ICC-2 [101]

Intestinal Obstruction

Surgery Department
Introduction
 Intestinal obstruction
Definition
Obstruction of the normal movement of bowel contents.

Epidemiology
Common. More common in elderly due to increasing incidence of adhesions,
hernias
and malignancy.
Notorius for the associated complications
Dehydration, toxaemia, bowel perforation or gangrene of ischaemic bowel wall
Prognosis
Variable. Dependent on the general state of patients and the prevalence of
complications.
The normal flow of intestinal contents can be blocked by a mechanical obstruction
or by a functional
obstruction that occurs because of impaired intestinal motility. An acute abdomen
often ensues.

Intestinal
obstruction

Mechanical Functional
 Functional obstructions
Functional obstructions are blockages in the intestinal flow that result from impaired motility(paralytic
or adynamic ileus).
These are usually treated by observation and by fluid and nutritional support until the causal agent
resolves.
Possible causes include:
1. Direct irritation of the intestine, such as generalized peritonitis. Irritation may also be
a factor in the postoperative adynamic ileus that can last for 3-7 days following surgery.
2. Extraperitoneal causes, such as retroperitoneal haematoma or nerve root compression.
Retroperitoneal dissections, such as a nephrectomy or sympathectomy, can cause
a prolonged ileus.
Small bowel ileus is, by far any surgical procedures the most common form of intestinal obstruction as
it is seen after many surgical procedures whether they are performed in the abdomen or not. The exact
aetiologyof the ileus is unclear but is probably multifactorial taking into account anaesthesia and narcotic
usage.
 Mechanical obstructions
Mechanical obstructions are common and have various benign and malignant causes. If not
treated expeditiously (usually by surgical removal of the cause), mechanical obstructions can rapidly
become lethal.
Acute obstruction occurs over hours to days and has a rapidly evolving course, whereas chronic
obstruction may have a slow course with malnutrition, constipation, and other signs of chronic
illness.
 Mechanical obstructions
1. Types
a. Simple obstruction. There are no complicating factors, such as ischaemia or
perforation.
b. Strangulating obstruction. The blood supply to the involved segment of bowel is
significantly impaired. The ischaemia may result from a twisting of the intestinal blood
supply upon itself (volvulus) or from a constriction of the blood flow by a tight band or
hernial opening.
c. Closed loop obstruction. Both limbs of the bowel are obstructed; therefore, gas and
liquid cannot pass in either direction.
d. Intussusception. The bowel invaginates itself, causing a narrowing of the lumen and
subsequent obstruction. It may result from either viral infections or intraluminal polypoid
tumours.
e. Perforating obstruction. The bowel proximal to the obstruction overdistends and
perforates. The most common area of perforation when the colon is obstructed is the
caecum.
Causes of mechanical
obstruction
 Causes of
intestinal
obstruction
 Causes of
obstruction

Extramural: Intramural: Intraluminal:

1) Hernia, 1) Pedunculated
1) Tumours, tumours leading to
2) adhesions, intussception,
2) inflammatory
3) Congenital bands, 2) foreign bodies, e.g.
strictures, e.g. in
4) volvulus, Crohn’s disease or bezoars, gallstones;
infestation,e.g. worms,
5) external compression diverticulitis, 3) constipation/faecal
by space-occupying
impaction
lesion.
 Causes of mechanical obstructions
by Frequency of occurrence
1) Intestinal adhesions are the most common cause of obstruction.
(a) They may result from a previous surgical exploration, particularly when talc was used
to lubricate the surgeon's gloves, or their aetiology may be obscure.
(b) They may be diffuse, involving all peritoneal structures, or solitary, blocking only one
area of the intestine.
2) Hernias are a second very common cause of intestinal obstruction. A segment of intestine
migrates through a defect in the abdominal wall (external hernia) or through a mesenteric or omental
defect (internal hernia) and becomes blocked by the narrow ring that is present at the peritoneal
communication of the hernia.
 Causes of mechanical obstructions
by Frequency of occurrence
3) Intestinal tumours are the third most common cause of obstruction. The most common
obstructing tumour is an adenocarcinoma of the colon or rectum. Benign lesions of the small bowel
and colon, such as lipomas, can become the leading point of an intussusception. Other malignant
tumours, such as carcinoid or lymphoma, can obstruct the intestinal lumen.
4) Other intrinsic lesions within the bowel wall or the lumen can cause acute obstruction.
(1) Congenital lesions: webs, malrotations, and atresias
(2) Inflammatory lesions: Crohn's disease, diverticulitis, ulcerative colitis, and
infections such as tuberculosis
(3) Luminal foreign bodies: bezoars, parasites, and gallstones
(4) Radiation injury, other trauma, or endometriosis
5) Other extrinsic lesions, such as large intra-abdominal tumours or abscesses, can compress the
intestinal lumen.
Examples of mechanical intestinal
obstruction
 Band
Obstruction
Splenic flexure
carcinoma
 Bezoars as cause of luminal obstructions

