid-filled small bowel lumen >2.5 cm historically had diagnostic sensitivity approaching 85%, Adv : Initial evaluation of hemodynamically unstable patients with ambiguous clinical presentation In patients for whom radiation exposure should be avoided, such as pregnant women Disadv : Operator-dependent Bowel gas artifact Difficult to perform in obese patients 14

15. CONT…. Simple Versus Strangulating Obstruction Simple obstructions Mechanical blockage of the flow of luminal contents without compromised viability

16. CONT… Strangulation obstruction Closed-loop obstruction with compromised vascular supply Increased morbidity and mortality risk “Classic” signs and symptoms Tachycardia Fever Leukocytosis Constant, noncramping abdominal pain Tenderness

17. Management Fluid resuscitation NG tube for decompression Catheterize to monitor urine output Broad spectrum IV antibiotics

18. CONT… Complete bowel obstruction – expeditious surgery Conservative early postop obstruction partial small bowel obstruction obstruction due to crohn’s disease carcinomatosis

19. CONT… Operative Management Complete small bowel obstruction requires operative intervention Approach depend on cause and patients condition Adhesive band – adhesion release Volvulus - derotation or resection Incarcerated hernias – reduction and closure Malignant tumors Nonoperative management Simple by pass

20. CONT…. Intussusceptions – reduction , resection Crohn’s disease Acute obstruction- conservative Chronic fibrotic stricture – bypass/resection Intra-abdominal abscess Drainage of the abscess Radiation enteropathy Non operatively with tube decompression In the chronic setting - operation

21. Large bowel obstruction Classification Dynamic (mechanical) Adynamic ( pseudo-obstruction ) Colorectal cancer is the single most common cause in the United States C olonic volvulus is the more common cause in Russia, Eastern Europe, and Africa

22. ETIOLOGY LBO : industrialized countries Malignancies(60%) Diverticular ds(20%) Colonic volvulus (1-5%) Miscellaneous (15-20%) 22 LBO: Ethiopia sigmoid volvulus (69.0 %) colonic tumor (13.8 %). ( Soressa et al(2016), Adama LBO: Ethiopia sigmoid volvulus(58.6%) Colonic ca Cecal volvulus ( B.Kotiso et al.(2007 ))

23. Sigmoid Volvulus Torsion of sigmoid volvulus along its own mesentery. Torsion 180 degrees results in clinical obstruction, and further torsion to 360 degrees causes strangulation. Perforation occurs in areas of necrosis at the point of torsion, within the closed loop, or in the proximal thin walled cecum. 23

24. CONT…. Risk factors Anatomic risk factors A long redundant sigmoid colon Wide mesentery & narrow mesenteric root attachment.  advancing age(?due to colonic dysmotility) High fecal load- high fiber diet Constipation Pregnancy HSD 24

25. Diagnosis Clinically: abdominal pain, nausea, abdominal distension, and constipation. more insidious , recurrent attacks of abdominal pain, with resolution presumably due to spontaneous detorsion The big drum-like abdomen is typical. peritonitis and sepsis. 25

26. CONT… Plain AxR establish the diagnosis in approximately 60 % of patients " bent inner tube “ or coffee bean appearance 26

27. CONT… Contrast enema - “ bird’s beak sign ” (~100 %) Pathognomonic CT scan: ~ 100%sensitivity and > 90% specificity Typical findings include a whirl pattern Split wall sign 27

28. Managment Goals: - To prevent development of gangrene to address the anatomic abnormality that led to the volvulus General management - resuscitation,bowel rest Patients with alarming signs Resuscitation followed by endoscopic detorsion flexible sigmoidoscopy /rigid proctoscopy /colonoscopy leave a rectal tube in place with its proximal end beyond the area of twisting. blind passage of rectal tube rectal tube may lessen colonic distension and reduce the chance of recurrent volvulus in the acute setting. . 28

29. CONT…. . Indication to surgery: Endoscopic evidences of bowel gangrene/perforation Failed endoscopic detorsion Patients with alarming signs ( gangrene,peritonitis,perforation ) Immediate surgical exploration without an attempt is recommended 29

30. CONT… Intraoperative finding of Viable sigmoid Non- resective methos Simple detorsion Sigmoidopexy Resective methods Primary resection & anastomosis Hartmann’s procedure 30 High recurrence rate:9-44%

31. Colonic tumor Obstruction Malignant bowel obstruction is bowel obstruction caused by cancer . In cancer patients SBO- more commonly benign causes LBO-commonly malignant causes(60%) Colorectal carcinoma presents with acute intestinal obstruction in 7% to 30% of cases. 31

32. Diagnosis: colonic tumor … Clinical features: Symptoms of intestinal obstruction Sn / sm suggestive of malignancy Imaging (abdominal x-ray & CT scan) Features of large or small bowel obstruction Diameter of the cecum If cecal diameter > 12 cm, u rgent intervention is required to prevent perforation. 32

33. CONT Any surgical intervention in cancer patients should be preceded by a multidisciplinary evaluation patient’s clinical condition performance status life expectancy Patient’s preferences of care Resectability of the tumor Location of the tumor Presence of synchronous tumor Status of bowel Intraabdominal condition Goals of therapy 33

34. CONT…. Resectable tumor Proximal, right side resection with primary enterocolonic anastomosis Alternative: terminal ileostomy with colonic fistula left side tumor Strategies: 1. one-stage procedure: On-table lavage with segmental colon resection, intraoperative colonoscopy,& primary anastomosis 2.Two-stage procedure Hartmann’s procedure 34

35. CONT… Unresectable Right side tumor Internal bypass –side to side ileotransverse anastomosis Terminal loop ileostomy Left side tumor Diversion-loop colostomy, tube colostomy Bridge to surgery or palliative procedure Diversion self-expanding metallic stent(SEMS) 35

36. Summary Bowel obstruction continues to be one of the most common intra-abdominal problems. Early recognition and aggressive treatment are crucial in preventing irreversible ischemia and thereby in decreasing mortality and long-term morbidity. 36

37. References 37

38. Mortality correlated Gangrene Age over 60 years Existences of an associated disease Presence of shock