Management of

Intestinal Obstruction
Yonas Ademe, MD
September 25, 2019

Moderator: Dr. Hailu, Consultant General Surgeon

1
Presentation
Outline objectives

• Proper diagnosis of intestinal obstruction

• General management of a patient with bowel obstruction

• Management of common etiologies of bowel obstruction

2
Presentation
Outline outline
• Part I: Basics of bowel obstruction
• Introduction
• History
• Epidemiology
• Pathophysiology
• diagnosis
• Part II: General management of bowel obstruction
• Operative
• Non-operative
• Part III: Management of specific etiologies of bowel obstruction
• Small bowel
• Large bowel
• Summary
• References 3
Part I:
Basics

4
Introduction
• Intestinal obstruction, is a complete or partial mechanical or functional
obstruction of the intestines which prevents the normal movement of
the products of digestion

• The small bowel, large bowel or both may be affected

• Independent of the underlying etiology, bowel obstruction remains a

major cause of morbidity and mortality

5
History
• Bowel obstruction has been documented throughout history, with cases
detailed in the Ebers Papyrus of 1550 BC and by Hippocrates

• Praxagoras appears to have performed the earliest recorded operation

for bowel obstruction around 350 BC when he relieved the obstruction of
a bowel segment by creating a decompressive, diverting
enterocutaneous fistula

6
Epidemiology
• Intestinal obstruction account for 1.2% of all surgical diseases and 5% of
emergency surgical admissions

• Both sexes are equally affected and the condition can occur at any age

• In rural Africa, acute intestinal obstruction accounts for a great

proportion of morbidity and mortality, and Ethiopia is one of the
countries where intestinal obstruction constitutes a major cause of
morbidity and mortality
7
Epidemiology

• The etiologies and thereby the prevalence of bowel obstruction

vary widely throughout the world depending on:
• Ethnicity
• The age group considered
• Dietary habits
• Geographic location
• Time of the year

8
Etiology: Mechanical

Intraluminal Intramural Extramural

• Foreign body • Neoplasms • Hernias

• Gall stone • Strictures • Volvulus
• Worm ball • Intussusception
• Adhesions
• Compression

9
Etiology: Functional

Paralytic ileus Pseudo-obstruction

• Abdominal surgery • Smooth-muscle disorders
• Intra-abdominal collection • Neurologic disorders
• Electrolyte disturbance • Endocrine disorders
• Medications
• Retroperitoneal hemorrhage

10
Etiology: Developed countries
• Bowel obstruction: 20% of acute abdomen
• Small bowel: 80%
• Large bowel: 20%

• Etiology
• Small bowel • Large bowel
• Adhesions: 60% • Malignancies: 60%
• Neoplasms: 20% • Diverticualar disease: 20%
• Obstructed hernia: 10% • Colonic volvulus: 1-5%
• Crohn disease: 5% • Miscellaneous: 15 -20%
• Miscellaneous: 5%
11
Etiology: Ethiopia
• Bowel obstruction: 26% of acute abdomen
• Small bowel: 52.3% Pattern of Acute Abdomen in Adult Patients in
• Large bowel: 46.7% Tikur Anbessa Teaching Hospital
B. Kotiso et al., 2007

Surgically Treated Acute Abdomen at Gondar

University Hospital, Ethiopia.
• Etiology S. Tsegaye et al., 2007
• •Small
Smallbowel
bowel • Large bowel
Pattern of Non-traumatic Acute Abdomen in
• •Adhesions (51%) volvulus
Small bowel • Colonic
Patients fromvolvulus (58.5%)
Ayder Comprehensive Specialized
• Small bowel volvulus (23%) • Malignancies (15%)
Hospital
• •Larger bowel
Obstructed hernia • Intussusception
Girmay Hagos Araaya et al., 2019
• •Miscellaneous
Sigmoid volvulus • Miscellaneous
12
Classification
• Duration
• Acute Vs. Chronic
• Site
• Small bowel Vs. Large bowel
• Pathophysiology
• Mechanical Vs. Functional
• Extent
• Complete Vs. Partial
• Type of obstruction
• Simple Vs. Complicated (Closed loop and Strangulated)
13
Pathophysiology
Sequestration of fluid and gas inside intestinal lumen

• Dysmotility
Distention of intestine + increase in
• Decreased absorption
intraluminal and intramural pressure • Intraluminal hypersecretion

Intestinal perforation Impairment of microvascular perfusion Bacterial overgrowth

