Intestinal Obstruction

Mohammad Al-Haj Qasem, MD

General & laparoscopic surgeon
Specialized Arab Hospital
Introduction

 Arrest of downward propulsion of intestinal content.

 Accounts for 5% of all acute surgical admissions
 Can involve:
 Small bowel
 Large bowel
 Both (ileus)
 Intestinal Obstruction

Pathological Level of Onset and Mechanical Vs Partial Vs

cause obstruction course Adynamic complete
 simple  High small bowel  Acute
 strangulated  Low small bowel  Chronic
 Closed loop  Large bowel
Anatomy

 The entire small bowel ~270-290 cm

 Deudenal length~20 cm
 Jejunal length~100-110 cm
 Ileal length~150-160 cm

 Jejunum begins at deudojejunal angle, which is supported by ligament of

Trietz (peritoneal fold)
 Jejunum: 2/5 of small bowel
 Ileum: 3/5 of small bowel
 The mucosa of small bowel is characterized by transverse folds (plicae
circularis), which are prominent in the distal duodenum and jejunum.
 Intestinal obstruction

Dynamic Adynamic
 Intraluminal  Paralytic ileus
 Intramural  Mesenteric vascular occlusion
 Extramural  Pseudo-obstruction
Mechanical bowel obstruction

 Physical blockage of intestinal lumen.

 May be intrinsic or extrinsic.
 Partial obstruction: the intestinal lumen is narrow but still allow the transit
of some intestinal content distally.
 Complete obstruction: the lumen is totally obstructed, and none of
intestinal contents can move distally.
Ileus

 Intestinal distention and the slowing or absence of passage of luminal

contents without mechanical obstruction.
 Abdominal distention, usually without the colicky abdominal pain, is the
typical and most notable finding.
 Nausea and vomiting may occur but may also be absent.
 Patients may continue to pass flatus and diarrhea
 Plain abdominal radiographs may reveal distended small and large bowel
loops.
Acute colonic pseudo-obstruction (Ogilvie syndrome)

 ACPO is a functional obstruction.

 It is typically seen in elderly or debilitated patients who are hospitalized with
severe medical or traumatic illnesses.
 Medications that decrease intestinal motility are also associated with this
disorder.
 In a retrospective review of more than 1400 cases of ACPO, the most common
predisposing conditions were operative and nonoperative trauma (11%),
infections (10%), and cardiac disease (10-18%).
Epidemiology

 80% of bowel obstruction occurs in the small bowel, the other 20% occur in
the colon.
 Colorectal cancer: 60-70% of all large bowel obstruction
 Diverticulitis & volvulus: 30%
 Mortality rate:
 3% for simple obstruction
 30% when the is vascular compromise or perforation.
 Recurrence rate:
 After primary conservative management: 12%
 After operative management of adhesive bowel obstruction: 8-32%
Pathophysiology

 Distension, absorption, and secretion

 Intestinal motility

 Circulatory changes

 Bacterial translocation
Distension, absorption, and secretion

 Most of gas distending the small bowel in the early phases of obstruction
accumulates from swallowed air.
 Dilatation and inflammation, causing damage to secretory and motor
processes, increase in the local release of nitric oxide.
 First 12 hrs: water and electrolytes accumulate within the lumen secondary
to a decrease in net absorption.
 24 hrs: intraluminal water and electrolytes accumulate more rapidly
secondary to a further decrease in absorptive flux and a concomitant increase
in net intestinal secretion (secretory flux).
Intestinal motility

 Early phase of bowel obstruction: intestinal contractile activity increase in

attempt to propel intraluminal content past the obstruction
 Later: contractile activity diminishes probably secondary to intestinal wall
hypoxia and the exaggerated intramural inflammation.
 Some investigators have suggested: alternation in intestinal motility are
secondary to a disruption of the normal autonomic parasympathetic (vagal)
and sympathetic splanchnic innervation.
Circulatory changes

 Ischemia of the bowel wall can occur by several different mechanisms:

 Extrinsic compression of the mesenteric arcades by adhesion, fibrosis, mass, or a
hernia defect.
 An axial twist of the mesentery.
 Local chronic serosal based pressure on a segment of the bowel wall (e.g. fibrous
band).
 Vascular compromise is more acute in large bowel obstruction, 40% of
people have a competent ileocecal valve, closed loop obstruction
Bacterial translocation

 In the presence of obstruction, a rapid proliferation of bacterial organisms

occurs proximal the point of obstruction, consisting predominantly of fecal
type organisms.
 In persistent bowel obstruction, bacterial translocation can occur secondary
to impairment of barrier function of the intestinal mucosa.
 Reduction of perfusion of the intestinal wall further compromises the mucosal
defenses.
Etiology

 Adhesions
 Hernia
 Malignant bowel obstruction
 Granulomatous diseases and Crohn`s disease
 Intussusception
 Volvulus
 Other causes
Adhesions

 Abnormal connective tissue attachments between tissue surfaces

 Congenital or acquired (post inflammatory or postoperative)
 Postoperative adhesions are the leading cause of small bowel obstruction
 Congenital or inflammatory are infrequent causes.
Hernia

