Intestinal obstruction

Terefe Meshesha, MD, FRCAS

General, upper GI and Laparoscopic surgeon
September 2025
Outline
Introduction
Definition and classification
Etiology
Pathophysiology
Clinical feature
Investigation
Treatment
Objectives

To understand the different classification and

pathophysiology of intestinal obstruction
To understand the clinical presentation and physical
finding of patient with bowel obstruction
To understand the the way of investigation
To understand the treatment option of bowel
obstruction
Introduction
 Intestinal obstruction is one the most common cause of an
acute abdomen
 Small intestinal obstruction is more common than large
intestinal obstruction accounting 60%
 Small intestinal ileus is the most common form of intestinal
obstruction; it occurs after most abdominal operations and is
a common response to acute intra abdominal inflammatory
conditions
 Mechanical small bowel obstruction commonly result from
volvulus, intra-abdominal adhesions, hernias, or cancer
 Mechanical colonic obstruction most often develops in
response to volvulus, carcinoma, diverticulitis.
 Acute colonic pseudo-obstruction occurs most frequently in
the postoperative period or in response to another acute
medical illness.
 When the bowel is occluded at a single point along the intestinal
tract, simple obstruction is present.
 When a segment of bowel is occluded at two points along its course
by a single constrictive lesion that occludes both the proximal and
the distal end of the intestinal loop as well as traps the bowel’s
mesentery, closed-loop obstruction is present.
 When the blood supply to a closed-loop segment of bowel becomes
compromised, leading to ischemia and eventually to bowel wall
necrosis and strangulation
 The most common causes of simple obstruction are intra-abdominal
adhesions, tumors, and strictures.
 The most common causes of closed-loop obstruction are hernias,
band/adhesions, and volvulus.
 Definition and classification
Definition : Arrest of downward propulsion of intestinal content
Classification :
According to :
 Nature of obstruction or vascular compromise
simple intestinal obstruction
strangulated intestinal obstruction
Level of obstruction
high small intestinal obstruction
low small intestinal obstruction
large intestinal obstruction
Onset and course of obstruction
Acute
Chronic
Degree of obstruction
Complete
Incomplete

;
 Aetiology of obstruction : Dynamic vs adynamic
Dynamic obstruction
cause is in the lumen .
Faecal impaction, gall stone ileus, or pedunculated
tumor
cause is in the wall.
atresia, crohns disease, benign or malignant
tumors.
cause is outside the wall
strangulated hernia, volvulus, adhesions or bands.
Adaynamic obstruction
Postoperative ileus
Electrolyte and metabolic disturbance
Post inflammatory/infection, drugs
Etiology according to age
Etiology according to the site of obstruction
Cause of small intestinal obstruction
 Adhesion and bands
 Volvulus
 Hernias
 Inflammatory bowel disease
 Intussusception
 Neoplasms
Cause of large intestinal obstruction
 Volvulus
 Neoplasms
 Fecal impaction
 Diverticular disease
 Foreign bodies
 Pathophysiology
 Early in the course of an obstruction, intestinal motility and
contractile activity increase in an effort to propel luminal contents
past the obstructing point. Later in the course of obstruction, the
intestine becomes fatigued and dilates, with contractions
becoming less frequent and less intense.
 As the bowel dilates, water and electrolytes accumulate both
intraluminally and in the bowel wall itself. This massive third-
space fluid loss accounts for the dehydration and hypovolemia.
 The metabolic effects of fluid loss depend on the site and duration of the
obstruction. With a proximal obstruction, dehydration may be accompanied
by hypochloremia, hypokalemia, and metabolic alkalosis associated with
increased vomiting. Distal obstruction of the small bowel may result in large
quantities of intestinal fluid into the bowel; however, abnormalities in
serum electrolytes are usually less dramatic.
 Oliguria, azotemia, and hemoconcentration can accompany the
dehydration. Hypotension and shock can ensue. Other consequences of
bowel obstruction include increased intra-abdominal pressure, decreased
venous return, and elevation of the diaphragm, compromising ventilation.

