Intestinal Obstruction
By: Nanjego Victoria
22/U/22703/HTP
Learning Objectives
At the end of this session, students are expected to
be able to:
• Define intestinal obstruction
• Outline the epidemiology of intestinal
• Identify different causes and risk factors of
intestinal obstruction.
• Describe the classifications of intestinal
obstruction
• Describe the pathophysiology of intestinal
obstruction
Learning Objectives cont..
• Describe clinical features of intestinal
obstruction
• Describe the differential diagnoses of intestinal
obstruction
• Identify the investigations intestinal obstruction
• Describe the treatment of intestinal obstruction
• Describe the complications of intestinal
obstruction
Activity: Brainstorming
• What is intestinal obstruction ?
Definition
Intestinal obstruction
• Failure of intestinal contents to pass through
the bowel lumen
• Blockage of the passage of intestinal contents
through the lumen of the bowel
Epidemiology
-33% of surgical cases in uganda are due to acute
abdomen with intestinal obstruction
-In newborns, it is 1 in 2000 live births
-The incidence of bowel obstruction increases with age
Causes
• Mechanical intestinal obstruction
– Also called dynamic obstruction
– Peristalsis is working against a mechanical
obstruction
7
Causes cont..
• Functional intestinal obstruction
– Also known as adynamic obstruction
– May occur in two forms:-
• Paralytic ileus
–Absence of peristalsis
• Pseudo-obstruction
–Peristalsis is present in a non-
propulsive form
8
Mechanical / Dynamic obstruction
• Intraluminal causes
– In the lumen
• Intramural / Intrinsic causes
– In the wall of the gut
• Extramural / Extrinsic causes
– Outside the wall
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Intraluminal causes
• Faecolith
• Worms eg ascaris
• Gall stone
• Foreign body
• Polypoidal tumors
• Bezoars
10
Intramural / Intrinsic causes
• Congenital
– Atresia/ stenosis
• Inflammatory
– Crohns diseases
• Neoplastic
– Primary or Secondary
• Traumatic
– Intramural hematoma
11
Extramural / Extrinsic causes
• Congenital bands
• Postoperative adhesions
• Hernias
• Volvulus
• Intussusception
• External mass effect
– Abscess
– Neoplastic
12
Functional Intestinal Obstruction
• Postoperative
• Metabolic
– Hypokalaemia
– Uremia
– Diabetic coma or ketoacidosis
– Hypothyroidism
• Neurogenic
– Spinal cord injury
– Hirschsprung’s disease
13
Functional intestinal obst. [cont’d]
• Infectious
– Peritonitis
• Vascular
– Mesenteric ischaemia
• Pharmacological
– Anticholinergics
– Opiates
– Antipsychotics etc
14
Classifications
The most practical used approach
• Partial bowel obstruction
• Complete bowel obstruction
15
Anatomical classification
Small bowel
extramural-(adhesions, hernias, neoplasms)
Mural-(strictures, intussuception, meckel
divertitilitis)
intramural-(gall stones, ingested FBs)
Large bowel
Extramural-(diverticular disease, volvulus)
Mura-(colorectal adenocarcinoma)
Intramural-(fecal impaction)
Partial bowel obstruction
• Meaning that the lumen is narrowed but permits
distal passage of some fluid and air
• E.g. Richter's hernia in which a strangulated
hernia involving only one sidewall of the bowel,
which can result in bowel perforation through
ischemia without causing bowel obstruction
17
Complete bowel obstruction
• In which there is complete mechanical blockage
of the normal progression of the intestinal
contents
• In this case the intestinal lumen is totally
occluded
• E.g. sigmoid volvulus
18
Pathophysiology
• Soon after the obstruction has occurred, there
will be proximal dilatation & Collapse of the
distal segment.
• That will be due to accumulation of fluid and
air
• Sources of fluid is from GI secretions such as
from saliva, gastric juices and pancreatic
juices and sources of air will be from
swallowed air, from bacterial fermentation,
from blood vessels.
19
Pathophysiology cont..
• Accumulation of fluid and air will cause
abdominal distention
• Collapse of the distal segment will cause the
patient to have sporious diarrhoea followed by
constipation
• Bowel dilatation will stimulates cell secretory
activity and impair absorption causing more
fluid accumulation and excessive bowel
distention.
