Intestinal Obstruction

By: Nanjego Victoria

22/U/22703/HTP
 Learning tasks
At the end of this session, students are expected
to be able to:
• Define intestinal obstruction
• Identify different causes and risk factors of
intestinal obstruction.
• Describe the classifications of intestinal
obstruction
• Describe the pathophysiology of intestinal
obstruction
 Learning tasks 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
 Causes
• Mechanical intestinal obstruction
– Also called dynamic obstruction
– Peristalsis is working against a mechanical
obstruction

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 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
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 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

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 Intramural / Intrinsic causes
• Congenital
– Atresia/ stenosis
• Inflammatory
– Crohns diseases
• Neoplastic
– Primary or Secondary
• Traumatic
– Intramural hematoma

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 Extramural / Extrinsic causes
• Congenital bands
• Postoperative adhesions
• Hernias
• Volvulus
• Intussusception
• External mass effect
– Abscess
– Neoplastic
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 Functional Intestinal Obstruction
• Postoperative
• Metabolic
– Hypokalaemia
– Uremia
– Diabetic coma or ketoacidosis
– Hypothyroidism
• Neurogenic
– Spinal cord injury
– Hirschsprung’s disease
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Functional intestinal obst. [cont’d]
• Infectious
– Peritonitis
• Vascular
– Mesenteric ischaemia
• Pharmacological
– Anticholinergics
– Opiates
– Antipsychotics etc
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 classification
The most practical used approach
• Partial bowel obstruction
• Complete bowel obstruction

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 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

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 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

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 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.
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 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.
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 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

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 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

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 clinical features
• Abdominal pain
• Vomiting
• Abdominal distension
• Constipation

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 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 obstruction

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 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

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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

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 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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 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
• Serum creatinine
• Serum electrolytes

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 Investigations cont..
Radiological/imaging investigations
• Radiographs
– Chest radiography
– Abdominal radiography
• Contrast studies
• Abdominal ultra-sound

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 Chest radiography
• Can show air under
the diaphragm in case
of associated bowel
perforation

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 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
 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
 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
– Analgesics

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 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
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

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 Preoperative care cont…..
• Monitor
– Urine output [normal=
– Input-output
– Vital signs [T, PR, RR, BP]
– The volume of NGT

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 Early complications
• Fluid and electrolyte imbalance
• Hypovolemic shock
• Bowel perforation Peritonitis
• Intra-abdominal abscesses
• Wound sepsis
• Circulatory collapse
• Wound dehiscence
• Fecal fistula
• Aspiration pneumonia
• Postoperative paralytic ileus
• Short-bowel syndrome (as a result of multiple surgeries
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 Late complications
• Incisional hernia
• Keloids
• Postoperative adhesions

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 Key points
• Intestinal obstruction is defined as a blockage of
the passage of intestinal contents through the
lumen of the bowel

• The cause of intestinal obstruction can be grouped

into dynamic causes and adynamic causes.

• Treatment of intestinal obstruction can be either

conservatively or requiring surgical intervention.
 Review questions
1. What is intestinal obstruction?

2. What are the causes of intestinal obstruction?

[Link] are the clinical features of intestinal

obstruction?

4. Outline management of intestinal obstruction?

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 References
• [Link],A Manual on clinical surgery 2011
• Bailey &Love’s short Practice of Surgery 26 th
Edition
• SRB_s Manual of Surgery
• Surgery Notes from Prof. Aziz, compiled by
Dr. Ndile [Link],Pg 61-66.