Phytobezoars Trichobezoars
Pathophysiology
 Pathophysiology
1) Simple obstruction (bowel occlusion without vascular
compromise):
Intestine distal to occlusion rapidly empties and collapses while
bowel above the obstruction dilates with gas and fluid. With "
distension, the intestinal wall blood supply becomes impaired and
mucosal ulceration and bowel perforation may occur.
2) Strangulated obstruction: The blood supply to the affected
segment is compromised, leading to impairment of the normal mucosal
barrier with bacterial transudation into the peritoneal cavity and
peritonitis, with the unrelieved bowel developing gangrene and
perforating.
 Pathophysiology
1) Bowel distal to obstruction collapses.
2) Bowel proximal to obstruction distends and becomes hyperactive. Distension is due to swallowed
air and accumulating intestinal secretions.
3) The dilation and increased intraluminal pressure can progress to cause venous congestion,
oedema, and increased permeability of the bowel .
4) Fluid and electrolytes accumulate in the wall and lumen (third space loss).
5) Bacteria proliferate in the obstructed bowel.
6) As the bowel distends, the intramural vessels become stretched and the blood supply is
compromised, leading to ischaemia, necrosis and perforation.
7) Moreover, with intestinal dilation and resulting diaphragmatic elevation, respiratory and cardiac
function may be impaired. Therefore, patients presenting with bowel obstruction secondary to
malignancy require surgical consultation and early intervention.
Clinical features
 Clinical
presentation
of intestinal
obstruction
 Clinical presentation
HISTORY EXAMINATION
1) Severe gripping colicky pain with 1) Dehydration and loss of skin turgor, occasional
Hypotension, and always tachycardia.
periods of ease, located in the central
(small intestine) or lower abdomen 2) Abdominal distension with generalised
tenderness.
(large intestine).
3) Visible peristalsis may be seen.
2) Abdominal distension. 4) " Bowel sounds (more frequent ‘tinkling’ in
3) Frequent vomiting of greenish bile- character).
stained vomit, early in SBO or late with 5) Guarding and percussion tenderness suggest
faeculent vomiting in distal SBO or peritonitis has developed, and bowel sounds may be
absent.
LBO.
6) Inspect for hernias. Any abdominal scars raise
4) Absolute constipation – failure to possibility of adhesions.
pass either stool or flatus. 7) Inspect for abdominal mass (e.g. in
intussusception, carcinoma)
8) PR empty rectum usually however a mass in the
pouch of Douglas or faecal impaction maybe felt.
Investigations
 Investigations

Laboratory Imaging
1) ABG: Lactic acidosis may suggest 1) Plain X-ray abdomen erect and supine.
bowel ischaemia and impending 2) Erect chest x-ray
perforation.
2) Blood picture: 3) Water-soluble contrast enema
a. Hb, PCV: elevated due to dehydration. 4) Water-soluble contrast follow-through
b. WCC: normal or slightly elevated. 5) CT scan
c. Microcytic anaemia may indicate large
bowel malignancy. Instrumental
3) Urea and electrolytes for dehydration Sigmoidoscopy – ?sigmoid volvulus
and electrolyte disturbance secondary to (allows flatus tube passage).
vomiting. ( urea elevated, Na+ and Cl−low)
 Imaging
1) Plain x-ray (AXR): Assists diagnosis and localisation of obstruction.
Abdominal erect: Fluid levels may be seen
Abdominal supine: a) Level of obstruction:
Central ladder pattern of dilated loops with valvulae conniventes crossing the entire width of
bowel suggest SBO.
If distended bowel lies more peripherally, with haustrations that do not cross the bowel width,
this suggests LBO.
b) look for cause (gallstone, characteristic patterns of volvulus, hernias)
c) gas in the bowel wall (pneumatosis intestinalis) suggests gas forming infection.

2) Erect CXR: To exclude perforation. Elevated diaphragm due to abdominal distension.

