Management Of Intestinal Obstruction

General & specific management of obstructed cases in acute abdomen.

1. Intestinal Obstruction

3. Assessment
Investigations
Treatment

4. History-Onset, acute/chronic, bleeding,
constipation, weight loss, anorexia, changes
in bowel habits, associated features,
previous surgery, drug usage.
Physical examination- General physical, vital
signs, abdominal distention/mass,
tenderness/guarding, auscultation (Bowel
sounds)-high pitched, tinkling sounds.

5. Complete blood count- A raised white cell
count will indicate an infection. A raised
hematocrit may indicate hemoconcentration
while a decreased hematocrit will signify
blood loss.
Serum Urea & electrolytes- Derangements
may be seen with vomiting & diarrhea.
Dehydration will be reflected in raised serum
urea & creatinine.

6. Liver function test- Elevated serum bilirubin
& alkaline phosphatase point towards an
obstructed cause.
Serum amylase
It is a non-specific test & may be raised in
cases of small intestinal obstruction.

7. Erect chest x-ray- Free air under the
diaphragm, without recent abdominal
surgery, shows perforated viscus.
Supine abdominal x-ray- It may show
abnormal bowel pattern (dilation of bowel
loops in case of obstruction or sentinel loop).
It may also show masses.
Erect Film- It shows fluid levels in case of
obstructed bowel.

8. Ultrasound- It is less useful but may indicate
presence of intraparitoneal fluid or mass. It
can also detect gallstones or other biliary
diseases.
CT- It is performed with oral or Intravenous
contrast. Lower abdomen CT is useful in
detection of acute appendicitis, acute
diverticulitis, intestinal obstruction, aortic
aneurysm & mesentric ischaemia.

9. Supportive
NPO
Rehydration & urine output monitoring
Cross-match blood & transfusion if required
Pass NG tube( diagnostic/therapeutic purpose)
I.V antibiotics if indicated
Symptomatic
Analgesia after confirming diagnosis
Specific
Therapy directed at underlying disease

11. Investigations- Plain X-ray
Duodenal obstruction- stomach & proximal
duodenum are distended- “double bubble”
Jejunal & ileal obstruction- air fluid levels
present

12. Treatment:
Correct electrolyte & fluid deficits
Duodenal atresia requires
duodenojejuostomy & spliting of the
anastomosis with a feeding tube.
Atretic segments in the jejunum or ileum may
produce dilated proximal loops that require
tapering prior to anastomosis.

13. Investigation:
Plain x-ray of the small bowel gas shows
malrotation & level of obstruction.

14. Treatment:
The volvulus is reduced, the
transduodenal band(Ladd’s
band) divided, the duodenum
mobilised & the mesentry
freed.
Appendicectomy is routinely
performed to avoid
diagnostic difficulty with
appendicitis in the future.
Infarcted bowel necessitates
resection.

15. Investigation
Differential white cell count is raised
A Merkel’s radioisotope scan will reveal acid
producing gastric mucosa.

16. Treatment:
Excision of the inflammed diverticulum
Presence of gastric mucosa requires the
resection of the ileal loop containing the
diverticulum to ensure complete excision of
all acid producing mucosa.

17. Plain x-ray
Shows small dilated bowel loops
Gastrograffin enema (in the absence of acute
obstruction) shows up the meconium &
excludes Hirshsprung’s disease.

18. Treatment:
Colonic washouts may restore patency
Proximal ileum is anastomosed end to side to
the colon with a distal ileostomy to clear the
obstruction.

19. Gastrograffin enema demonstrates
unhindered flow of contrast upto the cecum &
beyond
Relief of constipation requires bowel
washouts or manual evacuation.
Counselling

20. Investigations:
Double contrast Gastrograffin enema (‘claw
sign’ of ileocolic intussusception)
In adults, a contrast CT scan of the abdomen
or barium enema is confirmatory.

21. Rx:
The diagnostic enema may be used to reduce
the intussusception by hydrostatic pressure
(in children)
Surgical reduction by taxis; bowel resection if
there is gross edema preventing reduction or
vascular compromise.

22. Investigations:
Plain x-ray may be diagnostic
-Large gas-filled, ‘kidney bean-shaped’
swelling in the right upper zone: Sigmoid
volvulus
-Large gas-filled, ‘kidney bean
-shaped’ swelling in the left
lower zone: Caecal volvulus.

23. Rx:
Sigmoid volvulus may be relieved at right
sigmoidoscopy.
Emergency laprotomy & resection of the
volvulus for strangulated or recurrent cases.
Gangrenous bowel is exteriorised & resected,
with the formation of a ‘double barrel’
colostomy (Paul-Mikulicz procedure).

24. Investigations:
White cell count: >20×109 /L
Serum amylase: slightly raised (>200IU)
Mesentric angiography
Rx:
Laparotomy: superior mesentric
embolectomy;
Resection of areas of non-viable bowel.
‘second look’ laprotomy at 24 hours for further
resection of non-viable bowel.

25. Treatment:
Surgical bypass of occlusion.

26. Investigations:
Plain x-ray abdomen: Characteristics of the
distended bowel from which the level of
obstruction is identified
Contrast enhanced CT:
Delineates the type & level of obstruction

27. Treatment:
Nasogastric decompression of stomach &
bowel proximal to the obstruction.
I/v Fluids & electrolyte therapy
Analgesia
Antibiotics( inflammatory or infectious
causes)
Emergency surgery *
Post operative adhesion obstruction usually
resolves on conservative measures.

28. Operative procedures vary according to cause
of obstruction.
Resection- The diseased part of the small
intestine (ileum) is removed. The two healthy
ends are then sewn back together and the
incision is closed.
Indications
Gangrenous bowel

29. In cases of strangulated Inguinal/femoral
hernias the standard groin incision is given &
the weakness repaired using hernioplasty or
herniorrhaphy, with bowel resection if
required.

30. In adhesive obstructed cases, laproscopic
adhesiolysis (adhesive band lysis) maybe
performed in selected patients or using open
procedure through an incision dictated by
scar from previous surgery.
Bypass: Anastomosis of proximal small bowel
or large intestine distal to the obstruction
may be a good procedure in some cases of
carcinoma or radiation injury.

31. Decompression-Done by use of gastrostomy
or jejunostomy tube where adhesions can’t
be freed & bypass can’t be done. Parentral
nutrition is provided that
allows spontaneous resolution.
The tube can be passed orally or
By needle aspiration through the
bowel wall.

33. Short Practice of surgery- Bailey & love’s
Acute surgical management- Hwang Nian Chi
Current surgery
Medlineplus