Intestinal Obstruction

General Classification
- A blockage that prevents the normal passage of food or - By location:
fluid through the small or large intestine. è Small Intestine (SBO):
- Pathophysiology: P Most common causes (in order):
è Proximal segment (above the obstruction): § Adhesions (post-surgical).
P Initial increase in peristalsis in an attempt to § Bulge (hernia).
overcome the obstruction. § Cancer.
P Accumulation of fluid and gas leads to progressive
distension (dilation). è Large Intestine (LBO):
P As distension worsens: P Most common causes (in order):
§ Peristalsis decreases due to muscle fatigue and § Colorectal cancer.
wall stretching. § Volvulus.
§ Eventually leads to paralytic (adynamic) ileus. § Diverticular disease.

è Distal segment (below the obstruction): - By etiology:

P Initially maintains normal peristalsis and absorption. è Mechanical obstruction (peristalsis is present):
P As contents are evacuated, the bowel becomes P Caused by physical blockage.
collapsed and empty. P Intraluminal causes:
§ Fecal impaction.
è Bowel Sounds: § Foreign body.
P Initially increased (hyperactive, "tinkling" sounds) due § Gallstone ileus.
to increased peristalsis. § Bezoars.
P Later decreased or absent due to paralysis of bowel § Worm infestation.
musculature.
P Intramural causes:
§ Stricture.
§ Malignancy.
§ Volvulus.
§ Intussusception.
 Intestinal Obstruction

P Extramural causes: Adhesions

§ Hernia.
§ Adhesions.
- General:
è Fibrous bands of scar tissue that abnormally connect
§ Fibrous bands.
loops of bowel or bowel to other structures.
è MC cause of SBO.
è Functional obstruction (peristalsis is absent or impaired):
P Aperistalsis (neuromuscular failure):
§ Hirschsprung disease.
- Etiology:
è Postoperative adhesions (MC): especially after
§ Acute mesenteric ischemia.
abdominal or pelvic surgery.
è Peritoneal inflammation.
P Pseudo-obstruction:
è Foreign materials: gloves and gauze.
§ Paralytic ileus.
è Certain drugs: practolol.
§ Ogilvie’s syndrome.

P Drug-induced: opiates, CCBs, diuretics. - To limit formation:

P Metabolic: electrolyte imbalances. è Good surgical technique.
è Washing of the peritoneal cavity with saline to remove clots.
- By degree of obstruction: è Minimizing contact with gauze.
è Complete obstruction: no passage of luminal contents è Covering anastomosis and raw peritoneal surfaces.
beyond the blockage.
è Partial obstruction: some contents still pass through. - Management: adhesiolysis.
è Closed-loop obstruction:
P Bowel is obstructed at both proximal & distal points. Stricture
P This leads to:
§ Accumulation of gas and fluid. - Localized narrowing of the intestinal lumen due to fibrosis
§ Increased intraluminal pressure. and scarring of the bowel wall.
§ Progressive dilation. - Causes partial or complete mechanical obstruction.
§ # risk of strangulation " ischemia " necrosis " - Etiology:
perforation. è Inflammatory/Granulomatous: Crohn’s disease,
intestinal tuberculosis.
P Commonly seen in volvulus. è Neoplastic: lymphoma.
 Intestinal Obstruction

Volvulus P If bowel ischemia develops:

§ Tachycardia, hypotension.
- A twisting or axial rotation of a portion § Rebound tenderness (sign of peritonitis).
of bowel about its mesentery. § Hematochezia or positive DRE for blood.
- According to etiology:
è Primary:
è Imaging:
P Occurs without any anatomical abnormality.
P On x-ray: coffee bean sign.
P Seen in regions with high-fiber diets.
P CT scan: Whirl sign.
P Associated with long, redundant colon & mesentery.
P Contrast enema (gastrografin): bird’s beak sign.

è Secondary: è Management:
P Caused by predisposing factors such as:
P Non-operative:
§ Postoperative adhesions.
§ Resuscitation: IV fluids, correction of electrolytes, NPO.
§ Tumors.
§ Decompression:
§ Chronic constipation.
v Flexible sigmoidoscopy or colonoscopy for detorsion.
§ Pregnancy.
v Rectal tube placement after detorsion to
§ Congenital malrotation.
maintain decompression.
è Congenital: cecal, midgut. § Success rate: 80–90%.
è Acquired: sigmoid. § Recurrence after non-operative decompression: ≈40%.