3) Single contrast large bowel enema – ?large bowel obstruction – site and cause (‘bird-beak’ deformity with volvulus,
apple core with tumour).
4) Water-soluble contrast follow-through: To investigate level of obstruction.
5) CT scan: first investigation of choice for ALL suspected bowel obstruction Allows for pre-operative diagnosis of
the cause for and/or the level of obstruction and planning of management accordingly.
It may reveal metastases or perforation.
Upright and supine
abdominal radiograph
with features
suggestive of SBO.
(a) Erect radiography
exhibiting stepwise
air-fluid
levels characteristic
of SBO with a paucity
of colonic gas.
(b)Supine
radiography
demonstrating
distended loops of
bowel with
fecalization
 Large
intestinal
obstruction
Intestinal Obstruction
The x-ray demonstrates large-bowel
obstruction. In approximately 20 per cent of
patients, the ileocaecal valve is competent
resulting in a
‘closed-loop’ obstruction which does not allow
decompression into the small bowel. The large
bowel gradually dilates with maximal dilatation
occurring in the caecum. Gross dilation
(>10 cm) with tenderness over the caecum is a
sign of impending perforation and requires
prompt treatment. Decompression of the large
bowel with either a colonic stent or
defunctioning
loop colostomy may be required. More
definitive surgery can then be planned after
optimization and further imaging.
 Radiologic difference between small and
large bowel obstruction.
Small bowel obstruction Large bowel obstruction

Valvulae conniventes Thin complete lines Absent

Seen in jejunum.

Haustra Absent Thick incomplete bands

Number of loops Many Few

Distribution of loops Central Peripheral

Diameter of loops 3-5 cm More than 5 cm

Volvulus of the
sigmoid for the cases
Coffee bean
sign seen
here to the
left
originating in
the
left lower
quadrant
extending up
toward the
right upper
quadrant,
characteristic
of sigmoid
volvulus.
Conversely,
caecal
volvulus with
dilated colon
pointed back
up toward
left upper
quadrant.
A contrast enema or contrast CT
can be used to determine the level
of the obstruction and
if it is complete. If the patient is
stable and is suspected of having a
tumour, then histology
should be gained and staging
completed by computerized
tomography of the chest, abdomen
and pelvis prior to definitive
surgery.
barium enema demonstrating
a stricture at the rectosigmoid
junction
(arrow).
Barium enema showing
carcinoma of the large bowel
producing an ‘apple core’-
shaped narrowing of the colon
(arrows)
A barium enema in a patient
with a tumour at the splenic
flexure (arrow).
The appearance is typical of
the narrowing of the colon
lumen caused by an ‘apple-
core lesion’.
Stent crossing an
obstructing cancer at
the
splenic flexure that
was subsequently
treated by elective
subtotal colectomy
Colorectal surgery
companion
CT-axial cross-section of SBO. Arrow indicates
fecalization
of small bowel. Proximal small bowel dilatation
and distal collapse
are demonstrated
Multislice CT image with
intravenous
contrast demonstrating small-
bowel obstruction
secondary to a left-sided
Spigelian hernia.
(core topics in emergency )
CT showing a
picture
suggestive of gall
stone ileus
Closed loop
small bowel
obstruction.
(a) Upright
plain
radiograph
demonstrates
air fluid levels
with a paucity
of small
bowel gas. (b)
CT scan reveals
evidence of
possible
ischemia.
White
arrow
indicates
mesenteric
fluid and
stranding.
Bowel wall
thickening,
edema, and
enhancement
demonstrated
by white
carrots
Axial cuts
with hypo-
enhancing
liver lesions
consistent
with
metastases
Management
 Key points in management of intestinal
obstruction
1) Level of obstruction is an important pivotal point in decision making.
2) Small bowel obstruction is often rapid in onset and commonly due to adhesions or hernia.
3) Large bowel obstruction may be gradual or intermittent in onset, is often due to carcinoma or
strictures and never due to adhesions alone.
4) All obstructed patients need fluid and electrolyte replacement.
5) Many patients with adhesion small bowel obstruction will settle on conservative treatment.
6 ) The cause should be sought and confirmed wherever possible prior to operation.
7) Tachycardia, pyrexia and abdominal tenderness indicate the need to operate whatever the cause.
8) Relieve the obstruction surgically if:
a. underlying causes need surgical treatment (e.g. hernia, colonic carcinoma)
b. patient does not improve with conservative treatment (e.g. adhesion obstruction),
c. there are signs of strangulation or peritonitis.
 Management