Peritonitis Bacterial translocation

Sepsis Shock Hypovolemia

14
Pathophysiology

• Speed of progression
• Small bowel Vs. Large bowel

• Simple Vs. Closed loop

• Partial Vs. Complete

15
Clinical features - Symptoms
• Intermittent crampy abdominal pain • Acute Vs. Chronic

• Abdominal distention • Proximal Vs. Distal

• Nausea and vomiting • Partial Vs. Complete

• Acute obstipation • Mechanical Vs. Ileus

• Simple Vs. Strangulated

16
Clinical features – Physical findings
• GA • Diagnosis
• V/S
• HEENT • Etiology
• Abdominal findings
• Visible bowel loops • Patient status
• Abdominal distention
• Hyper/hypo-active bowel sounds
• Tenderness (localized or diffuse) • Mechanical Vs. Ileus
• DRE findings
• Simple Vs. Strangulated
17
Laboratories
• CBC
• Hemoconcentration
• Reflecting intravascular volume depletion
• Mild leukocytosis

• OFT

• Electrolytes

• Arterial blood pH and serum lactate concentrations 18

Imaging – X-ray

• Often confirmatory

• Sensitivity of 70 to 80 % but low specificity

• The abdominal series consists of:

• A radiograph of the abdomen with the patient in a supine position
• A radiograph of the abdomen with the patient in an upright position
• A radiograph of the chest with the patient in an upright position
19
Imaging – X-ray
• Small bowel Vs. Large bowel

• Proximal Small bowel Vs. Distal Small bowel

• Mechanical Vs. Ileus

• Complications

• Etiology (foreign body)

20
Imaging – X-ray

• Limitations
• Closed loop obstruction
• Because the involved bowel with a
proximal and distal occlusion may
be fluid filled and lack any gas

• Strangulation
• Portal venous gas
• Intestinal pneumatosis

• Etiology
21
Imaging – CT scan

• Becoming increasingly the imaging test of choice

• Diagnostic accuracy of >90% in intestinal obstruction

• 80 to 90% sensitive and 70 to 90% specific

• Ideally done with oral contrast

22
Imaging – CT scan

• Findings suggesting IO
• A discrete transition zone with
dilation of bowel proximally

• Decompression of bowel distally

• Intraluminal contrast that does not

pass beyond the transition zone

• Description of etiology
23
Imaging – CT scan

• Closed-loop obstruction
• U-shaped or C-shaped dilated
bowel loop associated with a
radial distribution of mesenteric
vessels converging toward a
torsion point

24
Imaging – CT scan

• Strangulation
• Pneumatosis intestinalis
• Portal venous gas
• Thickening of the bowel wall
• Poor uptake of IV contrast into the wall of
the affected bowel
• Mesenteric haziness
• Mallo et al. • Sheedy et al.
• Sensitivity: 83% • Sensitivity: 15%
• Specificity: 92% • Specificity: 94%
• Positive predictive value: 79%
• Negative predictive value: 93%
25
Imaging – Contrast studies
• Hyperosmotic water soluble contrast
(gastrograffin)
• Advantages
• Diagnostic
• Therapeutic
• Limitation
• Becomes diluted rapidly with an established SBO

• Dilute barium contrast

• Advantage
• Better details in distal obstructions
• Limitations
• Barium peritonitis
• Inspissation in the obstructed LBO
26
Imaging – Ultrasound
• Reported specificity is 82%, sensitivity is 95%, and overall accuracy is 81%

• Advantages
• Available, cheap and non-invasive
• Etiology

• Limitations
• Highly operator-dependent
• Bowel gas artifact
• Difficult to perform in obese patients
27
Imaging – MRI
• Diagnostic accuracy exceeding 90% is achievable

• Advantage
• Distinguishing benign from malignant bowel strictures in patients with suspected
malignant bowel obstruction

• Limitations
• Time consuming and requires substantial expertise
• Does not have a greater diagnostic accuracy than CT

28
Imaging – Video capsule endoscopy (VCE)
• A valuable diagnostic tool in patients with subacute or chronic intestinal
obstruction

• Particularly helpful in patients with obstruction related to a stricture

caused by inflammation or malignancy

• Overall, VCE may provide a diagnosis in nearly 40% of previously

undiagnosed patients

29
Detection of ischemia

30
Part II: General
Management

31
General management

• Hemodynamic and metabolic support

• Isotonic fluid should be given intravenously
• Crystalloids Vs. Colloids
• Correction of metabolic and/or electrolyte imbalances
• Monitoring
• Stable patients with normal renal function
• Indwelling bladder catheter
• Unstable patients or those with impaired cardiac, pulmonary or renal function
• Central venous or pulmonary arterial pressure

32
General management

• NG tube decompression
• Decreases distention
• Decreases nausea and vomiting
• Decreases risk of aspiration
• Improves ventilation in patients with respiratory compromise

Nasogastric Vs. Nasointestinal tube

A prospective, randomized trial of short versus long tubes in adhesive
small-bowel obstruction
Phillip R.Fleshner et al.
33
General management

