Intestinal obstruction
Prof. Soria
DEFINITION:
It is the condition in which the normal progression of the
intestinal content is partly or completely blocked due either to
a mechanical factor or peristalsis impairment.
CLASSIFICATION
• Dynamic (peristalsis is working).
• Adynamic (peristalsis may be absent - e.g.
paralytic ileus; or it may be present in a non-
propulsive form - e.g. mesenteric vascular
occlusion or pseudo-obstruction).
In both types a mechanical element is absent .
Classification
• Depending on absence/presence of peristalsis
• Dynamic IO
• Small Bowel
• High Small Bowel
• Low Small Bowel
• Large Bowel
• Adynamic IO ( rare)
• Depending on time of onset
• Acute
• Sub-acute
• Chronic
• Depending on interference in blood supply
• Simple
• Strangulated
Causes of intestinal obstruction
Dynamic
■ Intraluminal
o Impaction
o Foreign bodies
o Bezoars
o Gallstones
■ Intramural
o Stricture
o Malignancy
■ Extramural
o Bands/adhesions
o Hernia
o Volvulus
o Intussusception
Adynamic
o
Paralytic ileus
o
Mesenteric vascular occlusion
o
Pseudo-obstruct
Mechanisms of obstruction
■ Volvulus
■ Incarceration
■ Obstruction
■ Intussusception
Pathophysiology
• With onset of obstruction, gas and fluid accumulate within the
intestinal lumen proximal to the site of obstruction
• Increased in intestinal activity to overcome the obstruction,
accounting for the colicky pain and the diarrhea
• Accumulation of the gas originates from swallowed air, although some
is produced within the intestine (overgrowth of aerobic and anaerobic
organisms)
• The fluid consists of swallowed liquids and gastrointestinal secretions
(obstruction stimulates intestinal epithelial water secretion).
• Lead to bowel distension and intraluminal and intramural pressures rise
• And intestinal motility is eventually reduced with fewer contractions
• If the intramural pressure becomes high enough, intestinal microvascular
perfusion is impaired, leading to intestinal ischemia and, ultimately,
necrosis. This condition is termed strangulated bowel obstruction
• With partial small bowel obstruction,
• only a portion of the intestinal lumen is occluded, allowing passage of some gas
and fluid.
• The progression of pathophysiologic events described earlier tends to occur more
slowly than with complete small bowel obstruction, and development of
strangulation is less likely
• A particularly dangerous form of bowel obstruction is closed-loop
obstruction in which a segment of intestine is obstructed both
proximally and distally (e.g., with volvulus).
Clinical Presentation
• The symptoms of small bowel obstruction are
• colicky abdominal pain,
• nausea,
• vomiting, and
• obstipation.
• Vomiting
• More in proximal than distal obstruction
• The character of vomitus is important because with bacterial overgrowth, the
vomitus is more feculent, suggesting a more established obstruction
• Continued passage of flatus and/or stool beyond 6 to 12 hours after onset
of symptoms is characteristic of partial rather than complete obstruction
• The signs of small bowel obstruction include
• abdominal distention, which is most pronounced in the distal ileum and may
be absent in the proximal small intestine.
• Bowel sounds may be hyperactive initially, but in late stages, minimal bowel
sounds may be heard
• Laboratory findings reflect intravascular volume depletion and consist
of hemoconcentration and electrolyte abnormalities. Mild
leukocytosis is common.
• Features of strangulated obstruction include abdominal pain often
disproportionate to the degree of abdominal findings, suggestive of
intestinal ischemia.
• Patients often have tachycardia, localized abdominal tenderness, fever,
marked leukocytosis, and acidosis.
• Any of these findings should alert the clinician to the possibility of
strangulation and need for early surgical intervention.
Diagnosis
• The diagnostic evaluation should focus on the following goals:
a. distinguish mechanical obstruction from ileus,
b. determine the etiology of the obstruction,
c. discriminate partial from complete obstruction, and
d. discriminate simple from strangulating obstruction.
• Important elements to obtain on history include
• prior abdominal operations (suggesting the presence of adhesions) and the
presence of abdominal disorders (e.g., intra-abdominal cancer or inflammatory
bowel disease) that may provide insights into the etiology of obstruction.
• Upon examination, a meticulous search for hernias (particularly in the
inguinal and femoral regions) should be conducted.
• The diagnosis of small bowel obstruction is usually confirmed with
radiographic examination.
• The abdominal series consists of
(a) a radiograph of the abdomen with the patient in a supine position,
(b) a radiograph of the abdomen with the patient in an upright position, and
(c) a radiograph of the chest with the patient in an upright position.
• The finding most specific for small bowel obstruction is the triad of
• dilated small bowel loops
• air-fluid levels seen on upright films, and
• a paucity of air in the colon.
Therapy
• Small bowel obstruction is usually associated with a marked depletion of
intravascular volume due to decreased oral intake, vomiting, and
sequestration of fluid in bowel lumen and wall
• fluid resuscitation is integral to treatment
• Isotonic fluid should be given intravenously, and
• an indwelling bladder catheter may be placed to monitor urine output
• Broad-spectrum antibiotics are given by some because of concerns that
bacterial translocation may occur in the setting of small bowel obstruction
• The stomach should be continuously evacuated of air and fluid using a
nasogastric (NG) tube
• Effective gastric decompression decreases nausea, distention, and the risk of vomiting
and aspiration.
• “the sun should never rise and set on a complete bowel obstruction.”
Non operative management
• However, conservative therapy, in the form of NG decompression and
fluid resuscitation, is commonly recommended in the initial
recommendation for:
1. Partial small bowel obstruction
2. Obstruction occurring in the early postoperative period
3. Intestinal obstruction due to Crohn’s disease
4. Carcinomatosis