Mellss surgery y3 intestinal obstruction

Amalina Aminuddin 082012100067

INTESTINAL OBSTRUCTION

Clinical features Imaging Treatment of acute

intestinal obstruction

INTRODUCTION

Vary according to :• Location of obstruction• Age of obstruction• Presence or absence of intestinal ischemia• Underlying pathology

Classic quartet : • pain, distension, vomiting and absolute constipation

CLINICAL FEATURES OF DYNAMIC OBSTRUCTION

Based on location of obstruction:• Small bowel

• High : minimal distension ,early ,profuse vomiting , rapid dehydration, little evidence of fluid level

• Low : central distension with pain, delayed vomiting, multiple central fluid level

• Large bowel :pronounced distension, mild pain, late vomiting and dehydration, proximal colon and caecum distended

CLINICAL FEATURES

Based on duration of obstruction:• Acute

• Sudden severe central abdominal pain, distension, early vomiting and constipation

• Chronic• Lower abdominal pain, constipation followed by distension

• Acute on chronic• Short history of distension and vomiting against a

background of pain and constipation• Subacute

CLINICAL FEATURES

Pain •Sudden, severe•Colicky mild, constant diffuse pain•On umbilicus or lower abdomen•Not significant in paralytic ileus

Vomiting•Appear late in distal obstruction•Digested food faeculent material

CLINICAL FEATURES

Distension• SI: Increases the more distal • LI: Delayed

Constipation • Absolute or relative• Does not apply in

•Richter’s hernia, •Gallstone obstruction,•Mesentric vascular occlusion,•Associated with pelvic abscess

• Dehydration• In SI obstruction• Dry skin and tongue,

sunken eyes, oliguria

• Hypokalemia• Associated with

strangulation

• Pyrexia• Indicate ischemic onset,

intestinal perforation or inflammation

• Hypothermia • Septicaemic shock

• Abdominal tenderness• Local – ischemia• Generalised –

infarction or perforation

• Constant pain• Local tenderness with rigidity• rebound tenderness (Blumberg’s sign).• Shock• Occur suddenly and recur regularly• Hernia: • tense, tender, irreducible, no expansile cough and

increased size

CLINICAL FEATURES OF STRANGULATION

Episodes of screaming and drawing up of legs

For a few minutes and recur

Vomiting Redcurrant jelly

stoolSausage- shaped

lumpSign of Dance

CLINICAL FEATURES OF INTUSSUSCEPTION

PR- blood- stained mucus Palpable or protruding

apexDehydration,

distension, peritonitis

Differential diagnosis Acute gastroenteritis Henosh- Schoenlein

purpura Rectal prolapse

Volvulus of small intestineLower ileumPrimary or secondary

Caecal volvulusMay be congenitalMore in femalesPalpable tympanic

swelling in midline or left

Sigmoid volvulusIntermittent

symptoms followed by passage of large quantities of flatus and feces

Early progressive abdominal distension, hiccough, retching, late vomiting, constipation

CLINICAL FEATURES OF VOLVULUS

Erect and supine abdominal films• Jejunum: valvulae conniventes ( concertina effect)

IMAGING

•Ileum: featureless•Large bowel : haustral folds

• Caecum: rounded gas shadow in right iliac fossa

Fluid levels• Prominent on erect film• Physiological: at

duodenal cap and terminal ileum

• More in distal small bowel obstruction

• May have in high large bowel obstruction, paralytic ileus or pseudo-obstruction

• Seen in IBD, acute pancreatitis and intra-abdominal sepsis

•Gallstone ileus: gas in biliary tree with

stones

• Large bowel obstruction: large

amount of gas in caecum

INTUSSUSCEPTIONIleocaecal

intussusceptionAbsent caecal gas

shadowClaw sign with

barium enemaDoughnut

appearance on USG abdomen

IMAGING IN

VOLVULUSCaecal volvulus:

Gas-filled ileum and distended caecum

Bird beak deformity with barium enema

Sigmoid volvulus: Massive colonic distension Dilated loop running

diagonally from right to left with one fluid level within each loop

Volvulus neonatorium: Normal or duodenal

obstruction gasless

Measures to treat acute intestinal obstructioni. Gastrointestinal drainageii. Fluid and electrolyte replacementiii. Relief of obstructioniv. Surgical treatment

Principles of surgical intervention Management of:

The segment at site of obstruction The distended proximal bowel The underlying cause of obstruction

TREATMENT OF ACUTE INTESTINAL OBSTRUCTION

i. Gastrointestinal drainage/Nasogastric decompression passage of a non-vented (Ryle) or vented (Salem)

tube 4-hourly aspiration, continuous or intermittent

suction

ii. Fluid and electrolyte replacement Hartmann’s solution or normal saline

iii. Antibiotic therapy mandatory for patients undergoing surgery

SUPPORTIVE MANAGEMENT

Indications for early surgical intervention:• Obstructed/strangulated external hernia• intestinal strangulation• Acute obstruction

Indication for delay in surgical intervention:• Complete obstruction with no evidence of intestinal

ischemia• delayed until resuscitation is complete.

• Obstruction secondary to adhesion without pain or tenderness• Conservative management up to 72 hours

SURGICAL TREATMENT

• Adequate exposure is best achieved by midline incision

• Assessment is directed at :• Site of obstruction• Cause of the obstruction• Viability of the gut

CaecumCollapsed: small bowel obstructionDilated: large bowel obstruction

To display cause of obstruction:Displace small bowel loops and cover with warm

moist abdominal packsOperative decompression

If dilatation of loop prevent exposure Viability of gut is threaten Closure is compromised

1) ASSESSMENT OF SITE

Can be done by:Savage’s decompressor

within a purse-string suture

Nasogastric tube Milking the content

retrogradely to stomach

OPERATIVE DECOMPRESSION

Determine the type of surgical procedure Enterolysis Excision Bypass Proximal decompression

2)ASSESSMENT OF CAUSE

3)ASSESSMENT OF VIABILITYVIABLE INTESTINE

NON-VIABLE INTESTINE

Circulation

• Dark colour becomes lighter

• Dark colour remains

• Visible pulsation

• No

Peritoneum

• Shiny • Dull and lustreless

Musculature

• Firm • Flabby, thin and friable

• Peristalsis may be observed

• No peristalsis

• May have pressure rings

• Persist pressure rings

Infarcted gut are resected. If viability of gut is in doubt:

Wrap bowel in hot packs for 10 minutes with increased oxygenation and reassessed.

Resected: raise both ends of the bowel as stomas No resection/ multiple ischemic areas: laparatomy at 24-48

hours

Note the site of resection, length of resected and residual bowel

Bailey & Love’s Short Practice of Surgery, 26th Edition.

https://www.hawaii.edu/medicine/pediatrics/pemxray/v2c08.html

http://www.wikiradiography.net/page/The+Abdominal+Plain+Film-++Differentiating+Large+and+Small+Bowel

http://www.cdemcurriculum.org/ssm/gi/sbo/sbo.php

REFERANCE