Conservative Interventions
1) General: Resuscitation with IV fluids and 1) Endoscopic:
electrolyte replacement, nasogastric tube placement, a. Obstructing colonic tumours may be stented
close monitoring of vital signs, fluid balance, urine endoscopically either preoperatively to avoid emergency
output and clinical status. surgery, or as a palliative procedure.
2) Gastrografin follow-through may be therapeutic as b. Obstruction secondary to a sigmoid volvulus may
well as diagnostic for adhesional obstruction. The be treated endoscopically either with a flexible
hyperosmotic contrast is thought to reduce oedema in sigmoidoscope or by the passage of a flatus tube.
the bowel wall and thus, relieve the obstruction. If the 2) Surgical: Laparotomy/laparoscopy to treat cause:
study suggests an alternative diagnosis, then an early
operation can be planned. [Link] involve adhesiolysis or band division
3) Conservative measures may settle an acute b. or bowel resection +/-stoma.
obstruction; however, if not resolving or signs of i)Primary anastomosis in small-bowel resection
complications, operative intervention should be
carried out. ii) Hartmann’s operation or hemicolectomy
with defunctioning stoma in large bowel
resection
Post-op care in an HDU or ITU setting may be required.
 Algorithm of
management of
suspected small
bowel
obstruction
Algorithm
for SBO
 Management of small bowel obstruction

High risk groups High risk findings

1) Obstructed patient with a 1) Clinical findings
virgin abdomen. 2) Laboratory findings
2) Altered gastrointestinal 3) Imaging findings
anatomy
3) Hernia
 High risk groups
1) Obstructed patient with a virgin abdomen:
Patients who present with obstructive symptoms without prior abdominal surgery warrant close surgical
scrutiny. Previous dogma stated that all patients with a “virgin” abdomen and obstruction warrant operative exploration
because of the risk of malignant obstruction.
2) Altered gastrointestinal anatomy:such as roux-en-Y gastric bypass:
Patients with prior gastric bypass surgery are at risk of internal hernia formation, in addition to adhesive small bowel
disease as the source of bowel obstruction.
Internal hernias form through the mesenteric defects created when performing a Roux en- Y reconstruction. Bowel
herniated through these defects is at a high risk of incarceration and strangulation.
Any patient with prior gastric bypass warrants additional workup, including an upper gastrointestinal (UGI) or CT
scan with oral and intravenous contrast to evaluate for internal hernia.
Typical radiographic findings include swirling in the mesentery and loops of dilated bowel with intervening segments
of decompressed bowel.
Some surgeons advocate diagnostic laparoscopy in all gastric bypass patients who present with obstructive symptoms
because of the risk of strangulated internal hernia.
The risk of internal hernia is not unique to Roux-en-Y reconstructions but can occur anywhere a bowel resection and
anastomosis create a mesenteric defect.
 High risk groups
3) Hernia:
Abdominal wall hernias are a common cause of mechanical small bowel
obstruction. Herniated bowel is at risk of incarceration and strangulation.
CT evidence of a hernia with a narrow neck is more concerning for
strangulation than a hernia with a wide neck where the bowel can easily self-
reduce.
Attempts to manually reduce the hernia can be performed and, if
successful, often alleviates the obstruction.
If the patient has exam findings suggestive of strangulation, attempts to
manually reduce the hernia should be avoided, and the patient should be taken
to the operating room for exploration as this is a sign of an underlying
ischaemic bowel.
 High risk findings
1) Clinical findings:
Concerning findings in small bowel obstruction:
1) Abdominal complaints should be limited to mild generalized abdominal
distention and discomfort.
2) Evidence of fevers, chills, or peritoneal signs requires operative intervention.
3) Small bowel obstruction secondary to adhesive disease should not typically
cause significant haemodynamic, haematologic, or electrolyte abnormalities. The
presence of these findings should prompt closer evaluation.
4) Depending on the duration of symptoms, patients may demonstrate
tachycardia associated with hypovolemia, which should respond to intravenous fluid
resuscitation.
5) Hypotension that is unresponsive to a weight-based fluid bolus is abnormal
and should prompt further workup.
 High risk findings
2) Laboratory findings:
a) Significant leukocytosis is suggestive of compromised bowel and
should lower the threshold for operative intervention.
A mild leukocytosis can be seen with obstructive symptoms due to
bowel oedema and hypovolemic state.
This should begin to normalize with appropriate nasogastric
decompressionand resuscitation.
b) Likewise, lactic acidosis should prompt earlier surgical intervention.
It should, however, be regarded carefully as a normal lactic acid
level does not rule out intestinal ischaemia in the setting of
venous outflow obstruction.
 High risk findings
3) Imaging:
Findings on imaging include:
(i) Isolated segments of dilated bowel (closed loop obstruction).
(ii) Nonphysiologic free fluid (i.e., male/amenorrheic females).
(iii) Dilation greater than 3 cm in diameter (could perforate).
(iv) Pneumotosis intestinalis (anaerobic wound infection).
(v) Free abdominal air (perforation).
(vi) Mesenteric oedema (venous involvement in strangulation)
 Conclusions about SBO management.

