SECOND YR (RGN)

SURGERY II

TOPIC : INTESTINAL OBSTRUCTION

GROUP ONE:

Abubakar Suela Jumai

Ackahenrewie Emmanuel

Adam Michael

Addo Viviene

Adjei Kwabena Ebenezer

MACROSCOPIC STRUCTURE OF THE INTESTINES

INTESTINAL OBSTRUCTION

Intestinal obstruction is a partial or complete blockage of the bowel that prevents the
contents of the intestine from passing through. Or

Refers to any pathologic impediment to the normal flow of intestinal contents through the
intestinal tract.

Intestinal obstruction is most likely after abdominal surgery or in persons with congenital
bowel deformities.

It may occur in the small or large intestine and can be partial or complete. It is commonly a
medical emergency, and needs immediate intervention.
PATHOPHYSIOLOGY

Bowel obstruction occurs when the normal flow of intraluminal contents is interrupted. The
cause of the obstruction may be external to the bowel (extrinsic), within the wall of the
bowel (intrinsic), or due to a luminal defect that prevents the passage of gastrointestinal
contents. Obstruction of the small intestine can be partial or complete. A closed-loop
obstruction, occurs when the intestine is obstructed at two locations. Closed-loop
obstruction can rapidly progress to bowel strangulation.
EPIDEMIOLOGY

Acute, mechanical small bowel obstruction is a common surgical emergency. Intestinal

obstruction accounts for about 20% of all admissions to the surgical service.

It is estimated that over 300,000 laparotomies per year are performed in the United States
for adhesion-related obstructions. Ischemia, which complicates 7 to 42 percent of bowel
obstructions, significantly increases mortality associated with bowel obstruction.

The small bowel is involved in about 80 percent of cases of mechanical intestinal

obstruction. The incidence is similar for males and females.
OBSTRUCTION MECHANISMS

The flow can be impeded by two types of processes, that is: mechanical or non-
mechanical(ileus or functional) intestinal obstruction.
 Mechanical obstruction:

This is a physical block to the passage of the intestinal content. It can result from inside the
lumen i.e. there is an intra-luminal obstruction from pressure of the intestinal walls or
outside the lumen and could occur at one point or at several points, that is simple
mechanism or closed-loop.

Examples of mechanical obstruction are:

 Adhesions
 Strangulated hernias (portions of intestine that protrude into another part of your body).
 Tumours (usually associated with large bowel obstruction).
 Foreign bodies: such as fruit pits, or worms.
 Gall stones (> 2.5 cm)
 Congenital bowel stenosis

 Atresia of the bowel

 Imperforate anus
 Intussusceptions,
 Volvulus (Twisting of the intestine)
 Impacted stool
 Inflammatory bowel diseases (Crohn's disease)
 Diverticulitis — a condition in which small, bulging pouches (diverticula) in the digestive
tract become inflamed or infected
 Amyloidosis ( amyloid - waxy compound of protein and polysaccharides)
 b. Non-mechanical / Functional Obstruction:

It is due to a neuro-muscular and vascular defect and it is the most common of the
intestinal obstruction. The intestinal musculature cannot propel the content along the
bowel. Interrupted blood supply give rise to mesenteric thrombosis.

Examples are:
 Paralytic ileus (the most common intestinal obstruction)
 Decreased blood supply to the abdominal area (mesenteric artery ischemia).
 Injury to the abdominal blood vessels (causing tissue necrosis).
 Intra-abdominal infection.
 Use of certain medications, esp. narcotics.(anticholinergic effects)
 Neurogenic abnormalities: (such as spinal cord lesions.)
 SIGNS AND SYMPTOMS

 Hiccups and bad breath are a common complaint in all types of obstruction.
 Other specific s/s depends on the cause of obstruction.
 a. Mechanical obstruction of small bowels:

 Crampy, colicky abdominal pain.

 Passage of bloody and mucus stool with no faecal matter or flatus.
 Nausea.
 Vomiting (If the obstruction is complete, patient may vomit faecal contents.)
 Signs of dehydration including intense thirst, body aches, parched tongue and dry mucous
membrane, etc.
 Constipation (complete)
 Diarrhoea (partial)
 Distended abdomen on inspection (the hallmark of all types of mechanical obstruction).
 Abdominal tenderness, or rebound tenderness in an obstruction that is due to strangulation
or ischemia.

b. Mechanical obstruction of the large bowels:

S/S is more gradual than in small bowel obstruction.

 Constipation (complete)
 Diarrhoea (partial)
 Bloody stool
 Sudden colicky abdominal pains several days after constipation begin. This produces spasms
that last less than 1 minute and recur every few minutes.
 Constant hypogastric pain.
 Nausea, weakness, weight loss
 Vomiting in the latter stages.
 Inspection reveals a dramatically distended abdomen, with visible loops of large bowel.
 Auscultation may reveal loud, high-pitched borborygmi.
 In Non mechanical obstruction, such as paralytic ileus, patients usually
describe:

 Diffused abdominal discomfort, instead of colicky pain.