- Sigmoid volvulus: P Definitive treatment:

è MC type of volvulus (especially in adults).
§ Elective sigmoid colectomy is recommended after
è Typically seen in elderly.
successful detorsion to:
è Clinical presentation:
v Prevent recurrence.
P Slowly progressive abdominal distention and
v Reduce risk of complications (ischemia/perforation).
constipation (MC presentation).
P Intermittent abdominal pain relieved by explosive
passage of stool/gas (suggesting partial or
intermittent torsion).
P In some cases, symptoms may progress rapidly to
complete obstruction.
 Intestinal Obstruction

- Cecal volvulus: è Investigations:

è Results from failure of cecal fixation during embryologic P US: whirlpool sign.
development " mobile cecum. P X-ray abdomen: double bubble sign.
è Less common than sigmoid volvulus. P Barium enema: bird’s beak sign.
è Typically affects younger adults (30–60 years). P Upper GI series (gold standard):
è Slight female predominance. § Shows abnormally positioned duodenojejunal (DJ) junction.
è Usually presents acutely with the classic features of § Corkscrew sign.
obstruction.
è Ischemia is common. è Management:
P Surgical Procedure (Ladd’s procedure):
- Midgut volvulus with malrotation of midgut: § Detorsion of the volvulus.
è Due to congenital intestinal malrotation: § Division of Ladd’s bands.
P Failure of normal 270° counterclockwise rotation of § Widening of the mesenteric base to prevent recurrence.
the midgut during fetal development. § Appendectomy.
P Results in narrow mesenteric base " risk of volvulus
(twisting of bowel around the SMA).

è A surgical emergency, leads to vascular compromise and

necrosis if not promptly treated.
è Clinical presentation:
P Age: 1 week-2 months. Bezoars
P Acute: dramatic presentation.
§ Bilious vomiting with abdominal distension in a
- A mass of undigested or indigestible material found within
neonate/infant. the GI tract, typically the stomach or small intestine.
§ Signs of bowel ischemia if severe: hematochezia,
- Clinical Presentation:
è Often asymptomatic (especially gastric)
hematemesis, hypotension, and tachycardia.
è If symptomatic:
§ Tender abdomen.
P Epigastric discomfort or pain.
P Early satiety, nausea, vomiting.
P Chronic: intermittent abdominal pain, vomiting, FTT.
P Halitosis.
 Intestinal Obstruction

Intussusception è Other findings:

P Lethargy or altered consciousness between attacks.
- General: P Bilious vomiting (especially if obstruction is distal).
è Invagination (telescoping) of one segment of intestine
(proximal) into an adjacent distal segment. è Dance sign: feeling of emptiness on palpation of the
è Most common cause of intestinal obstruction in infants
right lower quadrant of the abdomen.
(6 months–3 years).
è Peak age: 8–12 months.
- Investigations:
è Ileocolic is the most common type in children.
è US:
è Colocolic is more common in adults.
P Best initial test.
P Target sign / Donut sign / Bull's eye.
- Etiology/lead points:
è Children (mostly idiopathic):
è Contrast enema: crescent sign.
P Enlarged Peyer’s patches (after viral infections like
è Abdominal X-ray:
adenovirus or rotavirus). P May show soft tissue mass.
P Meckel’s diverticulum.
P Signs of obstruction.
P Intestinal polyps.
P Lymphoma (less common).
- Management:
è Non-operative reduction (1st line):
è Adults (90% with pathological lead point): P Air enema (pneumoreduction): preferred, more effective.
P Colon cancer.
P Hydrostatic enema (with saline or contrast).
P Lipomas, polyps.
P 10% recurrence rate.

