Intestinal obstruction lecture
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This document provides an overview of intestinal obstruction, including its classification, causes, symptoms, diagnosis, and management. It defines intestinal obstruction as a restriction in the normal passage of intestinal contents. Obstructions can be classified as dynamic/mechanical or adynamic/paralytic, acute or chronic, and by the level and nature. Common causes include adhesions, hernias, tumors, and volvulus. Symptoms include pain, distention, vomiting, and constipation. Diagnosis involves history, examination, and imaging tests. Management depends on the underlying cause but generally involves resuscitation with IV fluids, antibiotics, and surgery to remove or bypass the obstruction.
Intestinal obstruction lecture
- 1. Intestinal Obstruction Dr. Faiez Alhmoud Albashir Hospital Amman-Jordan
- 3. Intestinal Obstruction is: Restriction to the normal passage of intestinal contents or Luminal intestinal contents can’t pass through or Failure of propulsion of intestinal contents
- 4. CLASSIFICATION According to: - Type - Onset - Level - Nature
- 5. According to TYPE Intestinal obstruction may be classified into two types : 1• Dynamic or mechanical where peristalsis is working against a mechanical obstruction. 2• Adynamic or paralytic where the mechanical element is absent and may occur in two forms: Peristalsis may be absent (paralytic ileus) or non-propulsive form (mesenteric vascular occlusion or pseudo obstruction).
- 6. According to ONSET NATURE OF PRESENTATION ACUTE :sudden severe central colicky pain, central distention and early vomiting with late constipation(Usually small bowel) CHRONIC :lower abd. Pain with constipation followed by distenton of long duration (usually large intestine) ACUTE ON TOP OF CHRONIC :short history of distention with vomiting on longer history of pain & constipation SUBACUTE :incomplete or ON & OFF intestinal obstruction
- 7. According to LEVEL High or Low Proximal or Distal Small or Large bowel High (Proximal) or Low (Distal) small bowel
- 9. ETIOLOGY In both types there are : CAUSES FROM OUTSIDE THE WALL (Extraluminal) CAUSES FROM THE WALL (Intramural) CAUSES IN THE LUMEN (Intraluminal)
- 10. ETIOLOGY DYNAMIC(MECHANICAL) FROM THE WALL 1- TB 2- CROHN’S 3- TUMORS 4-STICTURE 5- CONGENITAL ……… . .
- 11. ETIOLOGY MECHANNICAL IN THE LUMEN 1- GALL STONES 2- F.B 3- BEZOARS 4- WARMS 5- FECES ……….. GALL STONES BEZOARS WARMs FECES
- 12. ETIOLOGY MECHANICAL EXTRALUMINAL 1- BANDS 2- ADHESIONS 3- ABSCESS 4- HERNIAS 5-COMPRESSION …….. BANDS ABSCESS COMPRESSION HERNIA
- 13. ETIOLOGY Adynamic Intestinal Obstruction. 1- Peritonitis 2- Electrolytes’ Imbalance 3- Postoperative 4- Ischemia 5- Drugs 6- Retroperitoneal causes...
- 14. CLINCAL PICTURE HISTORY- INSPECTION- PALPATION-& AUSCULTATION -ABD. PAIN, DISTENTION, VOMITING ,CONSTIPTION - DEHYDRATION & LOSS OF SKIN TURGOR - TACHYCARDIA & HYPOTENTION - INCREASED OR ABSENT BOWEL SOUNDS - TENDERNESS ,REBOUND OR GUARDING - RECTUM SOMETIMES EMPTY
- 16. MOST COMMON CAUSES SMALL INTESTINE -ADHESIONS & - EXTERNAL HERNIAS (both are more than 75% of cases) - CROHN’S, TB, TUMORS, INTUS., CONGENITAL……… LARGE INTESTINE - TUMORS & - VOLVULUS (both are 90% of cases - DIVERTIDULITIS (rare) - ADHESIONS (extremely rare if at all)
- 17. CAUSES ACCORDING TO AGE BIRTH : Atresia, Meconium, NE, Volvulus,Hirschsprung’s 3 WEEKS : Pyloric stenosis 6-9MONTHS : Intussusception TEENAGE : Appendicitis , Meckel’s diverticulitis YOUNG ADULT : Adhesions , Hernia ADULT : Adhesions , Hernia, Appendicitis, Crohn’s, Carcinoma ELDERLY : Carcinoma, Diverticulitis, Sigmoid Volvulus , Feces
- 18. PATHOPHYSIOLOGY THE OBSTRUCTION COULD BE : - Simple - Closed loop - Strangulated