The evaluation and management of SBO has become somewhat protocolized in

the past decade, employing both CT scans and Gastrografin challenges in the
workup of nonacutely ill patients.
Failure of contrast to reach the caecum in 24–48 hours suggests that
nonoperative management will not be possible, and an operation should be
performed.
A laparoscopic approach can be performed in patients with favorable anatomy.
 LBO
Large bowel obstructions are defined as an intestinal obstruction distal to the ileocecal valve.
Large bowel obstructions can be mechanical or functional and the aetiology can be extrinsic or
intrinsic to the colon.
Malignancy is the most common cause of large bowel obstruction. Other causes include
diverticulitis, volvulus, hernia, and extrinsic compression.
Malignant bowel obstructions can be partial or complete. A closed loop bowel obstruction can
occur in the scenario of multiple tumour primaries or competent ileocecal valve. This confers a
higher risk for ischaemia and perforation.
Functional bowel obstructions result in ileus and can be due to narcotic pain medication or
neurovascular invasion of malignant tissue compromising colonic motility in the setting of
malignancy.
 Malignant colonic emergencies
Colorectal cancer is the second leading cause of cancer death for men and women
in the USA with 100,000 new cases and 50,000 deaths annually.
Despite screening programs implemented in North America, up to 40% of the
population in the USA do not participate. As a result, 33% of patients with colorectal
cancer present acutely with complicationsand 15% present with bowel obstruction or
perforation.
In the initial stages of the disease, patients may present with symptoms secondary
to local and invasive malignancy. In the later stages, patients will present with
metabolic and infectious complications due to the malignancy.
Risk factors which increase patient likelihood to present with an acute emergency
due to colorectal cancer are advanced stage and age.
Patients may present with a variety of ailments including obstruction and
perforation.
 Considerations in the management of LBO
1 ) History taking:
Since large bowel obstructions (LBO) can result from a variety of both benign
(e.g., diverticular disease, ischemic colitis) and malignant (e.g., colorectal cancer,
extrinsic compression from ovarian cancer) diseases, a detailed history is essential
for determining the diagnosis. Important factors to consider include:
a) the onset and duration of obstructive symptoms
b) any associated symptoms. Patients will report complaints of abdominal
pain and distention, as well as progressively worsening obstipation.
Competency of the ileocecal valve can impact patient presentation: patients
with competent valves are at risk for a closed-loop obstruction and are less likely to
have nausea/vomiting, which is commonly seen in large bowel obstructions .
Considerations in the management of LBO
2) Physical examination:
A thorough physical exam evaluating for signs of peritonitis and systemic
toxicity should be performed.
3) laboratory studies to assess for electrolyte derangements or signs of bowel
ischaemia
4) Initial radiographic evaluation with an acute abdominal series can be obtained, in
order to
(a) evaluate for signs of perforation,
(b) assess the degree of colonic distention,
(c) potentially identify an aetiology, such as a volvulus .
 Systemic toxicity or signs of Haemodynamically stable with clear
free perforation, diagnosis
Patients with
LBO
Haemodynamically stable with
unclear diagnosis
 Haemodynamically unstable LBO
In patients with systemic toxicity or signs of free perforation, intravenous broad-spectrum
antibiotics and emergent exploratory laparotomy are indicated:
1) If unresectable disease (e.g., carcinomatosis) or disease that requires initial medical treatment
(e.g., neoadjuvant therapy for obstructing rectal cancer) is encountered, then proximal diversion is an
appropriate procedure.
2) If resectable disease is found, resection of the diseased intestine is indicated, along with
careful inspection of the remaining large intestine for either ischemia or synchronous lesions.
Preferably no primary reconstruction in these high risk conditions.
 Haemodynamically stable LBO
1) In haemodynamically stable patients with a clear diagnosis, such as colonic volvulus (10– 15%
of LBO), acute colonic pseudoobstruction, or foreign body impaction, further management should
proceed according to the underlying aetiology of bowel obstruction.