- Clinical presentation: è Surgical reduction:

è Classic triad:
P Critically ill patient.
P Intermittent colicky abdominal pain (sudden onset,
P If non-operative failed or contraindicated:
crying, pulling knees to chest). § Suspected perforation, strangulation.
P “Sausage-shaped” mass in the RUQ: pathognomonic.
§ Small bowel intussusception.
P “Currant jelly” stools: late sign, pathognomonic.
 Intestinal Obstruction

Paralytic Ileus - Management:

è Conservative (mainstay):
- General: P NPO, IV fluids.
è A functional obstruction of the intestine due to absence
P Electrolyte correction.
of coordinated peristalsis. P Bowel rest with nasogastric decompression if needed.
è No mechanical blockage, but the bowel is inactive
(aperistalsis). è Prokinetic agents: metoclopramide, erythromycin.
è Results in accumulation of gas and fluid, leading to
è Remove underlying cause:
distention and symptoms mimicking bowel obstruction. P Stop offending medications.
P Treat infection or inflammation.
- Etiology:
è Electrolyte imbalances:
Ogilvie’s Syndrome
P Especially hypokalemia (MC cause).
P Hyponatremia, hypocalcemia, hypomagnesemia. - General:
è Also called acute colonic pseudo-obstruction.
è Post-operative ileus: è A condition that mimics large bowel obstruction, but
P Common after abdominal surgeries. without a mechanical cause.
P Risk ↑ with early feeding, opioid use, and è Due to autonomic nervous system dysfunction "
manipulation of intestines. impaired colonic motility.
è Affects mainly the cecum and right colon, leading to
è Peritonitis or sepsis. massive colonic dilation.
è Drugs
P Opiates (e.g., morphine, codeine). - Clinical features:
P Antidepressants (especially tricyclics). è Gradual abdominal distention (especially in the right
P Anticholinergics. colon/cecum).
è Mild or no abdominal pain.
- Clinical features: è Nausea, vomiting.
è Painless abdominal distention. è Bowel sounds may be present (unlike paralytic ileus).
è Absent bowel sounds.
è Mild nausea, bloating.
è Minimal or no abdominal tenderness.
è Can be a late stage of untreated intestinal obstruction.
 Intestinal Obstruction

- Diagnosis: History
è Abdominal X-ray / CT scan:
P Shows massive colonic dilation, especially of cecum
- Depends on:
è The location of the obstruction.
(may exceed 12 cm).
è The duration of the obstruction.
P No mechanical obstruction seen.
è The underlying pathology.
è The presence or absence of intestinal ischemia.
è Must exclude mechanical causes (e.g., via contrast
enema or CT).
- 4 cardinal symptoms:
è Pain:
- Management:
P 1st symptom encountered.
è Conservative (initial):
P Coincides with increased peristaltic activity.
P NPO, IV fluids, bowel rest.
P Pathophysiology: contraction against obstruction.
P Discontinue offending medications.
P Sudden, severe, colicky.
P Correct electrolyte imbalances (K⁺, Mg²⁺).
P Centered on the umbilicus (small bowel) or lower

è Pharmacologic: abdomen (large bowel).

P Does not usually occur in paralytic ileus.
P Neostigmine (IV cholinesterase inhibitor):
P Can be temporarily relieved by vomiting.
§ 1st line if no response to conservative one.
P Think of strangulation if:
§ Acts by increasing colonic motility.
§ Very severe pain.
§ Not responding to IV opiates.
è Invasive (if unresponsive or perforation risk):
P Colonoscopic decompression.
P Cecostomy (surgical opening of cecum) in
è Vomiting:
P The higher the level of obstruction, the earlier the
recurrent/severe cases or perforation risk.
onset of vomiting.
P More profuse in proximal obstructions.
P May contain bile or even fecal matter in distal obstruction.
 Intestinal Obstruction

è Constipation: Physical Examination

P The lower the obstruction, the earlier constipation
appears. - General:
è Vital signs: tachycardia and orthostatic hypotension.
P Constipation = no passage of stool.
è Signs of dehydration, due to:
P Obstipation = no passage of stool or flatus (complete
P Vomiting " fluid loss.
obstruction).
P Reduced intestinal absorption.
P Decreased oral intake.
è Abdominal distention:
P The lower the level of obstruction, the earlier and
more pronounced the distention. - Inspection:
è Visible distention.
P More marked in large bowel or distal small bowel
è Surgical scars " suggest previous surgery (adhesions).
obstruction.
è Visible hernias " may indicate a mechanical cause.