• Broad spectrum antibiotics

• Indications
• Bowel ischemia
• Peritonitis
• Surgery is planned

• They are given by some because of concerns that bacterial

translocation may occur in the setting of SBO

34
Operative Management

• Indications
• Closed loop obstruction
• Suspected ischemia
• Perforation

• Large bowel obstruction

35
Operative Management

• Incision
• First surgery
• Incision providing adequate exposure

• Previous surgery
• Early post-operative obstruction
• Previous incision Vs. Virgin incision

• Late post-operative obstruction

• Previous incision Vs. Virgin incision
36
Operative Management

• Exploration
• Identify the site and cause of obstruction
• If the point of obstruction is not obvious, decompressed bowel
distal to the obstruction can be identified and followed proximally
to the point of obstruction

• Care should be taken when handling the obstructed bowel at

or near the point of obstruction when acutely obstructed

37
Operative Management

• Operative procedure
• Address the etiology

• Address the bowel

• Viable
• End of exploration
• Short lengths of ischemic bowel
• Resection and primary anastomosis

38
Operative Management

• Operative procedure
• Long segment of ischemic bowel
• Bowel of uncertain viability should be left intact and the patient re-explored
in 24 to 48 hours in a "second-look" operation

• Ischemia close to ileocecal valve

• Ileoileostomy in the region adjacent to the ileocecal valve is safe and

results in fewer complications than ileotransverse anastomosis
39
Operative Management

• Criteria suggesting viability

• Usually visual inspection alone is adequate
• Normal color
• Peristalsis
• Marginal arterial pulsations
• Snipping a small piece of the mesenteric fat and checking for bleeding

• In borderline cases
• Doppler probe
• IV fluorescein
40
Operative Management

• Intraoperative intestinal decompression

• Manual retrograde decompression into the stomach
• Intraoperative passage of a long nasointestinal tube
• Performance of a controlled enterotomy
Clinical
Effect ofoutcomes of manual
manual bowel bowel decompression
decompression (milking)
(milking) in the in thesmall
obstructed mechanical
bowel
small bowel
Törer N et obstruction: a prospective randomized clinical trial
al., 2008
Ezer A. et al., 2012
Post-operative
• •Although
• The
it reduces muscle advantage or disadvantage?
contractility, a milking procedure in an intestinal obstruction model
doesresumption of a regular
not cause peristaltic diet and postoperative
deterioration, hospital
histopathologic stay (P = .68) changes,
or inflammatory were notor
significantly
different in in
alterations the milking
the degreeand
of control
bacterialgroup. Similarly, there were no differences between the 2
translocation
groups regarding respiratory complications (P = .34), bacterial translocation (P = 1), or wound
infection (P = 1)
41
Operative Management

• Post-op complications
• General complications
• Paralytic ileus

• Resection associated
• Anastomotic leak
• Internal hernias
• Short bowel syndrome
• Recurrent obstruction
42
Non-operative management
• When indicated, this approach is reported to be successful in 62–85% of
patients
• Only 5 to 15% have been reported to have symptoms that were not substantially
improved within 48 hours after initiation of therapy

• Rate of success is influenced likely by:

• Type of bowel obstruction (Complete Vs. Partial)
• The surgeon’s threshold for conversion to operative management

43
Non-operative management

• Indications
• No closed loop obstruction • Contraindications
• No evidence of bowel ischemia • Absolute
• Closed loop obstruction
• No sign of peritonitis
• Evidence of bowel ischemia
• Sign of peritonitis
• Relative
• LBO
• Complete obstruction

44
Non-operative management

• A study of 145 patients with CT-diagnosed HGSBO

• 46% of the overall cohort were managed non-operatively
• Length of stay and complications were significantly increased in the
operative group
• Non-operative management was associated with a higher recurrence rate and
shorter time to recurrence
45
Non-operative management

• 55 patients with SBO were studied

• 45% of patients with a complete obstruction successfully managed non-operatively
• 66% of patients with a partial obstruction were successfully managed non-operatively
• No mortality
• Incidence of intestinal ischemia at operation based on the presence or absence of
complete versus partial obstruction was not described
• There was no advantage of one type of tube over the other in patients with adhesive SBO
46
Non-operative management

• 166 patients with SBO were studied

• 42% of patients with complete obstruction were successfully managed non-operatively
• 79% of patients with partial obstruction were successfully managed non-operatively
• There was a greater rate of bowel strangulation (10% vs 4%) and need for resection (14% vs
8%) in the group with complete obstruction at the time of operation for treatment failure
• 6% mortality in patients with a complete obstruction initially managed non-operatively
versus 0% mortality for patients with a partial obstruction initially managed non-operatively
47
Non-operative management

• The studies and the unreliability of clinical acumen to

recognize strangulation obstruction accurately have led many
surgeons to favor early operation for all patients with a
complete small bowel obstruction!