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Pathophysiology cont..
• Stimulation of stretch receptors in the wall of
the gut due to bowel distension will lead to
increase in peristalsis both above and below
the obstruction with frequent loose stools and
flatus early in its course
• Further rise in Intraluminal pressure will cause
increased wall tension (causing colicky
abdominal pain) and hence the cessation of
peristalsis.
21
Pathophysiology cont..
• Also further increase in bowel distension and
intraluminal pressures will compress mucosal
lymphatics causing bowel wall lymphedema
and impair venous return
• Capillary engorgement and loss of
intravascular fluid into bowel lumen will lead
to dehydration
22
Pathophysiology cont..
• Any progressive bowel wall edema will lead to
intestinal arterial supply occlusion causing
intestinal ischaemia
• Bacteria in the gut proliferate proximal to the
obstruction.
• Migration of aerobic and anaerobic bacteria
across intestine wall and/or intestinal
perforation will cause peritonitis then
generalized peritonitis
Activity: Brainstorming
• What are the signs and symptoms of intestinal
obstruction ?
Clinical Presentations
• History / Symptoms
• Physical examination /Signs
– Abdominal guarding
– Dehydration
– Shock
– Pyrexia
25
clinical features
• Abdominal pain
• Vomiting
• Abdominal distension
• Constipation
26
Abdominal pain
• Pain is the first symptom experienced by the patient
• It occurs suddenly and usually severe and colicky in nature
• Site: periumbilically in small bowel obstruction and lower in
colonic obstruction
• Often, the presentation may provide clues to the approximate
location and nature of the obstructionAbdominal pain:
-In small bowel obstruction, it is crampy, recurrent paroxysms
occurring as short crescendo/decrescendo episodes (of 30
seconds).
-In large bowel obstruction, it is of longer episodes ofminutes
(In paralytic/adynamic ileus, pain is diffuseand mild)
27
Vomiting
• Vomiting occurs early and profuse if the level of
obstruction is proximal
• It is delayed in case of distal obstruction
• As obstruction progresses the characteristics of vomitus
alters from digested food to faeculent material due to
presence of enteric bacterial overgrowth
-jejunal obstruction, it is early and persistent.
-ileal obstruction, it is recurrent occurring at an interval;
initially bilious later faeculent.
-In large bowel obstruction, vomiting is a late feature.
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Abdominal distension
• Proximal small bowel has less distension
when obstructed than the distal bowel has
when obstructed
• The more distal the obstruction the greater the
degree of distention
i is absent or minimal in case of jejunal obstruction
Obvious with visible intestinal peristalsis (VIP) and
borborygmi sounds in case of ileal obstruction—Step
ladder peristalsis.
29
Constipation
• Classified as absolute or relative
• Absolute constipation meaning neither faeces nor
flatus is passed
• Relative constipation means only flatus is passed
• Absolute obstruction is a cardinal feature of
complete obstruction where relative obstruction is
a feature of incomplete obstruction
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Others
-Dehydration
-Features of toxaemia and septicaemia
(Tachycardia, tachypnoea, fever, sunken eyes,
cold periphery).
-Abdominal tenderness: It is initially localised but
later becomes diffuse—is a feature of IO
-Rebound tenderness and guarding will not be
present in simple obstructions which are features
of strangulation.
Others cont….
-Features of strangulation (Continuous severe pain, shock, tenderness, rebound
tenderness (Blumberg’s sign).Guarding and rigidity, absence of bowel sounds.
In case of strangulated hernia, a swelling which is tense, tender, rigid,
irreducible, no expansile impulse on coughing and history of recent increase
in size is seen.
-Temperature: Fever signifies inflammation in the bowel
wall/ischaemia/perforation.
-Hypothermia can occur when septicoemia develops due to lack of pyrogenic
response. It suggests poor prognosis.