2) In haemodynamically stable patients without signs of perforation, but for whom the diagnosis
remains unclear, further imaging should be obtained.
Either contrast enema (particularly for left-sided lesions) or CT scans can be helpful in
determining the aetiology of the obstruction.
Colonoscopy, preferably with CO2 insufflation, can also be used to obtain a tissue diagnosis in
patients with suspected intraluminal disease, such as colorectal cancer (~50% of LBO).
LBO management
Further management of LBO in the nonemergent setting is dependent upon aetiology.
In general, the two main options are surgical (either resection or diversion) or endoscopic stenting,
the latter of which can be used as a bridge to surgery or as definitive palliation.
Stents offer lower initial morbidity than surgical resection, with the possibility of converting a
more urgent surgery to an elective procedure with a lower likelihood of requiring a stoma .
However, stents are often less effective at relieving the initial obstruction (53% vs. 99%) and
have high rates of reobstruction .
Since stents are safest when used as a bridge to elective surgery within several weeks, careful
consideration of the goals of care is necessary in choosing how to relieve the patient’s obstructive
symptoms.
Algorithm of LBO
 Acute abdomen Obstruction of hollow
viscus
Clinical Investiigations Need for laparotomy
2) Small intestinal 1) Intermittent pain around 1)Plain abdomen 1) Manage the
obstruction: the umbilicus. erect—multiple complicated external
Hernia,adhesive 2) Vomiting early fluid levels. hernia.
obstruction ,tumours and 3) Distension central 2) Plain abdomen 2) Attempt at
gall stone ileus 4) Absolute constipation late supine to detect conservative ttt in
5) Hyperaudible intestinal level ; jejunal or adhesive obstruction.
sounds. ileal. 3) If neither nor---
6) History of operations, 3) Pneumobilia in Exploratory
7) Evident complicated gall stone ileus laparotomy.
external abdominal hernia
 Acute abdomen Obstruction of hollow viscus
Clinical Investigations Need for laparotomy
3) Large bowel 1) Insideous onset of 1) Plain X-ray abdomen 1)If colonic stenting is
obstruction: intermittent erect either: applicable better for later
Mainly malignant, less abdominal pain in the a- Multiple fluid adequate preparation
common benign eg hypogastric area. levels if incompetent 2) Laparotomy after
volvulus 2) Sudden onset of iliocaecal valve. resuscitation:
intermittent pain b- Huge peripheral a) Proximal diversion if
maybe volvulus loop if competent poor general
3) Vomiting late iliocaecal valve condition.
4) Distension peripheral c- Coffee bean b) Resection with no
5) Constipation earlier appearance in sigmoid primary anastomosis.
6) Maybe history of volvulus. c) Resection with
bowel habit changes 2) Supine abdominal X-ray primary anastomosis
If previous multiple fluid and a covering stoma.
levels shadows of colon , d) Resection and primary
ileum and jejunum. anastomosis.
3) CT for liver metastases
Special entities of obstruction
1) Intussusception
2) Volvulus
 1) Intussusception
DEFINITION
The process of invagination of an intestinal segment, the intussusceptum, into the adjoining
intestinal lumen, the intussuscipiens, potentially resulting in vascular compromise of the bowel or
obstruction.
AETIOLOGY
<3 years: Many idiopathic (up to 90%), association with lymphoid hyperplasia in Peyer’s patches,
Meckel’s diverticulum, polyp, haematoma.
Children: Recent upper respiratory tract infections, blood dyscrasias (due to submucosal
haematomas), Henoch–Schonlein purpura.
Juvenile/Adult: Mass in bowel wall or lumen, e.g. polyp, tumour, Meckel’s
diverticulum,approximately one-third of small-bowel cases and two-thirds of large-bowel cases are
due to malignancy.
EPIDEMIOLOGY
Incidence is 1–3/1000. Usually affects <3-year-olds (majority in 3- to 9-month-olds). Rare in
adults
 1) Intussusception
PATHOLOGY/PATHOGENESIS
A pathological ‘lead point’ causes abnormal peristalsis and telescoping of the bowel. The ileocolic
junction is the commonest site, although ileo-ileal and colo-colic also occur.
Bowel wall venous congestion and oedema results, with risk of infarction and perforation if not
treated
COMPLICATIONS
Can lead to ischaemia, haemorrhage, obstruction, perforation.
PROGNOSIS
Spontaneous reduction can occur in up to 10% paediatric cases. Recurrence rate is 5–10%.
Good with prompt treatment, could be fatal if untreated.
 1) Intussusception
Clinically
HISTORY
In children, intermittent episodes of severe abdominal pain, often accompanied by drawing up of
legs. Bloody mucus can be passed PR that is said to resemble ‘red currant jelly’.
In later stages, it can resemble bowel obstruction with vomiting and distension.
In adults, symptoms can be nonspecific.
EXAMINATION
Classically, ‘sausage-shaped’ mass in right hypochondrium.
Signs of shock: Pale, hypotensive, tachycardia.
Signs of obstruction: Abdominal distension, tinkling bowel sounds.
Signs of peritonism: Abdominal guarding, rebound, absent bowel sounds.
 For an
intussusception
to occur