- Level-based:
- Palpation:
Level Pain Location Vomiting Distention è Abdominal rigidity or guarding " suggests peritonitis
High SBO Periumbilical Early, profuse Minimal
(may indicate strangulation or perforation).
Low SBO Periumbilical Delayed Central
è Palpable mass " tumor, volvulus, or intussusception.
LBO Suprapubic Late Early
peripheral è Hernia sites.

- Past medical history: - Auscultation:

è Early stage: hyperactive, high-pitched bowel sounds due
è Previous abdominal surgeries " adhesions.
è History of cancer or radiation " tumors, strictures.
to increased peristalsis against obstruction.
è Late stage or functional obstruction: $ or absent bowel
è Inflammatory bowel disease (IBD) " strictures, fistulas.
è Hernias.
sounds indicating paralytic ileus or bowel fatigue.
Red flags for complicated bowel obstruction:
- Drug history. • Pain out of proportion.
• Peritoneal signs.
• Signs of systemic toxicity.
• Hemodynamic instability.
 Intestinal Obstruction

Investigations § LBO:
v Peripheral dilated loops.
- Labs: v Haustrations visible.
è CBC:
P Anemia " suggests malignancy (especially colon CA):
P Erect abdominal X-ray:
§ Rt-sided colon Ca " iron deficiency anemia (IDA).
§ Shows air-fluid levels:
§ Lt-sided colon cancer " more likely to present
§ Up to 2 air-fluid levels is normal.
with obstruction. § Paralytic ileus → fluid levels at the same height.
§ Mechanical obstruction → fluid levels at different heights.
P Leukocytosis " may be strangulation or ischemia.
è CT abdomen with contrast:
è Electrolytes: P Most accurate test.
P Hypokalemia " may worsen paralytic ileus.
P Identifies:
P Hyponatremia.
§ Site of obstruction.
P Hypochloremia.
§ Cause (e.g., mass, adhesion, obturator hernia).
§ Degree (partial vs complete).
è KFT: #BUN/Creatinine ratio " due to dehydration. § Complications (ischemia, perforation, abscess).
è Arterial Blood Gas (ABG): § Special signs.
P Early: metabolic alkalosis (from vomiting).
P Late: metabolic acidosis (from ischemia or sepsis).

- Imaging:
è Plain X-rays (abdominal series):
P Initial test of choice.
P Upright chest X-ray: free intraperitoneal air / air
under diaphragm (perforation). Complications
P Supine abdominal X-ray:
§ Assesses bowel diameter and gas distribution. - Perforation, ischemia.
§ SBO: - Strangulation.
v Central dilated loops. - Necrosis, gangrene.
v Stepladder appearance.
 Intestinal Obstruction

Management P Surgically correctable causes:

§ Tumor.
- Conservative (non-surgical): § Foreign body.
è Indications:
§ Gallstone ileus.
P Stable patient.
§ Hernia.
P Partial obstruction.
§ Intussusception.
P No signs of strangulation or peritonitis.
§ Volvulus.

è Includes: è Surgical procedures (based on cause & location):

P NPO (nil per os).
P Lysis of adhesions: adhesive obstruction.
P IV fluids: correct dehydration & electrolyte imbalance.
P Hernia repair.
P NG tube: gastric decompression.
P Gallstone or foreign body extraction: gallstone ileus or
P IV antibiotics: only in certain cases (suspected
foreign body.
strangulation, peritonitis, or perforation). P Bowel resection + primary anastomosis: small bowel
obstruction or large bowel obstruction before the
è Outcome: 75–80% of adhesive mechanical SBOs resolve splenic flexure.
with conservative treatment alone. P Hartmann’s procedure:
§ For large bowel obstruction after the
- Surgical: splenic flexure (left-sided).
è Indications for emergency surgery:
§ Involves resection, end colostomy,
P Closed-loop obstruction.
and rectal stump closure.
P Signs of ischemia (persistent pain, tachycardia,
leukocytosis, metabolic acidosis). è Intraoperative assessment of bowel viability:
P Necrosis or bowel perforation (free air under
diaphragm, peritonitis).

è Indications for elective or delayed surgery:

P Failure of medical management:
§ No resolution of symptoms within 3–5 days.
§ Any clinical deterioration during conservative
therapy.

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