Source of fluid accumulation Source of gas accumulation

Swallowed air…N2, O2, CO2
secretion absorption
Bacterial biproduct...H2S
Oral intake 2000ml Diffusion from blood…Co2, O2
saliva 1500ml
Gastric juice 2500ml
bile 500ml
pancreatic 1500ml
Small intest 1000 7500ml
Large intes 1500ml
 As the intraluminal pressure increases in the bowel, a decrease in
mucosal blood flow can occur. These alterations are particularly
noted in patients with a closed-loop obstruction in which greater
intraluminal pressures are attained. A closed-loop obstruction,
produced commonly by a twist of the bowel, can progress to
arterial occlusion and ischemia if left untreated and may
potentially lead to bowel perforation and peritonitis.
 Stasis leads to bacterial growth and multiplication, which releases
toxins that will impair mucosal secretion and absorption. There is
also bacterial translocation to mesenteric lymph nodes and even
systemic organs. However, the overall importance of this
bacterial translocation on the clinical course has not been entirely
defined.
 Clinical picture
 Cardinal symptom
 Abdominal pain
 Distention
 Vomiting
 Absolute constipation
The nature of the presentation will be influenced by the site
In high small bowel obstruction
 Abdominal pain is moderate to severe
 vomiting occurs early and is profuse with rapid dehydration.
 Distension is minimal with little evidence of fluid levels on
abdominal radiography
In low small bowel obstruction,
 pain is predominant with central distension.
 Vomiting is delayed. Multiple central fluid levels are seen on
radiography
In large bowel obstruction
 Distension is early and pronounced.
 Pain is mild
 vomiting and dehydration are late.
 The proximal colon and caecum are distended on abdominal
radiography
The nature of the presentation will also be influenced by whether
the obstruction is: • acute;• chronic;• acute on chronic;•
subacute.
Acute obstruction usually occurs in small bowel obstruction, with
sudden onset of severe colicky central abdominal pain, early
vomiting, late distension and constipation
Chronic obstruction is usually seen in large bowel obstruction, with
lower abdominal colic and absolute constipation followed by
distension.
 Common clinical presentation
 The typical crampy abdominal pain associated with intestinal
obstruction occurs in paroxysms at 4 – 5 minute interval and
occurs less frequently with distal obstruction. It is usually centred
on the umbilicus (small bowel) or lower abdomen (large bowel).
With increasing distension, the colicky pain is replaced by a mild
constant diffuse pain.
 The development of severe persistant pain is indicative of the
presence of strangulation. Pain may not be a significant feature in
postoperative simple mechanical obstruction and does not usually
occur in paralytic ileus.
Nausea and vomiting are more common with a higher obstruction
and may be the only symptoms in patients with gastric outlet or
high intestinal obstruction. An obstruction located distally is
associated with less emesis, and the initial and most prominent
symptom is the cramping abdominal pain.
As obstruction progresses the character of the vomitus alters
from digested food to faeculent material, as a result of the
presence of enteric bacterial overgrowth.
 In the small bowel the degree of distension is dependent on the site of
the obstruction and is greater the more distal the lesion. Visible
peristalsis may be present. Distension is delayed in colonic obstruction
and may be minimal or absent in the presence of mesenteric vascular
occlusion.
 Constipation may be classified as absolute (i.e. neither faeces nor
flatus is passed) or relative (where only flatus is passed). Absolute
constipation is a cardinal feature of complete intestinal obstruction.
Some patients may pass flatus or faeces after the onset of obstruction
as a result of the evacuation of the distal bowel contents. The rule
that constipation is present in intestinal obstruction does not apply in:
• Richter’s hernia; gallstone obturation; mesenteric vascular
occlusion; obstruction associated with pelvic abscess; partial
obstruction (faecal impaction/colonic neoplasm) in which diarrhoea
may often occur.
 Physical Examination
 The patient with intestinal obstruction may present with tachycardia
and hypotension, demonstrating the severe dehydration that is present.
 Fever suggests the possibility of strangulation.
 Abdominal examination demonstrates a distended abdomen, with the
amount of distention some what dependent on the level of obstruction.
Previous surgical scars should be noted. Early in the course of bowel
obstruction, peristaltic waves can be observed, particularly in thin
patients, and auscultation of the abdomen may demonstrate
hyperactive bowel sounds with audible rushes associated with vigorous
peristalsis (i.e., borborygmi). Late in the obstructive course, minimal or
no bowel sounds are noted.
 Mild abdominal tenderness may be present with or without a
palpable mass; however, localized tenderness, rebound, and
guarding suggest peritonitis and the likelihood of
strangulation.
 A careful examination must be performed to rule out
incarcerated hernias in the groin, the femoral triangle, and
the obturator foramen.
 A rectal examination should be performed to assess for
intraluminal masses and to examine the stool for occult
blood, which may be an indication of malignancy,
intussusception, or infarction.
 Strangulation
• “Classic” picture of strangulation include
 constant, noncrampy abdominal pain
 tenderness with rigidity
 Fever
 tachycardia
 low blood pressure
 leukocytosis.
• In cases of intestinal obstruction in which pain persists despite
conservative management, even in the absence of the above signs,
strangulation should be diagnosed.
• When strangulation occurs in an external hernia, the lump is tense,
tender and irreducible, there is no expansile cough impulse and it has
recently increased in size.
Pathology
The venous return is compromised before the arterial supply.
The resultant increase in capillary pressure leads to local
mural distension with loss of intravascular fluid and red blood
cells intramurally and extraluminally. Once the arterial supply
is impaired, haemorrhagic infarction occurs
As the viability of the bowel is compromised there is marked
translocation and systemic exposure to anaerobic organisms
with their associated toxins.
Causes of strangulation
External:
 Hernia
 Adhesions/bands
Interrupted blood flow
 Volvulus
 Intussusception
Increased intraluminal pressure
 Closed-loop obstruction
Primary
 Mesenteric infarction
Closed-loop obstruction
This occurs when the bowel is obstructed at both the proximal and
distal points.
It is present in many cases of intestinal strangulation. Unlike cases of
non-strangulating obstruction, there is no early distension of the
proximal intestine. When gangrene of the strangulated segment is
imminent, retrograde thrombosis of the mesenteric veins results in
distension on both sides of the strangulated segment.
A classic form of closed-loop obstruction is seen in the presence of a
malignant stricture of the right colon with a competent ileocaecal
valve (present in up to one-third of individuals). The inability of the
distended colon to decompress itself into the small bowel results in
an increase in intraluminal pressure, which is greatest at the
caecum, with subsequent impairment of blood supply. Unrelieved,
this results in necrosis and perforation
 Investigations
 Complete Blood count
 Renal function test and serum electrolyte
 Plain X ray of the abdomen: Radiological features of obstruction
 The obstructed small bowel is characterised by straight segments
that are generally central and lie transversely. No gas is seen in the
colon
 The jejunum is characterised by its valvulae conniventes, which
completely pass across the width of the bowel and are regularly
spaced, giving a ‘concertina’ or ladder effect
 Ileum – the distal ileum has been described as featureless
 Caecum – a distended caecum is shown by a rounded gas shadow in
the right iliac fossa
 Large bowel, except for the caecum, shows haustral folds, which,
unlike valvulae conniventes, are spaced irregularly, do not cross the
whole diameter of the bowel and do not have indentations placed
opposite one another
 U.S.
 CT scan
 Endoscopy
Erect plain abdominal Xray