Relatively fixed Lead point

Organ has a
distal point to appreciably
mesentery
act as a pivot mobile
Pedunculated
polyps
GIST jejunal tumour
Ileal carcinoid tumour
 1) Intussusception
INVESTIGATIONS
1) Laboratory:
Blood picture (leucocitosis), Urea and electrolytes(dehydration) , ABG (for lactic acidosis).
2) Imaging
AXR: May show absence of air on the right side of the bowel or features of obstruction.
Ultrasound: Intusscepted segment appears as a target-shaped mass.
Contrast/Air enema: This is the classical way of showing intussusception, with contrast at the
site showing a ‘coiled spring’ appearance. This can be therapeutic (see Management).
CT may show the target sign.
A child presents with
a history of
intermittent severe
abdominal pain and
vomiting
A 65-year-old
woman presents
with abdominal
pain, anaemia and
weight loss
(polypoid mass
with starting
ileocolic
intussusception)
Target
Sign
 1) Intussusception
MANAGEMENT
1) Supportive: Resuscitation with IV fluid, analgesics, antibiotic cover, NG tube insertion if
vomiting.
2) Therapeutic enema: To reduce the invaginating segment back, can be performed with barium,
air or saline. Contraindicated if there is perforation, peritonitis or suspected tumour.
3) Surgical: Performed in case of failure to resolve with enema or if there are signs of peritonitis.
The affected bowel is gently manipulated to reduce intussusception. If the involved bowel is non-
viable, cannot be reduced or Meckel’s diverticulum is found, resection of theinvolved segment is n
ecessary. Can be performed laparoscopically.
Claw sign and barium enema reduction
Ileoileal Intussception.
Reduction of intussusception.
 2) Volvulus

I. Volvulus is a twist or torsion of an organ on a pedicle.

2. Symptoms are produced by occluding the bowel lumen (obstruction) or occluding the blood
supply (ischaemia).
3. The incidence is low in the United States.
a. Diverticulitis and cancer are more common causes of colon obstruction.
b. Volvulus is the most common cause of colon obstruction in Africa.
4. Volvulus of the colon may either be :
a- Volvulus of the sigmoid (more common)
b- Volvulus of the caecum.
 Sigmoid volvulus
Sigmoid volvulus accounts for more than 80% of cases of colonic volvulus. Patients with this condition are often from
nursing homes or mental institutions.
Sigmoid volvulus is most common in men, and it occurs more often in blacks.
The average age of a patient with this condition is 60years.
Aetiology.
Several predisposing conditions are required:
a. A long, freely movable sigmoid colon
b. An ample, freely mobile sigmoid mesentery
c. A point of fixation about which the colon can twist (a loop of bowel with the
limbs lying close together)
Pathogenesis.
The sigmoid colon usually twists counterclockwise around the axis of the mesentery .
This torsion about the mesentery is accompanied by an axial torsion of the bowel wall.
The combined torsions of the mesentery and bowel cause obstruction of the colon lumen.
 Sigmoid volvulus
Diagnosis
a. History usually indicates increasing abdominal distention, discomfort, and obstipation.
b. Physical examination reveals abdominal distention and tympany.
c. Abdominal radiographs usually show a massively distended loop of bowel, with both ends in
the pelvis and the bow near the diaphragm (i.e., bent inner tube sign).
d. Barium enema reveals the pathognomonic obstructing twist (i.e., ace of spades or bird’s beak
deformity).
Treatment
a. Sigmoidoscopic decompression is indicated for nonstrangulated sigmoid volvulus. This
procedure should be terminated if necrotic mucosa is observed or if the volvulus cannot be reduced
by gently inserting a rubber tube through the sigmoidoscope past the point of torsion. If the tube
successfully reduces the volvulus, it should be left in the sigmoid and taped to the skin of the thigh to
prevent immediate recurrence.
b. Sigmoidectomy with colostomy (Hartmann's operation) is indicated if decompression cannot
be achieved or if there is gangrenous bowel.
c. Elective sigmoidectomy with colorectal anastomosis is recommended after the bowel has
been decompressed and prepared as usual for colonic resection.
Algorithm for the
management of
volvulus
 Caecal volvulus
Caecal volvulus occurs much less frequently than sigmoid volvulus. It occurs most
commonly in women, and patients are often younger than 40 years.
Aetiology.
A congenital anatomic anomaly is required for caecal volvulus.
a. Incomplete peritoneal fixation of the right colon is required for the caecum and right
colon to have the mobility to form a volvulus.
b. Other contributing factors may include:
(1) Cancer of the distal colon
(2) Midgut nonrotation
(3) Adhesions from previous surgery
Pathogenesis.
The caecum and ascending colon usually twist clockwise. Bowel and vascular obstruction
occur in a manner similar to that described for sigmoid volvulus.
 Caecal volvulus
Diagnosis
a. History usually indicates increasing abdominal pain. Diarrhea may have occurred initially,
Obstipation follows.
b. Physical examination reveals abdominal distention and tympany. Percussion tenderness suggests
gangrenous bowel.
c. Abdominal radiographs reveal a large, distended caecum that may occupy the left upper
quadrant.
d. Barium enema reveals the ace of spades or bird's beak deformity.
Treatment
a. Right colectomy with ileotransverse colonic anastomosis is generally indicated if the bowel is
viable.
b. Colonoscopic decompression has been successfully performed, but right colectomy is still
indicated to prevent recurrence.
c. Caecopexy is an alternative to right colectomy, but recurrence rates have been high in some
reports.
Caecal volvulus.
Caecal volvulus
Caecal volvulus
Caecal Volvulus.
Image shows
swirling of the
mesenteric
vessels
Coffee bean
sign seen
here to the
left
originating in
the
left lower
quadrant
extending up
toward the
right upper
quadrant,
characteristic
of sigmoid
volvulus.
Conversely,
caecal
volvulus with
dilated colon
pointed back
up toward
left upper
quadrant.
Volvulus of
the
sigmoid
Ischaemic caecal
volvulus.
(coreb topics in
emergency)
 Caecal bascule
• A condition in which caecum folds in a cephalad direction
anteriorly over a fixed ascending colon
• Caecal bascule commonly causes intermittent bouts of abdominal
pain
• Mobile caecum permits intermittent episodes of isolated caecal
obstruction that are spontaneously relieved as the caecum falls back
into its normal position
Comparison of caecal and sigmoid volvulus
Caecal volvulus Sigmoid volvulus