• “The sun should never rise or set on a (complete) small bowel

obstruction”

48
Non-operative management

• Indications
• No closed loop obstruction • Contraindications
• No evidence of bowel ischemia • Absolute
• Closed loop obstruction
• No sign of peritonitis
• Evidence of bowel ischemia
• No complete obstruction
• Sign of peritonitis

• Relative
• LBO
• Complete obstruction
49
Non-operative management

• Measures
• NPO (For complete obstruction)
• Fluid and electrolyte replacement
• NG tube decompression
• Connected to sump suction
• Close monitoring
• History, P/E, Investigations

• ?Antibiotics
• ?Analgesics
• Contrast agents 50
Non-operative management
• Administration of water-soluble oral contrast has not only diagnostic but
also therapeutic and prognostic value

• Diagnostic: Partial Vs. Complete

• Predicts likelihood of success of non-operative management
• Reduces the need for surgery
• Reduces length of stay by about 2 days
• Reduces time to resolution by about 28 hours

• Therapeutic
• The hypertonic water-soluble contrast agent causes a shift of fluid into the intestinal lumen,
thereby increasing the pressure gradient across the site of obstruction accelerating
resolution of partial SBO
51
Non-operative management

Oral Urografin in Postoperative Small Bowel Obstruction

Therapeutic
Water-soluble
Shyr-Chyr Value
contrast
Chen, 1999 of Gastrografin
agent in adhesive
in Adhesive
smallSmall
bowelBowel
obstruction:
Obstruction
a
systematic
After Unsuccessful
review and Conservative
meta-analysis
• A study of 116 patients with SBO
Treatment:
of diagnostic
A Prospective
and therapeutic
Randomizedvalue
Marco
Trial• Ceresoli et al. 2016
In 63.8% of the patients the contrast medium reached the colon within the first
Hok-Kwok Choi et al., 2002
• WSCA 8 hours
had a sensitivity of 92% and a specificity of 93% in predicting
• • In 36.2% of the patients the contrast medium failed to reach the colon within
Patients
resolution in of
whom
obstruction
contrastwithout
failed tosurgery
reach the large bowel within 24 hours
the first 8 hours
• were
Diagnostic
• The considered
accuracy
to have
increased
complete
significantly
obstruction,
if abdominal
and laparotomy
X-rays were
was
presence of Urografin in the colon within 8 hours of ingestion as an
performed
taken after 8for
indicator hours
non-operative treatment had a sensitivity of 90.2%, a specificity of
100%, and an accuracy of 93.1%
52
Non-operative management

• When to convert to operative management?

• Worsening of clinical condition • Continuous abdominal pain
• Complete obstruction • Fever
• Signs of bowel ischemia
• Tachycardia
• Signs of peritonitis
• Localized/diffuse tenderness
• Imaging (X-ray/CT scan)
• Signs of complete obstruction • Leukocytosis
• Signs of ischemia 3 signs: 82% predictive value for strangulation
• Signs of perforation 4 signs: 100% predictive value for strangulation

Preoperative recognition of intestinal

• No improvement in symptoms strangulated obstruction
Sarr MG et al. 53
Non-operative management
• Most patients with partial SBO whose symptoms do not improve within
48 hours after initiation of non-operative therapy should undergo surgery

The authors concluded that a 2-day limit of watchful waiting before

surgery is not associated with an increase in mortality or postoperative
morbidity, although inpatient costs were higher

54
Non-operative
management
• An algorithm to a non-operative
management of SBO

55
Outcome of management

56
 Part III:
Management of Specific
Etiologies

57
Adhesive bowel
obstruction

58
Introduction
• Adhesions may be defined as abnormal,
inflammatory attachments of connective
tissue between tissue surfaces

• They can be congenital or acquired (Post-

inflammatory or post-op)

• Leading cause of SBO in Western societies

59
Introduction

• Following laparotomy, there is >5% lifetime incidence of SBO

caused by adhesions

• Following surgery for SBO caused by adhesions, the probability

of recurrent obstruction ranges from 20 to 30%

60
Pathophysiology
• Adhesion formation to some degree is nearly universal after laparatomy
and starts as early as the first postoperative hours

• Adhesion formation is a surface event associated with some form of

peritoneal injury

• The inciting trauma triggers a local fibrinous inflammatory response

• The full establishment of this response is present 5-7 days post-op

61
Pathophysiology

• The operations associated most frequently with adhesive bowel

obstruction are those involving the structures in the infra-
mesocolic compartment and especially in the pelvic region
• Colonic, rectal, and gynecologic procedures

62
Timing of obstruction
• Adhesive bowel obstruction may occur at any time postoperatively after
a laparatomy
• As early as within the first postoperative months to more than 8 decades after the
index operation

• 20% occur within 30 days

• 20 occur between 1 and 12 months
• 20% occur between 1 and 5 years
• 40% occur after 5 years
63
Diagnosis