 Vomiting (may consist of gastric and bile contents and, rarely, faecal content)
 severe abdominal pain,
 distended abdomen,
 decreased bowel sounds
 Constipation (complete)
 Diarrhoea (partial)

DIAGNOSTIC INVETIGATIONS

 Patients history and physical examination

 Abdominal x-rays and CT scan: confirm intestinal obstruction and reveal the presence and
location of intestinal gas or fluid or both.
 Sigmoidoscopy, colonoscopy, or a barium enema may help determine the cause of
obstruction. These are contraindicated if perforation is suspected.
 Complete blood cell count: decreases plasma volume and possible infection).
 Electrolyte studies ;(Serum sodium, chloride, and potassium etc) levels may fall because of
vomiting and, reveal a picture of dehydration,
 WBC count: may be normal or slightly elevated if necrosis, peritonitis, sepsis, perforation
or strangulation occurs.
 Serum amylase level: may increase possibly from irritation of the pancreas by a bowel loop.

TREATMENT

Surgery is usually the treatment of choice. An important exception however, is in paralytic

ileus where non operative therapy is tried first.

Surgical Interventions:

1. Colostomy(mostly for cancer obstruction)

2. Surgical resection: to remove the obstruction lesion
3. Ileal pouch-anal anastomosis (IPAA). [The lining of the rectum is removed, and the lower
end of the small intestine (the ileum) is attached to the opening of the anus]
4. Caecostomy: It may be performed in patients who have poor surgical risk and urgently
need relief from the obstruction.
 Pre operative Care

 Nil per os and if surgery won’t be performed, small ice chips may be allowed.
 Keep patient in semi or Fowlers position as much as possible to promote pulmonary
ventilation and ease respiratory distress from the distension.
 Correct fluid and electrolyte imbalances by administering the prescribed IV fluids.
 Decompress the bowel by Passing NG tube attached to continuous suction to relieve
vomiting, reduce abdominal distension and prevent aspiration.
 Irrigate suction tube with normal saline if necessary to maintain patency.
 Monitor and treat for shock.
 Administer prescribed analgesics such as diclofenac, broad spectrum antibiotics such as
ceftriaxone and other medications as ordered. Note that analgesics may be delayed until a
diagnosis is confirmed.
 Begin and maintain IV therapy as ordered. Provide blood and fluid replacement taking care
to maintain normal range.
 If you suspect bladder compression, catheterize to remove residual urine immediately after
patient voids.

Postoperative Care

 Ensure bowel sound returns and start oral fluids such as Glucose solution.
 Maintain fluid and electrolyte balance through IV replacement therapy, and check the
patient regularly for signs of dehydration such as decreased urine output and poor skin
turgor.
 For the first few days after surgery, carefully monitor the intake and output and weigh the
patient daily.
 Keep the NG tube patent. Warn the patient that, if the tube becomes dislodged, he/she
should never attempt to reposition it, as doing so could damage the anastomosis.
 Provide frequent mouth care to help keep the mucous membranes moist.
 Check vital signs such as temperature, respiration, apical pulse and blood pressure 15min
for 1st 30min, 30min for 1hr, 2hrly record and report any deviation to the nurse in charge.
 Observe the patient for signs of peritonitis or sepsis, caused by leakage of bowel contents
into the abdominal cavity.

 Continually assess the patient’s pain. A colicky pain that suddenly becomes constant could
signal perforation.
 Watch for signs of metabolic alkalosis (change in sensorium; slow, shallow respiration;
hypertonic muscles; tetany), or acidosis (shortness of breath; disorientation; and, later,
deep rapid breathing; and malaise).
 Monitor urine output carefully to assess renal function, circulating blood volume, and
possible urine retention due to bladder compression by the distended intestine.
 Auscultate for bowel sounds, and watch out for signs of resuming peristalsis (passage of
flatus, faeces, or mucus from the rectum).
 Measure abdominal girth frequently to detect progressive distension, and examine for
rigidity which may indicate post resection obstruction.
 Once the patient regains peristalsis and bowel function, take steps to prevent constipation
and straining during defecation, both of which can damage the anastamosis. Encourage
patient to drink plenty of fluids and administer stool softeners or other laxatives as ordered.
 Note and record the frequency and amount of all bowel movements as well as the
characteristics of the stool.

 Encourage deep breathing and coughing to prevent atelectasis, remind patient to splint the
incision site when coughing.
 Complication

 Intestinal perforation
 Peritonitis
 Secondary Infection
 Metabolic alkalosis or acidosis
 Hypovolemic shock or septicaemia
 If untreated, death
 Education Upon Discharge

 Instruct the patient to record the frequency and character of bowel movements and to
return when there are any changes in normal pattern. Warn patient against using laxatives
without consulting the doctor.
 Caution the patient to avoid abdominal straining and heavy lifting until the sutures are
completely healed and the doctor gives permission to do so.
 Instruct the patient to maintain the prescribed semi bland diet (foods that are generally
soft, low in dietary fiber, cooked rather than raw, and not spicy.) until the bowel has healed
completely (usually 4-8 weeks after surgery). In particular, urge patient to avoid carbonated
beverages and gas producing foods.
 Because extensive bowel resection may interfere with the patient’s ability to absorb
nutrients from food, emphasize the importance of taking prescribed vitamin supplements.
 Encourage patient and significant others to keep with follow up schedule.

REFERENCE:
[Link]
[Link] .com
[Link]
[Link]/org