-Bowel sounds: They are increased—high pitched metallic (rushes and groans)
sounds followed by metallic tinkling sounds of dilated bowel. Eventually
once fatigue occurs or gangrene
develops, bowel sounds are not heard—silent abdomen of peritonitis develops
(In paralytic ileus, there are only continuous metallic sounds of dilated bowel)
Differential diagnoses
• Pseudo-obstruction/ogilvie syndrome
• Mesenteric ischemia
• Post-operative paralytic ileus
• Perforated viscous/intra-abdominal abscess
• Colorectal cancer
• Medication adverse effects e.g narcotics and
tri-cyclic antidepressants
• Appendicitis etc
Investigations
Laboratory investigations
• Full blood count-Total count is increased. But
can be significantly low in severe stage of
sepsis.
• Serum creatinine
• Serum electrolytes:. Hypokalaemia is
common.
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Investigations cont..
Radiological/imaging investigations
• Radiographs
– Chest radiography
– Abdominal radiography
• Contrast studies
35
Abdominal ultra-sound-is useful to see dilated
bowel and fluid in the peritoneal cavity. It is
better than X-ray but not as good as CT
-small bowel loops >2.5cm in diameter
Chest radiography
• Can show air under
the diaphragm in case
of associated bowel
perforation
37
Abdominal radiographs
• 2 views are required which are Supine and Erect
• Dilated bowel loops with air-fluid levels indicate
Intestinal obstruction
• Able to show the level of obstruction
• Small bowel lie centrally and colon peripherally
Triad of small bowel obstruction in plain X-ray
1. Dilated small bowel loops > 3 cm
2. Multiple air fluid levels in erect X-ray
3. Paucity of air in the colon
Abdominal radiographs cont..
• Jejunal obstruction shows valvulae
conniventes i.e. parallel lines spanning the
entire width of the bowel lumen
• Obstructed ileum appears cylindrical with less
clearly valvulae conniventes
• Obstructed colon shows dilated bowel with
haustral markings
CT scan-In CT scan small bowel loop > 2.5 cm
suggests dilatation and large bowel >5cm. It can
show dilated loop, transition zone and collapsed
part which are definitive features of intestinal
obstruction.
-It can also give idea of changes in the bowel wall,
ischaemia, strangulation, mesenteric oedema
thickening and twisting.
-It also shows bowel wall gas, portal venous gas and
mass lesion.
Definitive treatment
• Conservative treatment
• Surgical treatment
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Conservative treatment
• Includes:-
– Correction of fluid and electrolyte imbalance
– Nasogastric decompression
– Nil per oral
– Prophylactic antibiotics: Ampicillin,
gentamycin, metronidazole, cephalosporins.
– Analgesics
– Blood transfusion: FFP or platelet
transfusions are often
needed in critical patient. 42
Conservative treatment cont..
• Other modalities include:-
– Decompression of sigmoid volvulus with a
sigmoidoscope
– Hydrostatic reduction of intussusception
with a contrast enema
– Endoscopic or radiological placement of
metal stent
Surgical treatment
Immediate laparotomy is done and the site (by
finding the junction of dilated proximal and
collapsed distal bowel) and cause of the
obstruction is identified.
Indications for surgical interventions
• Failure of conservative treatment
• Presence of underlying disease process that
must be treated e.g. hernia, obstructing tumor
• Signs of peritoneal irritations
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Preoperative care
• IV fluid resuscitation with crystalloid fluids
• NGT
• Nil orally
• Prophylaxis antibiotics
• Analgesics
• Pre-anesthetic visit
• Informed written consent
45
Preoperative care cont…..
• Monitor
– Urine output [normal=
– Input-output
– Vital signs [T, PR, RR, BP]
– The volume of NGT
46
Early complications
• Fluid and electrolyte imbalance
• Hypovolemic shock
• Bowel perforation Peritonitis
• Intra-abdominal abscesses
• Wound sepsis
• Circulatory collapse and ARDS
• Wound dehiscence
• Fecal fistula
• Aspiration pneumonia
• Postoperative paralytic ileus
• Short-bowel syndrome (as a result of multiple surgeries
47
Late complications
• Incisional hernia
• Keloids
• Postoperative adhesions
• Complications of intestinal obstruction
• Peritonitis
• Hypovolaemic and septic shock
• Renal failure
• Intra-abdominal abscess formation
• Moribund status
48
References
• Bailey &Love’s short Practice of Surgery 26 th
Edition
• [Link],A Manual on clinical surgery 2022,
16th Edition
• SRB_s Manual of Surgery 5th edition