• Clinical features
• Partial Vs. Complete
• Simple Vs. Complicated

• History of previous abdominal operation

• Imaging
• X-ray
• CT-scan 64
Treatment

• General management
• Applicable

• Operative Vs. Non-operative management

• Many patients who are treated conservatively for adhesive
SBO do not require future readmissions
• Less than 20% of such patients will have a readmission over the
subsequent 5 years with another episode of bowel obstruction
65
Treatment

• SBO within 6 weeks of a prior laparotomy

• Conservative management preferred
• Surgery if there are signs of complete obstruction, bowel ischemia, or
peritonitis

• SBO after 6 weeks of a prior laparotomy

• Initial conservative treatment
• Operative treatment

66
Treatment

• Operative intervention Early versus late adhesiolysis for adhesive-

• Access related intestinal Obstruction
• Open Vs. Laparascopic Chu DI, 2013

• Position • Laparoscopic approach associated with significantly

• Supine Vs. Modified lithotomy lower rates of overall complications and a shorter
• Incision length of hospital stay (4 Vs. 10 days)
• Early post-operative obstruction
• Previous incision Vs. Virgin incision
• Late post-operative obstruction
• Previous incision (enter above or below the prior
incision)
• Virgin incision (e.g. paramedian incision) 67
Treatment

• Lysis of adhesions
• Skin: Knife
• Subcutaneous tissue: electrocautery
• Fascia: Mayo scissors
• Take down adhesions from the anterior abdominal wall
• Separate the central abdominal contents from each other
• Close sero-myotomies using interrupted sutures
• ?Put adhesion barrier over the bowel

68
Complications of surgery
• Entero-cutaneous fistula
• Gentle adhesion release

• Prolonged paralytic ileus

• Intra-op
• Post-op

• Recurrent obstruction
• ?Adhesion barriers

69
Prevention
• Laparoscopy
• Swedish National Inpatient Register
• Laparascopy has 4 fold less risk of adhesion compared to open surgery

• Cornerstones of adhesion prevention during open surgery

• Good surgical technique
• Careful handling of tissue
• Minimal use and exposure of peritoneum to foreign bodies

• Use of Hyaluronan based agents

70
Primary small Bowel
Volvulus

71
Introduction

• Small bowel volvulus is twisting of the

small intestine about its mesentery
• Primary Vs. Secondary

• It results in obstruction and hampered

venous return followed by ischemia
ultimately causing gangrene

72
Epidemiology
• Incidence Seasonal variation
Trend of small of primary
intestinal small
volvulus in
• Western world: 1.5 to 5.7 per 100,000 intestinal
north
Smallwesternvolvulus in North Western
Ethiopia
intestinal volvulus in
• Africa and Asia: 24 to 60 per 100,000 Ethiopia
Ghebrat K., 1998
southern Ethiopia
Ghebrat K., 2001
M.Demissie, 2001
• More commonly seen in people who eat large • SIV is commonest cause of SBO
meals infrequently Prevalence
•• SIV was most
235is patients
second significantly
with common higher
acute IO cause
• Young males, from rural areas, with bulky fiber rich diet duringIOthe
• ofSIV: months of June through
98 (41.7%)
• Tense and muscular abdominal wall October
Meanthan
•• Primary during
more
age: 34commonthe months
years than of
• Erect posture during and/or after eating
• Muslims during the month of Ramadan November
Male toto
• secondary May ratio: 8.8:l
female
•• Typical
Young patient: young
adults most of adult,
whommale,
were
• Parasitism muscular,
farmers farmer, from a rural area
• Higher incidence seen in regions with endemic • whose dietrate
Mortality is bulky
was and mainly
13.3%
parasitism
made of cereals 73
Pathophysiology

Rapid filling of the proximal intestines with high bulky chyme

Proximal bowel loops pulled down to the pelvis and distal bowel loops pushed up

74
Diagnosis

• Clinical features
• Features of SBO

• Imaging
• X-ray
• CT-scan
• C-shaped loop
• “Whirl’ sign
75
Treatment

• SBV without ischemia

• Simple detorsion (recommendation)
• The risk of recurrence is not well established but generally rare
• Post-laparotomy intra-peritoneal adhesions are thought to be the factor to prevent
recurrence

• Gangrenous SBV
• Resection and anastomosis

76
Outcome

• Prognosis depends on:

• Age
• Duration of symptoms
• Length of small intestine involved

• The mortality reported from different places varies from 9% to

32.1%

77
Sigmoid Volvulus

78
Introduction
• Torsion of the sigmoid colon along its own
mesentery

• Torsion of 180 degrees results in clinical

obstruction, and further torsion to 360 degrees
causes strangulation

• Perforation occurs in areas of necrosis at the point

of torsion, within the closed loop, or in the proximal
thin-walled cecum
79
Epidemiology
• 1.9% of cases of large bowel obstruction in the United States and up to
10% to 50% of cases in Africa, the Middle East, and South America

