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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