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7/26/2019 K26-Ileus Obs. 2009
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GIS-K-26
INTESTINAL OBSTRUCTIONSyahbuddin Harahap
Division of Digestive Surgery
Department of SurgeryFaculty of Medicine University of North Sumatera
Adam Malik Hospital
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DEFINITION
Bowel /Intestinal obstruction occurs when the normalpropulsion and passage of intestinal contents does not
occur
BO can involve:
SBO Small intestine
LBOLarge intestine
Generalized Ileus
via systemic alterations
involving both the small and large intestine
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Etiopathogenesis
-Mechanical obstruction
- Non mechanical (Functional ) obstruction
Mechanical obstruction (Dynamic ) ileus refers to a lack
of passage due to an obstruction of the bowel,which can be located anywhere in the bowel
Non mechanical Obstruction (Paralytic )(adynamic)
(Fungsional) ileusParalytic ileus refers to a lack of passage due to
paralysis of the bowel
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Intestinal /Bowel Obstruction can also be classifiedaccording to :
Time of presentation and duration of obstruction:- Acute- Chronic
The extent of obstruction
-Partial-Complete
The type of obstruction-Simple-Closed-loop-Strangulation
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Nonmechanical ObstructionParalytic (adynamic)(Fungsional) ileus due to :
1. After abdominal operations
2. InflammationPeritonitis3. Systemic disorders e.g. sepsis, hyponatremia, hypokalemia,
hypomagnesemia
4. Retroperitoneal disorders e.g. ureter, spine fractures ,
hematoma5. Thoracic conditions e.g. pneumonia, rib fractures
6. Drugs e.g opiates, psychotropics , General anesthesie
Pseudo-Obstruction
Imbalance in the parasympathetic and sympathetic influenceson Colonic motility.
Acute colonic pseudo-obstruction, also known as Ogilvie
syndrome.
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MECHANICAL OBSTRUCTION
at each age group
NeonateCongenital atresia
Volvulus neonatum
Meconeum ileus
Hirschsprungs disease
Imperforate anus
Infant
Stranggulated inguinal hernia
Intussuception
Complication of Meckels diverticulum
Hischsprungs diseases
Young adult
Adhesions and bands
Strangulated ing.hernia
Middle ageAdhesesion and band
Strangulated Ing.hernia
Strangulated fem.hernia
Carcinoma colon
Volvulus
ElderlyAdhesion and bandsStrangulated Ing.herniaStrangulated fem.herniaCarcinoma colonVolvulus
Impacted faeces
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Incidence Mechanical Obstruction
May occur at any age
70 percent small bowel obstruction (SBO)
30 percent large bowel obstruction (LBO)
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Common Causes SBO
Adhesion 60%
Neoplasma 20%
Hernia 10%Crohn 5%
Miscellaneus 5%
Common Causes of LBO
Colon cancer 65 %
Diverticulitis 20 %
Volvulus 5 %Miscellaneous 10 %
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Etiology?
Extrinsic (Outside the wall )
Intrinsic (Inside the wall )
Inside the lumen
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Extrinsic (Outside the wall)
Adhesions Hernia
-- inguinal, femoral, umbilical
Neoplastic extraintestinal neoplasm
Volvulus (sigmoid, cecal)
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Intrinsic (Inside the wall )
Congenital Malrotation
Neoplastic
Primary neoplasms
Metastatic neoplasms
Inflammatory
Crohn's disease
Miscellaneous
Intussusception
Radiation
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Intraluminal (Inside the lumen)
Gallstone
Enterolith
Bezoar Foreign body
ParasitBolus Ascaris
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Clinical Picture
Mechanical obstruction
The classic quartet
1. Colicky abdominal pain
2. Abdominal distension
3. Nausea and Vomiting
4. Decreased passage of stool or flatus
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Pathophysiology
Dependent upon :
1. Degree of obstruction
2. Duration of obstruction3. Presence and severity of ischaemia
Result in :
1. Accumulation of fluid and air(Sequestration within the dilated
loop)
Fluid disturbances massive third space losses
810 L of fluid are secreted
Hypovolumic shock oliguria, hypotension,hemoconcentration
2. Electrolyte depletion3. Bacterial overgrowth Rapid colonisation
-Maximal by 24 hrs after obstruction
-Bacterial translocation to node and portal system
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4. Bowel distension
-Chest compression by pushing up diaghragma muscle
-Decreases the ability mucosa to absorb ,stasis intestinal content
of fluids and electrolytes-Increased intraluminal pressure oedematouscyanosis
intraperitoneal exudation necrosisperforationperitonitis
-ACSimpediment in venous returnarterial insufficiency
5. LBO
Ileocaecal valve plays prominent role in pathophysiology of LBO.
