dr. H.
ACHMAD FUADI, SpB-KBD, MKes
1. Definition 2. Sites of obstruction Small bowel Large bowel 3. Causes of the obstruction Lesions extrinsic to the bowel wall Lesions intrinsic to the bowel wall Intraluminal obturator lesions 4. Types of intestinal obstruction Mechanical obstruction vs. Adynamic ileus Partial vs. Complete Simple vs. Strangulated High vs. low Small bowel vs colon 5. Clinical picture Radiogical tests Fluid and electrolyte status 6. Treatment of intestinal obstruction
INTERRUPTION IN THE PASSAGE OF INTESTINAL CONTENTS
1. Definition 2. Sites of obstruction Small bowel Large bowel 3. Causes of the obstruction Lesions extrinsic to the bowel wall Lesions intrinsic to the bowel wall Intraluminal obturator lesions 4. Types of intestinal obstruction Mechanical obstruction vs. Adynamic ileus Partial vs. Complete Simple vs. Strangulated High vs. low Small bowel vs colon 5. Clinical picture Radiogical tests Fluid and electrolyte status 6. Treatment of intestinal obstruction
Small Bowel vs. Large Bowel
Scenario
prior operations, change in bowel habits Clinical picture nausea, vomiting, flatus (-), defecation (-), scars, masses/ hernias, amount of distension, Radiological studies gas in colon, volvulus, transition point, mass (Almost) always operate on LBO, often treat SBO non-operatively
Common Causes of Small Bowel Obstruction (SBO) 60% Adhesions 20% Neoplasms 10% Hernias 5% Crohns 5% Miscellaneous
Common Causes of Large Bowel Obstruction (LBO) Colon cancer Diverticulitis Volvulus frequency Hernia Unlike SBO, adhesions very unlikely to produce LBO
1. Definition 2. Sites of obstruction Small bowel Large bowel 3. Causes of the obstruction Lesions extrinsic to the bowel wall Lesions intrinsic to the bowel wall Intraluminal obturator lesions 4. Types of intestinal obstruction Mechanical obstruction vs. Adynamic ileus Partial vs. Complete Simple vs. Strangulated High vs. low Small bowel vs colon 5. Clinical picture Radiogical tests Fluid and electrolyte status 6. Treatment of intestinal obstruction
Outside the wall Inside the wall Inside the lumen
Adhesions (usually postoperative)
Lesions Extrinsic to Intestinal Wall
Hernia External (e.g., inguinal, femoral, umbilical, or ventral hernias) Internal (e.g., congenital defects such as paraduodenal, foramen of Winslow, and diaphragmatic hernias or postoperative secondary to mesenteric defects) Neoplastic Carcinomatosis, extraintestinal neoplasm Intra-abdominal abscess/ diverticulitis Volvulus (sigmoid, small bowel)
Lesions Intrinsic to Intestinal Wall
Congenital Malrotation Duplications/cysts Traumatic Hematoma Ischemic stricture Infections Tuberculosis Actinomycosis Diverticulitis
Neoplastic Primary neoplasms Metastatic neoplasms Inflammatory Crohn's disease Miscellaneous Intussusception Endometriosis Radiation enteropathy/stricture
CT scan of a patient with Crohn's disease demonstrates marked thickening of the bowel (arrows) with a highgrade partial small bowel obstruction and dilated proximal intestine.
Resection of the ileum, ileocecal valve, cecum, and ascending colon for Crohn's disease of the ileum. Intestinal continuity is restored by end-to-end anastomosis.
Barium radiograph demonstrates a typical "apple-core" lesion (arrows) caused by adenocarcinoma of the small bowel, producing a partial obstruction with dilated proximal bowel.
Large circumferential mucinous adenocarcinoma of the jejunum.
Mesenteric metastases from a carcinoid tumor of the small bowel.
Gross pathologic features of Crohn's disease. A, Serosal surface demonstrates extensive "fat wrapping" and inflammation. B, Resected specimen demonstrates marked fibrosis of the intestinal wall, stricture, and segmental mucosal inflammation.
Barium study demonstrates Jejunojejunal intussusception.
Polip, poliposis
Intraluminal/ Obturator Lesions Gallstone Enterolith Bezoar Foreign body
Gall stone
Plain abdominal film demonstrates a number of ingested foreign bodies in a patient presenting with a small bowel obstruction.
1. Definition 2. Sites of obstruction Small bowel Large bowel 3. Causes of the obstruction Lesions extrinsic to the bowel wall Lesions intrinsic to the bowel wall Intraluminal obturator lesions 4. Types of intestinal obstruction Mechanical obstruction vs. Adynamic ileus Partial vs. Complete Simple vs. Strangulated High vs. low Small bowel vs colon 5. Clinical picture Radiogical tests Fluid and electrolyte status 6. Treatment of intestinal obstruction
Adynamic Ileus
vs
Mechanical Obstruction
Gas diffusely through intestine, incl. colon May have large diffuse air fluid levels Quiet abdomen No obvious transition point on contrast study Peritoneal exudate if peritonitis
Large small intestinal loops Definite laddered air fluid levels Tinkling, quiet= late Obvious transition point on contrast study No peritoneal exudate
Causes of Adynamic Ileus
Following celiotomy
small bowel- 24h, stomach- 48h, colon- 3-5d Inflammation e.g. appendicitis, pancreatitis Retroperitoneal disorders e.g. ureter, spine Thoracic conditions e.g. pneumonia, fracture of ribs Systemic disorders e.g. sepsis, hyponatremia, hypokalemia, hypomagnesemia Drugs e.g opiates, Ca-channel blockers, psychotropics
Is there strangulation?
