INTESTINAL OBSTRUCTION

Bernard M. Jaffe, MDProfessor of Surgery,

Emeritus

INTESTINAL OBSTRUCTION • Common Clinical Problem• Carries 3-5% Mortality Rate/Episode• Some Patients Have Multiple Bouts• Can Involve Small or Large Bowel• Requires Both Operative and Non-

Operative Care

SYMPTOMS• Specifics Depends on Site of

Obstruction• Crampy Abdominal Pain• Abdominal Fullness• Nausea, Vomiting• Thirst, Weakness, Dehydration

PHYSICAL FINDINGS• Abdominal Distention• Bowel Sounds• Early- Hyperactive• Rushes• High Pitched• Late- Hypoactive to Absent• Tachycardia, Dry Skin

DIFFERENTIAL- ILEUS• Functional Obstruction• Electrolyte Abnormalities- ↓Na, ↓K,

↓Mg• Meds- Opiates, Anti-Cholinergics, Anti-

Psychotics• Intra-Abdominal Infection/Inflammation• Systemic Sepsis• Post-Laparotomy

INITIAL MANAGEMENT• Done During Evaluation/ Diagnosis• Intravenous Fluid Resuscitation• Ringer’s Lactate• Electrolytes Close to Those Lost• Nasogastric Tube Decompression• Foley Catheter Placement

DIAGNOSIS• Upright Abdominal X-Ray• Air Fluid Levels• Obstruction- Step Ladder Pattern• Ileus- All at Same Level• ? Air in Colon- Incomplete

Obstruction • ? Thumb Printing- Ischemic Bowel

CT SCAN• Not Always Necessary• Can Localize Site- Transition Point

(Change from Distended to Flat Bowel)• Sometimes Diagnose Cause

Distinguish Complete from Incomplete Obstruction• Markedly Overused

CAUSES• Adhesions (60-70%)• Neoplasms (20%)• Hernias (10%)- External, Internal• Others- Intussusception• Volvulus• Intra-Abdominal Abcess/Infection• Gallstone Ileus• Stricture, Extrinsic Compression

GALLSTONE ILEUS• Fistula Between Biliary Tract

(Gallbladder) and Intestine• Stone Passes into Intestine• Travels to Narrowest Point –Distal

Ileum• X-Ray Diagnosis- Air in Biliary Tract• Stone Visible in RLQ

CARCINOID• Malignancy Ileum > Jejunum• 30% are Multiple• Metastasizes Nodes, Liver• Syndrome- Flushing• Diarrhea• Bronchoconstriction• Right Sided Cardiac

Valvular Lesions

OTHER NEOPLASMS• Adenocarcinoma• Lymphoma• Leiomyosarcoma• Other Sarcomas

COMPLICATIONS• Gangrene- • Intraluminal Tension>Venous

Pressure• Venous Flow Stops• Venous → Arterial Gangrene• Perforation• Short Gut Syndrome Following

Resection

EMERGENCY OPERATION• Closed Loop Obstruction• Complete Obstruction• Impending Gangrene• All Increase Risk of Intestinal

Gangrene

IMPENDING GANGRENE• Very Difficult to Diagnose- Variable,

Non-Specific• Abdominal Tenderness• Rebound Tenderness, Guarding• Fever, Tachycardia• Acidosis• Elevated White Blood Cell Count

NON-EMERGENCY OPERATIONS

• Failure to Respond to Conservative Management

• Partial Obstruction• Multiply Recurrent Bouts of

Obstruction

ACUTE POST-OP OBSTRUCTION

• Difficult to Diagnose• Behaves Like Ileus• Enteroclysis is Most Successful

Modality• Non-Operative Management Post-

Op Days 1-7

TREATMENT of ADHESIONS• Adhesiolysis at Site of Obstruction• ? Lysis of All Adhesions• Resect Gangrenous Bowel/Re-

Anastamose• Run Bowel of Site of Injury• Perforation

JEJUNUM• Proximal 40% of Intestine• Larger Circumference, Thicker Wall• Prominent Plicae Circulares• End-Arterial Blood Supply• Fewer Vascular Arcades (1-2)• Less Lymphatic Material

LAPAROSCOPY• Mild Abdominal Distention• Proximal Obstruction• Partial Obstruction• Anticipated Single Band

Obstruction

GALLSTONE ILEUS TREATMENT • Enterotomy with Removal of Stone• Try to Identify Site of Fistula• Cholecystectomy with Fistula

Closure• ONLY IF• RUQ Not Too Inflamed or Indurated

OPERATIVE COMPLICATIONS• Perforation- Missed Injury• Bovie Burn• Delay in Opening Up• Nutrition- Enteral, Parenteral• Wound Failure- Dehiscence, Hernia. • Infection- Superficial Wound• Intraperitoneal• Recurrent Obstruction