• Old age

• M>F

80
Pathophysiology

• Anatomic features • “Dolichomesocolic colon”

• Large and redundant colon • Commonly found in male
• Long mesentery with narrow base subjects and people over the
age of 30

• Predisposing conditions Bhatnagar et al., 2004

• Chronic fecal loading

• High fiber diet Acquired Vs. Congenital
• Constipation

• Pregnancy
• HSD 81
Pathophysiology

• Pattern of gangrene (Bhatnagar et al., 2004)

• Gangrene confined to sigmoid colon (74%)
• Gangrene extending beyond the confines of the area under
constriction on one or both sides (26%)

• In 15% of the cases, the gangrenous sigmoid may be involved in

knotting with ileum

82
Diagnosis
• Clinical features
• Features of LBO
• Simple Vs. Gangrenous
Girmay et al., 2019
Simple (60%) Vs. Gangrenous (40%)

• Imaging
• X-ray
• “Coffee bean” or “omega loop” sign (60%)
• Barium enema
• “Bird’s beak” sign (≈100%)
• CT-scan
• Whirl sign (≈100%)
83
Treatment
• No signs of gangrene or peritonitis
• Initially: resuscitation followed by endoscopic detorsion
• Rigid proctoscope Vs. Flexible sigmoidoscope or colonoscope
• Goals
• Relieve obstruction due to volvulus
• Prevent re-volvulization
• Allow time for bowel preparation prior to surgery
• Success rate: 60% to 90%
• Recurrence rate: 70%
• Mortality rate after recurrent sigmoid volvulus: 36%
• Screening colonscopy

• After some time: bowel preparation and colectomy

84
Treatment

• Obvious signs of gangrene or peritonitis (clinical or endoscopic

signs) • Overall patient condition
• 1 stage: R-E-E-A • Status of the bowel
• 2 stage: Hartman’s procedure • Intra-abdominal condition

AnBallantyne
algorithm GH etfor
al.,the
1982management of sigmoid colon volvulus and the safety of
• Clamping before detorsion?
Pahlman et al., 1989
primary
Kuzu MAresection:
et al., 2002 experience with 827 cases
Oren D, Atamanalp
Bhatnagar et al., SS,
2004Aydinli B, et al., 2007
Oren et al., 2007 •
Decompression
• Resection and primary anastomosis is the firstbefore resection?
choice, and it can be performed with acceptable
•mortality
Primary andresection
morbidity and
rates anastomosis
if the patient is stable and a tension-free anastomosis is possible
• Reported mortality rate of 16 to 33% 85
Treatment

• Intra-op finding of a viable sigmoid

• Non-respective methods (recurrence
rate of 9% to 44%)
• Simple detorsion
• Sigmoidopexy
• Meso-sigmoidoplasty
• Extraperitonealization

• Resective methods
• Primary R-E-E-A
• Hartmann’s procedure
86
Recurrence

• Recurrence rate: 40%, 60%, 80%

• The interval of time between recurrent episodes ranges from 2

to 35 months

87
Recurrence
• The presence or absence of a previous attack makes a significant
difference in the occurrence of gangrenous bowel

Treatment after
• Recurrence of sigmoid volvulus:
sigmoid experience in Gondar, north-west
colectomy
Ethiopia
Mohammed K. et al., 1998
Minimizing recurrence after sigmoid volvulus
• 24% ofChung
patients
et al. with no previous attack had gangrenous bowel compared
with 4% after recurrence
• 6/27 (22%) patients developed recurrent volvulus

88
Outcome - Mortality

• Overall mortality (Bhatnagar 2004, Asbun 1992, Bagarani 1993, Oren 2007, Pahlman 1989, Kuzu MA 2002)
• Non-gangrenous SV: 6 to 24%
• Gangrenous SV: 11 to 80% Septic shock

• Factors that influence the adverse outcome

• Advanced age
• Associated comorbidities
• Delay in presentation or diagnosis
• Fecal peritonitis
• Previous episodes of volvulus
89
Outcome

• Morbidity rate is approximately 6 to 26%

(Bhatnagar 2004, Asbun 1992, Bagarani 1993, Oren 2007, Pahlman 1989)

• Causes of morbidity
• Wound infection
• Intra-abdominal abscess
• Evisceration
• Anastomotic leakage
• Stomal complications
• Respiratory complications
• DVT 90
Colonic tumor
obstruction

91
Introduction
• 16% patients (7% to 30%) with colon
cancer present with acute bowel
obstruction

• Majority of the obstructions occur at the

rectosigmoid junction
• Followed by the sigmoid colon

• Synchronous lesions, in the setting of an

obstructing lesion, may occur in up to 15%
92
Diagnosis

• Clinical features
• Suggestive of malignancy

• Imaging studies (abdominal x-ray or CT scan)