- 19. PATHOPYSIOLOGY SIMPLE OBSTRUCTION : 1-ABOVE THE OBSTRUCTION OBSTRUCTION Peristalsis increases Intstine dilates Reduction in peristaltic strength Flaccidity and paralysis (protective but late) 2- BELOW THE OBSTRUCTION NORMAL PERISTALSIS & ABSORBTION Until it becomes empty It contracts & becomes immobile
- 20. PATHOPHYSIOLOGY Distention of the intestine is caused by accomulation of: 1- GAS 2- FLUIDS gas fluids Distention fluids
- 21. PATHPYSIOLOGY Gas in the intestine is due to: 1. Swallowed air 2. Bacterial overgrowth 3. Diffusion from blood
- 22. PATHOPHYSILOGY Fluids come from : 1. Ingested fluids 2. Saliva 3. Gastric and intestinal juice 4. Bile & Pancreatic secretions
- 23. PATHOPHYSIOLOGY Dehydration caused by : 1. Reduced intake 2. Reduced absorption 3. Increased loss (Vomiting & sequesration)
- 24. PATHOPHYSIOLOGY Systemic Effects of Obstruction : 1. Water and electrolyte losses (lead to hypovolemia) 2. Toxic materials and toxemia(lead to sepsis) 3. Cardiopulmonary dysfunction(atelectasis) 4. Renal failure 5. Shock and death
- 25. PATHOPHYSIOLOGY Strangulation leads to impaired venous return Increased congestion -free peritoneal fluid -edema of intestinal wall -blood in the lumen -impaired arterial blood supply -ischemia and gangrene
- 26. Pathophysiology : (1) Proximal segment •Hyperperistaltic phase •Antiperistaltic phase •Stage of dilatation •Fluid accumulation •Gas accumulation •Increased tension •Ischemia (2) Distal segment Collapsed
- 27. ADYNAMIC OBSTRUCTION causes Either localized or generalized Small intestine - Postoperative - Intra-abdominal abscess or peritonitis - Mesenteric embolism or thrombosis Large intestine - Retroperitoneal hematoma - Drugs - Hypokalemia - Idiopathic
- 29. SYMPTOMS & SIGNS Pain Distention Vomiting Constipation and obstipation
- 30. THE PAIN In small bowel obstruction is central & colicky In large bowel obstruction is dull & peripheral In strangulation is continuous & severe In paralytic ileus is absent
- 31. THE VOMITING Time of onset : Early: High small bowel obstruction Late: Low small bowel obstruction Delayed or absent: Large bowel obstruction Nature of vomitus Clear gastric: Pyloric obstruction Bilious: High small bowel obstruction Feculent: Low small bowel obstruction or late colonic
- 33. DISTENTION High obstruction: Little and central distention if at all Low obstruction: Great distention to the whole abdomen
- 34. CLINICAL EXMINATION Inspection: dehydration, distention, visible peristalsis, hernias, scars Palpation: mases, tenderness, guarding, rigidity, obstructed hernia Percution: tympani, tenderness Auscultation: frequent, metalic (high pitched), borburigmi, absent Digital rectal examination: impaction, masses, blood, empty rectum
- 35. PARACLINICAL EXAM. Plain abdominal X-ray : erect & supine CT Scan CBC KFT
- 36. LATE MANIFISTETIONS Oliguria. Dehydration: dry tongue & skin, sunken eyes and poor venous filling Hypovolemic shock Fever Respiratory embarrassment Peritonism
- 37. RADIOLOGICAL PICTURE Small Bowel Obstruction - Central distention (GAS) - Valvulae conniventes - “Ladder-like dilatation” - Small diameter Large Bowel Obstruction - Peripheral distention “Picture frame” - More gross distention - Haustral indentation & large diameter
- 41. DANGEROUS SIGNS (Red Flags) Constant pain Absent bowel sounds Tenderness with rigidity Leukocytosis Fever and tachycardia Shock
- 42. Do not take to OR if: Post-op Carcinomatosis Recurrent adhesive bowel obstruction Post radiotherapy
- 43. MANAGEMENT OF ACUTE CASE (Plan) I.V Fluids and electrolytes rescusitation for all N.G tube if repeated vomiting Antibiotics for all Hernia Operation Adhesions Conservative first Obstruction Remove Volvulus Derotate and or Operate Mesenteric ischemia Operate Abscess or Peritonitis Drain and Treat Intussusception Pneumatic or Barium Reduction or Operate
- 44. Thank you