Plain abdominal x ray finding of small bowel obstruction

Dilated loop of intestine >3cm but < 6cm
Multiple air fluid level
Centrally located
Valvulae conniventes
Large intestinal obstruction on x ray

Plain abdominal x ray finding of large bowel obstruction

Dilated loop of intestine > 6cm
Peripherally located loop
Few air fluid level
Haustral marking
 Treatment
The treatment is urgent relief of obstruction after preparation
Preoperative preparation ( fluid and electrolyte replacement ,antibiotics,
analgesics and Tube Decompression )
Operation :exploration
Immediate operation indicated in peritonitis, incarcerated hernia,
suspected or confirmed strangulation, sigmoid volvulus with systemic
toxicity or peritoneal irritation, small bowel volvulus, colonic volvulus
above sigmoid,
Conservative treatment of obstruction
Indication
 Adhesion
 Ileocaecal itussusception
 Sigmoid volvuls
 Feacal impaction
Conservative treatment of obstruction
 Reassess patient every 4 hr. Look for changes in pain, abdominal
findings and volume and character of NG aspirate.
 Repeat abdominal x-rays, and look for changes in air fluid level and the
presence of free intraperitoneal air.
 Classify patient’s condition as improved, unchanged, or worse.
 Decide whether operative treatment is necessary and, if so, whether it
should be done on urgent or elective basis.
Urgent operation Indications include:
 Lack of response to 24–48 hr of nonoperative therapy
(increasing abdominal pain, distention, or tenderness;
 NG aspirate changing from nonfeculent to feculent; ↑
proximal small bowel distention with ↓ distal gas).
 Treatment
Fluid Resuscitation and Antibiotics
 Patients with intestinal obstruction are usually dehydrated and depleted
of sodium, chloride, and potassium, requiring aggressive intravenous
replacement with an isotonic saline solution such as lactated Ringer’s.
 Urine output should be monitored by the placement of a Foley catheter.
 After the patient has formed adequate urine, potassium chloride should
be added to the infusion if needed. Serial electrolyte measurements, as
well as hematocrit and white blood cell count, are performed to assess
the adequacy of fluid repletion.
 Broad-spectrum antibiotics are given prophylactically by some surgeons
based on the reported findings of bacterial translocation occurring even
in simple mechanical obstructions. In addition, antibiotics are
administered as a prophylaxis for possible resection or inadvertent
enterotomy at surgery.
 Treatment
Tube Decompression and follow-up
 Nasogastric suction empties the stomach, reducing the hazard of
pulmonary aspiration of vomitus and minimizing further intestinal
distention from preoperatively swallowed air. Patients with adhesive
simple intestinal obstruction may be treated conservatively with
resuscitation and tube decompression alone. Resolution of symptoms
and discharge without the need for surgery have been reported in 60%
to 85% of patients with an adhesive simple intestinal obstruction .
 Although an initial trial of non operative management of most patients
with partial small bowel obstruction is warranted, it should be
emphasized that clinical deterioration of the patient or increasing small
bowel distention on abdominal radiographs during tube decompression
warrants prompt operative intervention.
 Non strangulated sigmoid volvulus is managed by insertion of rectal
tube deflation .
 Special forms
 Intussusceptions
 Volvulus
 Paralytic illeus
 mesenteric vascular occlusion
 Pseudo-intestinal obstruction
References

Baily and Love, short practice of Surgery

Schewart’s, principle of surgery
Sabston, text book of surgery