• Features of a large or small bowel obstruction
• Diameter of the cecum
• Urgent intervention required if diameter is ≥12 cm

93
Treatment
• Resectability of the tumor
• Site of the tumor
• Presence of synchronous tumors
• Status of bowel
• Intra-abdominal condition
• Patient status
• Expected patient survival

94
Treatment
• Resectable tumor • Unresectable tumor
• Right side • Right side
• Resection and anastomosis • Ileocolic bypass
• Left side • Diversion ileostomy
• 1 stage • Left side
• On-table lavage with segmental colon resection, • Diversion colostomy
intraoperative colonoscopy, and primary • Colonoscopic self-
anastomosis
expanding metallic stent
• 2 stage • Safe and highly successful
• Hartmann’s procedure (>90%)
• 3 stage
• Defunctioning loop colostomy, followed by resection
and anastomosis and last by closure of the
defunctioning stoma
95
Treatment

LBO secondary to a resectable tumor with liver metastases?

96
Outcomes

• Success in relieving colonic obstruction

• Emergency surgery: 99%
• Stenting: >90%

• Overall complication rate

• Emergency surgery: 51%
• Stenting: 48.5%
Cirocchi et al.

97
Post-op Ileus

98
Introduction

• Following most abdominal operations or injuries, the motility of

the GIT is transiently impaired
• Surgical stress-induced sympathetic reflexes
• Inflammatory response-mediator release
• Anesthetic/analgesic effects

99
Introduction

• The return of normal motility generally follows a characteristic

temporal sequence
• Small-intestinal motility: within first 24 hours
• Gastric motility: 48 hours
• Colonic motility: 3 to 5 days

• Routine postoperative ileus should be expected and requires no

diagnostic evaluation

100
Definition
• A recent global survey synthesized the results of available data

• Postoperative ileus • Prolonged postoperative ileus

• Interval from surgery until • ≥2 of the following occurring on or after
passage of flatus/stool AND day 4 post-op without prior resolution
tolerance of an oral diet of post-op ileus
• Inability to tolerate oral diet
• Nausea/vomiting
• Distension
• Absence of flatus
• Radiologic confirmation

101
Implications

• Prolonged ileus
• Reported to occur in 10% to 15% of patients undergoing intestinal
surgery
• Major cause of morbidity in hospitalized patients
• The most frequently implicated cause of delayed discharge following
abdominal operations

102
Etiology

• Intra-abdominal collection
• Pus
• Blood
• Bile
• GI content
• Electrolyte disturbances
• Medications
• Retroperitoneal hemorrhage
103
Diagnosis
• Clinical features
• Similar features as mechanical obstruction
• Abdominal pain
• Bowel sound

• Imaging
• Plain abdominal x-ray
• Distinction between ileus and mechanical
obstruction may be difficult
• Etiology
• CT-scan
• Preferable
104
Treatment
• Limit oral intake
• TPN may be required

• IV Fluids and electrolytes

• NG tube
• If vomiting or abdominal distention are prominent

• Correct the underlying inciting factor

• ?Prokinetic agents 105

Prevention

Intraoperative measures Postoperative measures

• Laparoscopic approach, if • Avoid nasogastric tubes
possible • Early enteral feeding
• Minimalize handling of the • Restricted IV fluid administration
bowel
• Correct electrolyte abnormalities
• Restricted intra-op fluid
administration • Epidural anesthesia, if indicated
• Consider mu-opiod antagonists

106
Early postoperative
bowel obstruction

107
Introduction
• It is a relatively uncommon problem but remains a very real dilemma
encountered in every practice
• Reported to occur in 0.7% to 9% of patients, with a higher rate in patients
undergoing pelvic surgery, especially colorectal procedures

• Definition
• Surgery literature defines early obstruction from 30 days to 6 weeks after the
original operation
• Schwartz’s: 30 days
• Maingot’s: 6 weeks
108
Etiology

Mechanical Functional
• Early post-op adhesions (90%) • Anastomotic leak
• Hernias • Intra-abdominal abscess
• Internal herniation • Hematoma
• Fascial herniation
• Bile
• Intususception
• Anastomotic edema/stenosis
• Intramural intestinal hematoma
109
Diagnosis

• It is often difficult, if not impossible, to distinguish early

obstruction from postoperative ileus
• Vague symptoms
• Unreliable physical findings
• Similar imaging findings

• CT scanning or small bowel series often required

• To look for etiology
• Poor at differentiating ileus versus partial mechanical obstruction

110
Treatment

• Conservative management
• No compelling indications
• Complete obstruction, strangulation, and/or peritonitis
• No Other remediable causes
• Collections
• Hernias

