Presentations text content in Intestinal Obstruction
Inability of the intestinal contents to pass distally in the lumen of intestine either from a mechanical barrier or absence of peristalsis without any mechanical barrier is known as Intestinal obstruction
Mortality and Morbidity depend upon the early recognition and correct diagnoses of obstruction.
If untreated death occur in 100% of patients with
Intestinal obstruction can be classified in many ways.
Depending upon the nature of obstruction
Dependind upon the Cause of obstruction
Food bolus obstruction
In the wall of the Gut
Outside the wall of the Gut
Depending upon Severity
Acute on Chronic Obstruction
Depending upon Blood Supply
Depending upon the site
Small bowel obstruction
Large bowel obstructionSlide5
Irrespective of the etiology and acuteness of onset, in Dynamic obstruction the proximal Bowel dilates and develops an Altered motility.
Obstruction leads to proximal dilation due to accumulation of intestinal secretions and swallowed air. this bowel dilation stimulates cell
activity resulting in more fluid accumulation and progressive dilatation.
accumulation of secretion in the intestine lumen stimulates increased peristalsis both above and below the obstruction . below the obstruction increased peristalsis leads to frequent loose stools and flatus early in the course of disease.
Above the obstruction increased peristalsis try to overcome the
the obstruction is not relieved the bowel begins to dilate causing a reduction in the peristaltic strength ultimately resulting in flaccidity and paralysis.Slide6
The distention Proximal to obstruction is caused by two factors
: obstruction leads to significant proliferation of both aerobic and anaerobic organisms resulting in considerable gas production , Nitrogen being the predominant(90%) Gas along with Hydrogen Sulfide.
: Fluid is made up of various digestive juices
of gastric juice\d,
of intestinal secretion\d,
of pancreatic juice and bile\d
. Following obstruction fluids accumulates in the bowel wall and any excess fluid is secreted in the lumen. Because absorption is retarded ,dehydration and electrolytes disturbance is inevitable. Causes include
Reduced oral intake
defective intestinal absorption
result of vomiting
sequestration in bowel lumenSlide7
Interference with blood supply
: as the tension within the bowel loops become more and more , venous congestion takes place resulting in edema of bowel wall. If the obstruction is not relieved capillary rupture and hemorrhage takes place. In case of
arterial compromise takes place fast which causes gangrene of bowel wall very early.
Transmigration of Organisms
: both aerobic and anaerobic organisms transmigrate through the gangrenous bowel and results in peritonitis. The organism release powerful
which are absorbed from
surface and cause gram negative shock or septic shock which caries high mortality.Slide8
There are Four Cardinal features of Dynamic Obstruction.
The clinical features are also influenced by the
and on the
onset of obstruction
Acute on ChronicSlide9
In High Small Bowel Obstruction
occurs early and is profuse with
is minimal with little evidence of fluid levels on abdominal radiograph.
In Low Small Bowel Obstruction
is predominant with
is delayed. Multiple central fluid levels are seen in abdominal radiograph.
In Large Bowel Obstruction
is early and pronounced.
is mild and
is late. The proximal colon and
are distended on abdominal radiograph.Slide10
: Most common in small bowel obstruction because of repeated vomiting and fluid sequestration. Signs of dehydration appears early
( ? )
: not a common feature in simple mechanical obstruction. An increase in serum potassium, amylase and LDH may be associated with presence of Strangulation along with
: In the presence of obstruction indicates
Onset of Ischemia
Inflammation associated with obstructing disease.
: Indicates Septic shock.
: localized tenderness indicates pending and established ischemia.
: indicates overt infarction or perforation.Slide11
Feature of Strangulation
It is important to distinguish strangulating from non-strangulating obstruction because the Former is a surgical emergency. The diagnoses is entirely clinical. Features include
Tenderness with Rigidity
Guarding and absent bowel sound
Features of Septic Shock
In case of External hernia the lump is tense, tender, irreducible with no
is never completely absent in strangulation.
Symptoms Usually commence suddenly and recur regularly.
present is of great significance and need frequent reassessment.Slide12
Complete Blood Picture
% indicates underlying malignancy. Increased total WBC count indicates infection or sepsis.
: most of the electrolytes are low in cases of intestinal obstruction.
Plain X-ray Abdomen
: in erect position is an important investigation in cases of intestinal obstruction.
Multiple gas fluid levels are
of IO. Gas level appears earlier than fluid levels.
Plain X-ray may demonstrate Gall stone
or foreign body.
appear as a large dilated loop.
Jejunum is characterized by Regularly placed mucosal folds called
placed opposite to each other. They are produced by valves of
Large bowel is characterized by
: Incomplete mucosal folds, not placed opposite to each other. They are large.
. However it appears as a round gas shadow in RIF.Slide13
Multiple air-fluid levelsSlide14
Small bowel obstructionSlide17Slide18Slide19Slide20Slide21
Treatment of Acute IO
There are Three main measures used to treat acute IO.
Fluid and electrolyte replacement
Relief of Obstruction
Surgical treatment is necessary for most cases of IO but should be delayed until resuscitation is complete, provided there is no signs of Strangulation or evidence of closed-loop obstruction.
Indications of early surgical intervention
Obstructed or strangulated external hernia
Internal intestinal strangulation