If competent valve = Closed loop obstruction
In 1020 % of individual ICV incompetent
Caecal around 1012 cmthe risk of perforation
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Clinical Manifestations
Altered mental stateVital Sign
Hypovolumic shock
Tachicardia
Hypotension
TachipnoeFever
Oliguria
http://en.wikipedia.org/wiki/Glasgow_Coma_Scalehttp://en.wikipedia.org/wiki/Glasgow_Coma_Scale7/26/2019 K26-Ileus Obs. 2009
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Abdominal Examination
PatientSupine position with the legs flexed at the hip
Abdominal Colicky painThe periodicity of pain:
3 to 4 minutes pain from proximal intestinal obstruction
15 to 20 minutes pain from distal small bowel or colon
On Inspection
Abdominal distension
Proximal obstructions may cause little or no distention
Distended small bowel loops usually occupy the central
abdomen Distended large bowel loops are typically seen
around the periphery .Visible peristalsis which are indicative of acute small bowel
obstruction
Abdominal ScarsAdhesion
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On AuscultationPerformed for at least 3 to 4 minutes
Metallic soundBorborygmi
The absence of bowel tones :
Is typical of intestinal paralysis .
LateQuiet abdomen (may also indicateintestinal fatigue from long-standing
obstruction).
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OnPalpation
Inguinal ,Femoral , Umbilical ,Incisional Hernias
Palpable mass Abdominal asymmetry or a protruding mass
suggests an underlying malignancy, an abscess, or closed-loopobstruction.
Peritoneal irritation
On Percuss
DullFluid or Mass
Tympanic Air (Intraluminal or not )
Peritoneal irritation
DRE(Digital Rectal Examination )
For Mass , Impacted faeces
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Vomiting NG Aspirates
Consistsfood and gastric chymebilefaeculent
GOOClear , food and gastric chymeMid to distal SBOBilious/Bile
Distal SBO to LBOFeculent
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Mechanical Obstruction Nonmechanical Obstruction
Abdominal
Pain
colicky pain severity may decrease over time as a
result of bowel fatigue and atony.
3 to 4 minutes from proximal SBO
15 to 20 minutes distal SBO or LBO
Diffuse , usually mild
Inspection Abdominal distension
Visible peristalsis
Abdominal distension
Auscultation Metalic SoundBorborygme
Late Quiet Abdomen
Quiet abdomen
Abd.X Ray
Erect
Supine
Large small intestinal loops
gas less in colon
Step ladder A/F levels
Gas diffusely through
intestine, incl. colon
May have large diffuse A/Flevels
Barium
Enema
Obvious transition point on contrast study No obvious transition point
on contrast study
Exudate No peritoneal exudate Peritoneal exudate if
peritonitis
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Fluid resuscitation
HYPOVOLEMIC SHOCK ARF
ACUTE RENAL FAILURE
PRERENAL
INTRARENAL POSTRENAL
ARF : OLIGURIA < 500 ML/dSERUM CREATININ > 3MG/dL
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TREATMENT PRE RENAL ARF
INITIAL FLUID THERAPY
RESPON TO URINARY OUTPUT0,51 cc /kg bw
Return of normal vital sign but NO RESPON TO URINARY OUTPUT OLIGURIA
CVP ------CVP 8-12 cm of water (or 10-15 cm of water in mechanically
ventilated patients).
VC RENAL VASCULATURE
TREATMENT
DIURESIS --FUROSEMIDE 80-200 MG IV/TWD
INOTROPIC AGENTS LOW DOSE DOPAMIN /DOBUTAMIN 0,5 -3 ug/kg bw/min
VD RENAL VASCULATURE
INCREASE MYOCARDIAL CONTRACTILITY
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EVALUATION OF FLUID RESUSCITATION
RETURN OF NORMAL VITAL SIGNS
MENTAL STATUS
URINARY OUTPUT
ACID/BASE BALANCE
CVP
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Diagnoctic Studies
Laboratory test Fecal Occult Blood Test
CBC
Serum electrolyte concentrations
The serum creatinine concentration / BUN
The coagulation profile
Urinalysis should be done to check for hematuria
Liver function profile
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Sigmoidoscopy
Exclude a rectal or distal sigmoid obstruction.
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Imaging/ X ray examination
Chest x-ray
Exclude a pneumonic processTo look for subdiaphragmatic air.
Plain abdominal X rayErect and lying downroutinely
Water soluble enema to excludecolonic obstruction.
Colonic pseudo obstuction
LBO + incompetent
ileocecal thereby
mimicking smallbowel obstruction.
Barium enema X ray
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Barium enema X raytransition point on contrast study
SIGMOID VOLVULUS
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bent inner tube = Coffe beanappearanceBird Beak
SIGMOID VOLVULUS
Management of Bowel Obstruction
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Management of Bowel Obstruction
Principles
Fluid resuscitation
Requirements = Deficit + Maintenance + Ongoing losses
Close monitoring hemodinamic
Foley catheterurine output
CVP Electrolyte, acid-base correction
NGT decompression
Antibiotics Diagnostic study
Informed concent
Exploratory laporotomy