Intestinal ObstructionLaila Tavazo, REM

Case• A 50 year old man presents with

abdominal pain, distension and absolute constipation. With repeated episodes of vomiting.• Vital sign were stable, abdomen

distended with diffuse tenderness but minimal peritonism. Bowel Sounds are hyperactive.• The plain abdominal xray was taken

on admission.

Definition

• Lack of transit of intestinal contents is called intestinal obstruction• Intestinal obstruction is a very common problem encountered in the

ED, accounting for up to 15% of all emergency admissions for abdominal pain.

Classification

Lesions Causing Small Bowel ObstructionRelative to the Intestinal Wall

Causes of Adynamic Ileus

Differentiating SBO from Paralytic Ileus

SBO Ileus

Etiology Patient with prior surgery weeks to years prior

Recent (hours) post-operative patient

Pain Colicky Not a prominent featureAbdominal distension Frequently prominent Sometimes not apparent

Bowel sounds Usually increased Usually absentSmall bowel

dilatation Present Present

Large bowel dilatation Absent Present

Intestinal obstruction

Colicky abdominal pain, vomiting, constipation (absolute), abdominal distension.

Proximal small bowel•Pain is rapid•Vomiting copious and contains bile jejunal content•Abdominal distension is limited or localized•Rapid dehydration

Distal small bowel•Pain: central and colicky•Vomitus is feculunt•Distension is severe•Visible peristalsis•May continue to pass flatus and feacus before absolute constipation

Colonic• Pre-existing change in bowel habit•Colicky in the lower abdomen•Vomiting is late•Distension prominent

Clinical Findings 1. History

General

•Vital signs: P, BP, RR, T, Sat•dehydration•Anaemia, jaundice, LN•Assessment of vomitus if possible•Full lung and heart examination

Abdominal

•Abdominal distension•Previous surgical scar•Hernia•Visible peristalsis•Cecal distension•Tenderness, guarding and rebound•Organomegaly•Bowel sounds

–High pitched–Absent

•Rectal examination

Others

Systemic examination If deemed necessary.•CNS•Vascular•Gynaecological•muscuoloskeltal

Clinical Findings 2. Examination

Diagnostic•Lab:•CBC (leukocytosis, anemia, hematocrit, platelets)•Clotting profile•Arterial blood gasses•BUN, Crt, Na, K, Amylase, LFT and glucose•CPK, LDH, I-FABP•Optional (ESR, CRP, Hepatitis profile)

Diagnostic

Plain radiographs can diagnose SBO in 50 to 60% of cases but usually cannot identify the cause of the obstruction. CT scanning is much better for determining the cause and is also very useful in identifying strangulation complicating SBO.

Diagnosis of small bowel obstruction

Diagnosis of large bowel obstruction

Normal Ileus

Sigmoid volvulus Cecal volvulus Bird’s beak volvulus

IBDGall stone IleusIntussusception

Other causes

Hernia

multiple fluid-filled and dilated loops of small bowel (white arrows) and collapsed right colon (red arrow)

String of pearl sign

Coffee bean sign Whirl sign

Ogilvie’s Syndrome

Ogilvie’s syndrome, or acute colonic pseudo-obstruction, is a rare clinical entity that usually accompanies other medical or surgical conditions. It usually responds to non-operative therapy, but occasionally requires surgical intervention. Sir Heneage Ogilvie, first described Ogilvie’s syndrome, or isolated colonic pseudo-obstruction, in 1948 in the British Medical Journal. He postulated that the colonic ileus was secondary to an imbalance between parasympathetic and sympathetic innervation caused by metastatic disease to the celiac plexus.

Treatment

A. Resuscitation.B. Conservative treatment

1. Previous surgery.2. Incomplete obstruction.3. Advanced malignancy.4. Uncertain diagnosis.

C. Indications for surgery 1. Generalized or

localized peritonitis.

2. Perforation.3. Irreducible hernia.4. Palpable mass.5. Closed loop6. Failure to improve.

Treatment

Thank you for your attention