 Incarceration of the bowel in congenital abdominal wall hernias, internal

hernias, or post operative hernias: second most common cause.
 5% of external hernias will require emergency operation.
 10-15% of incarcerated hernias contain necrotic bowel at exploration.
 Chronically incarcerated hernias can develop strangulation, but most
chronically incarcerated hernias can be managed electively.
Malignant bowel obstruction

 Colorectal, gastric, small bowel, and ovarian neoplasms are among the most
frequent causes of malignant bowel obstruction.
 The recurrence and morbidity are high.
 Metastatic cancer can also cause bowel obstruction.
 The most common form is peritoneal carcinomatosis, but melanoma and
carcinoma of the breast, kidney, or lung can also cause intraperitoneal
metastases that can obstruct the bowel.
Granulomatous diseases and Crohn`s disease

 Crohn`s disease is a chronic, transmural, inflammatory disease of

gastrointestinal tract that may affect any part of alimentary tract from mouth
to the anus.
 Responsible for about 5% of cases of small bowel obstruction, secondary to
the inflammatory process or stricture formation.
 Granulomatous diseases causing obstruction: Tuberculosis and
actinomycosis.
Intussusception

 Relatively frequent cause of bowel obstruction in infancy (the first 2 years of

life), but only 2% of bowel obstruction in adult
 Median age of presentation in adults: 6th to 7th decade.
 Etiology of adult intussusception: inflammatory lesion or neoplasm that is
malignant in almost 50% of patients.
Volvulus

 Axial twist of the bowel and its mesentery.

 Infrequent cause of small or large bowel obstruction
 Sigmoid volvulus: accounts for 75% of all patients with volvulus.
 Cecal volvulus: the remaining 25% of bowel volvulae.
 Speculation about the etiology of primary volvulus of the small intestine
has been related to abrupt dietary changes that occur during the religious
holiday when the people celebrating Ramadan fast during the days and then
consume a large meal after drink.
Diagnosis

 History and physical examination

 Labs
 Radiological investigations:
 Supine and upright abdominal radiographs
 Contrast studies
 Ultrasonography
 Computed tomography
History and physical examination

 History:
 Crampy abdominal pain
 Distension
 Acute obstipation
 Nausea & vomiting
 Physical examination:
 Inspection: previous surgical scars.
 Palpation: rebound, localized tenderness, and involuntary guarding.
 Auscultation: high pitched metallic sound
 DRE: blood, masses
Supine and upright abdominal radiographs

 Upright chest combined with supine and upright abdominal radiographes.

 Chest x- ray: helpful to detect extra-abdominal condition.
 Typical findings of small bowel obstruction: dilated loop of small bowel with
air fluid levels.
 Proximal bowel obstruction: little intestinal dilatation.
 Distal bowel obstruction: multiple loops of dilated small bowel and/or large
bowel.
Contrast studies

 The use of contrast is helpful when:

 Diagnosis is uncertain in patient with a non resolving partial small bowel

obstruction
 To differentiate between partial and complete bowel obstruction
 Can also identify the specific site and often the cause of the obstruction.
 Contraindicated in patients with a clear diagnosis of complete bowel obstruction
and when strangulation or perforation is suspected.
Ultrasonography

 Operator dependent
 Diagnosis of SBO is made when the intestinal loop measure more than 25 mm
in diameter and the distal ileum is collapsed
 Useful for the early recognition of strangulation in several studies.
CT scan

 Advantages:
 Allows imaging of structures other than just mucosal detail
 Sensitivity of 93%
 Specificity of up to 100%
 Accuracy of 94%
 The ability to visualize the entire inta-abdominal compartment
 Can demonstrate changes in the intestinal wall and associated mesentery.
 CT findings diagnostic of bowel obstruction include intestinal loops greater
than 25 mm in diameter and a transition zone between dilated and
collapsed bowel loops.
Detection of ischemia

 Primary concern in the patient with an intestinal obstruction.

 Clinical judgment and laboratory findings: unreliable for early detection of
intestinal vascular compromise.
 Acidosis, leukocytosis with left shift, and increase serum amylase activity
and lactate concentration may indicate strangulation.
 Abdominal US and pulsed doppler US have been reported to be useful in
identifying patients with strangulation.
 The presence of peritoneal fluid was also sensitive for strangulation.
Management

 Aggressive fluid resuscitation

 Decompression (NG tube)
 Prevention of aspiration
 Correct metabolic or electrolyte imbalance
 Monitor input & output
 Prompt surgical intervention (LBO)
Non operative management

 Only uncomplicated SBO should be considered for a trial of non operative

management.
 Contraindications to non operative management:
 Suspected ischemia
 Large bowel obstruction
 Closed loop obstruction
 Strangulated hernia
 Perforation
 Relative contraindication: complete SBO
When to convert to operative management?

1. Evidence of complicated obstruction:

 Fever
 Tachycardia
 Leukocytosis
 Continuous abdominal pain
 Peritonitis
 Any three of the signs above: 82% predictive value for strangulation
obstruction (four signs: 100%).
2. Develop free air or signs of closed loop obstruction on abdominal radiograph.
3. Evidence of ischemia, strangulation, or vascular compromise is noted on CT.
Operative management

 Midline celiotomy affords the best exposure to all 4 quadrants of the

abdomen.
 Non viable bowel needs to be identified and resected.
 If patient with malignant SBO or if the obstruction is unable to be released,
intestinal bypass can be performed.
Thanks..