Incidence Less common Commoner

More in females Equal frequency in both sexes
Younger age group In fifth decade
Cause Lack of fixation of the caecum to the Long and floppy mesentery, narrow base of origin of
retroperitoneum. mesocolon
Predisposing factors Previous surgery Old age
Pregnancy Chronic constipation
Malrotation. Neurologically impaired or psychiatric patients
Obstructing lesions of the left colon. Diet high in fibres and fresh vegetables

Rotation Clockwise direction Commonly anticlockwise.

Clinically Sudden onset of abdominal pain Sudden onset of abdominal pain
Asymmetric distension Markedly distended and tympanitic abdomen
Palpable tympanitic mass in left upper
quadrant or mid abdomen
Features of small bowel obstruction
Comparison of caecal and sigmoid volvulus
Caecal volvulus Sigmoid volvulus
Plain X-ray Dilated caecum displaced to the left side Marked dilated sigmoid colon rather central in
of the abdomen position
Caecum has a gas – filled comma shape Dilated sigmoid with the appearance of a bent
or kidney bean shape , the concavity of inner tube or coffee bean appearance, the inferior
which faces inferiorly and to the right convergence of the dilated loop points towards
left side of the pelvis
Contrast enema To confirm the diagnosis and to exclude Demonstrates the point of obstruction with the
a carcinoma of the distal bowel as a pathognomonic “bird’s beak” or “bird of prey” or
precipitating cause of volvulus. “ace of spades” sign
Treatment Resuscitation Resuscitation
No role for endoscopic decompression Endoscopic decompression and detorsion
Laparotomy and right hemicolectomy If successful detorsion—colectomy after patient
( high recurrence rate with attempt at stabilizes (50% recurrence)
caecopexy If detorsion fails –laparotomy and sigmoidectomy
( no role for sigmoidopexy)
If gangrenous bowel—colectomy with If gangrene or perforation—Colectomy with no
ileostomy anastomosis.
 Further readings
1) Baker CR, Reese G and Teo JTH (2010): Intestinal obstruction in Rapid Surgery
published by Wiley- Blackwell second edition p 33-36
2) Grace PA and Borley NR (2013): Intestinal obstruction in Surgery at a glance
published by Wiley-Blackwell fifth edition p128-129
3) Jarrell BE and Carabasi RA (2008);: Intestinal obstruction in NMS(national
medical series for independent study) published by Walters Kluwer/ Lippincott
Williams and Wilkins Fifth edition p 186-187
4) Juza RM and Alli VV (2019): Small bowel obstruction in Clinical algorithms in
general surgery a practical guide edited by Docomi S JR and Pauli EM , published by
Springer Nature Switzerland first edition p175-180
5)Kulayat AS and Stewert DBJr(2019): Management of large bowel obstruction in
Clinical algorithms in general surgery a practical guide edited by Docomi S JR and
Pauli EM , published by Springer Nature Switzerland first edition p213-216
Thank you