4 Cardinal Signs
fever, tachycardia, localized abdominal tenderness, leucocytosis 0/4 0% strangulated bowel 1/4 7% 2-3/4 24% 4/4 67% process accelerated with closed-loop obstruction.
Partial
Flatus Residual colonic gas above peritoneal reflection Adhesions 60-80% resolve with non-operative Mx Must show objective improvement, if none by 48h consider OR
vs
Complete
Complete obstipation No residual colonic gas
Almost all should be operated on within 24h
Characteristics of proximal and distal small bowel obstruction
Proximal Acute onset Vomiting prominent Vomiting not feculent Pain at frequent intervals Distention minimal Distal Less acute onset Less prominent Often feculent Less frequent intervals Noticable
Carcinoma (65 %) Diverticulitis (20 %) Volvulus (5 %) Others (10 %)
Right Colon Anemia Weight loss Palpable mass Fatigue
Left Colon Obstructive symptoms Gross blood in stool Change in bowel habits Characteristic x-ray +sigmoidoscopy
- Constipation-obstipation - Abdominal distention- sometimes tenderness - Abdominal pain - Nausea and vomiting (late) - Characteristic x-ray findings
1. Definition 2. Sites of obstruction Small bowel Large bowel 3. Causes of the obstruction Lesions extrinsic to the bowel wall Lesions intrinsic to the bowel wall Intraluminal obturator lesions 4. Types of intestinal obstruction Mechanical obstruction vs. Adynamic ileus Partial vs. Complete Simple vs. Strangulated High vs. low Small bowel vs colon 5. Clinical picture Radiogical tests Fluid and electrolyte status 6. Treatment of intestinal obstruction
Colicky abdominal pain Abdominal distension Vomiting Decreased passage of stool or flatus Typical radiographic picture
Hypercontractility--hypocontractility Massive third space losses oliguria, hypotension, hemoconcentration Electrolyte depletion bowel distension increased intraluminal pressure impediment in venous return arterial insufficiency
into the bowel lumen into the edematous bowel wall into the peritoneum vomiting or NG suction
Secretion Absorbtion
Nitrogen70% Oxygen 12% CO2 8% Hydrgen 5% N3 4%
The small bowel proximal to a point of obstruction distends with gas and fluid. Swallowed air is the major source of gaseous distention, at least in the early stages, because nitrogen is not well absorbed by mucosa. When bacterial fermentation occurs later on, other gases are produced; the partial pressure of nitrogen within the lumen is lowered, and a gradient for diffusion of nitrogen from blood to lumen is established. Numerous quantities of fluid from the extracellular space are lost into the gut and from the serosa into the peritoneal cavity. Fluid fills the lumen proximal to the obstruction, because the bidirectional flux of salt and water is disrupted and net secretion is enhanced. Mediator substances (eg, endotoxin, prostaglandins) released from proliferating bacteria in the static luminal contents are responsible. Somatostatin effectively inhibits secretion in animal models of intestinal obstruction, but it has no defined role in humans. Reflexly induced vomiting accentuates the fluid and electrolyte deficit. Hypovolemia leads to multiorgan system failure and is the cause of death in patients with nonstrangulating obstruction. Audible peristaltic rushes are manifestations of attempts by the small bowel to propel its contents past the obstruction. The vomitus becomes feculent particularly with distal obstructionas the illness progresses. Bacterial translocation from lumen to mesenteric nodes and the bloodstream occurs even in simple obstruction. Abdominal distention elevates the diaphragm and impairs respiration, so that pulmonary complications are frequent.
Physical findings: I P P A
Lab: Hyponatremia, Hypocloremia, urine osm. met. asc. Leukocytosis ( 1525.000/mm3 )
1. Definition 2. Sites of obstruction Small bowel Large bowel 3. Causes of the obstruction Lesions extrinsic to the bowel wall Lesions intrinsic to the bowel wall Intraluminal obturator lesions 4. Types of intestinal obstruction Mechanical obstruction vs. Adynamic ileus Partial vs. Complete Simple vs. Strangulated High vs. low Small bowel vs colon 5. Clinical picture Radiogical tests Fluid and electrolyte status 6. Treatment of intestinal obstruction
NEVER LET THE SUN RISE OR FALL ON A PATIENT WITH BOWEL OBSTRUCTION
Fluid resuscitation Electrolyte, acid-base correction Close monitoring foley, central line NGT decompression Antibiotics controversial TO OPERATE OR NOT TO OPERATE
Preoperative preparation
Partial-complete Malignant benign Early postoperative
Nasogastric suction + CVP + Foley Cath. Fluid and electrolyte resuscitation
Ringer lactate+ Saline+ K + Antibiotics
Operative therapy
Adhesiolysis, enterotomy, resection, by-pass, ostomy
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