• No response
• Wait
111
Summary

• Intestinal obstruction is a common surgical emergency

• Imaging has a key role in diagnosis

• Pre-operative stabilization of the patient is of paramount

importance for good surgical outcome

• Management decisions should be individualized

112
References
Literatures - Local
• B. Kotiso, Z. Abdurahman. Pattern of Acute Abdomen in Adult Patients in Tikur Anbessa Teaching Hospital,
Addis Ababa, Ethiopia. 2007
• S. Tsegaye, M. Osman, A. Bekele. Surgically Treated Acute Abdomen at Gondar University Hospital, Ethiopia.
2007
• Girmay Hagos Araaya (MD, FCS), Temesgen G/Mariam (MD). Pattern of Non-traumatic Acute Abdomen in
Patients from Ayder Comprehensive Specialized Hospital, Northern Ethiopia: A retrospective analysis. 2019
• A. Tegegne. Cultural bowel patterns and sex difference in sigmoid volvulus morbidity in an Ethiopian
hospital. 1995
• Ali MK. Treatment of sigmoid volvulus: experience in Gondar, north-west Ethiopia. 1998
• Asefa Z. Pattern of acute abdomen in Yirgalem Hospital, southern Ethiopia. 2000
• K. Ghebrat. Seasonal variation of primary small intestinal volvulus in North Western Ethiopia. 1998
• Ghebrat K. Seasonal variation of primary small intestinal volvulus in North Western Ethiopia. 2001
• M. Demissie. Small intestinal volvulus in southern Ethiopia. 2001
113
References
Literatures - Abroad
• Tushar Patial , Sahil Chaddha , Namit Rathore , Vishal Thakur. Small Bowel Volvulus: A Case Report. 2017
• Ali Nuhu, Abubacar jah. Acute sigmoid volvulus in west African Population.2010
• Flavio G. Rocha, MD; Todd A. Theman, BS; Evan Matros, MD; Stephen M. Ledbetter, MD, MPH; Michael J.
Zinner, MD; Stephen J. Ferzoco, MD. Nonoperative Management of Patients With a Diagnosis of High-grade
Small Bowel Obstruction by Computed Tomography. 2009
• Tim Jancelewicz, Lan T. Vu Alexandra E. Shawo, Benjamin Yeh, Warren J. Gasper, Hobart W. Harris. Predicting
Strangulated Small Bowel Obstruction: An Old Problem Revisited. 2009
• Mallo RD, Salem L, Lalani T, Flum DR. Computed tomography diagnosis of ischemia and complete obstruction
in small bowel obstruction: a systematic review. 2005
• Sheedy SP, Earnest Ft, Fletcher JG, Fidler JL, Hoskin TL. CT of small- bowel ischemia associated with
obstruction in emergency department patients: diagnostic performance evaluation. 2006
• Oren D, Atamanalp SS, Aydinli B, et al. An algorithm for the management of sigmoid colon volvulus and the
safety of primary resection: experience with 827 cases. 2007

114
References
Literatures - Abroad
• Wei-Wei Jiang, Xiao-Qun Xu, Qi-Ming Geng, Jie Zhang, Huan Chen, Xiao-Feng Lv, Chang-Gui Lu, and Wei-
Bing Tang. Enteroenteroanastomosis near adjacent ileocecal valve in infants. 2012
• Flavio G. Rocha, MD; Todd A. Theman, BS; Evan Matros, MD; Stephen M. Ledbetter, MD, MPH; Michael J. Zinner,
MD; Stephen J. Ferzoco, MD. Nonoperative Management of Patients With a Diagnosis of High-grade Small Bowel
Obstruction by Computed Tomography. 2009
• B. T. Fevang, D. Jensen, K. Svanes. Early Operation or Conservative Management of Patients with Small Bowel
Obstruction? 2002
• Jeffrey Landercasper, MD; Thomas H. Cogbill, MD; William H. Merry, MD; et al. Long-term Outcome After
Hospitalization for Small-Bowel Obstruction. 1993
• Phillip R.Fleshner MD, Michael G.SiegmanMD, Gary I.SlaterMD, Robert E.BrolinMD, James C.ChandlerMD, Arthur
H.AufsesJr.MD. A prospective, randomized trial of short versus long tubes in adhesive small-bowel obstruction. 1995
• Shyr-Chyr Chen, King-Jen Chang, Po-Huang Lee, Shih-Ming Wang, Kai-Mo Chen, Fang-Yue Lin. Oral Urografin in
Postoperative Small Bowel Obstruction. 1999
• Daniel I chu et al. Early Versus Late Adhesiolysis for Adhesive-Related Intestinal Obstruction: A Nationwide Analysis
of Inpatient Outcomes. 2013
115
References
Literatures - Abroad
• Marco Ceresoli et al. Water-soluble contrast agent in adhesive small bowel obstruction: a systematic
review and meta-analysis of diagnostic and therapeutic value. 2016
• D. Menzies et al. Intestinal obstruction form adhesion - how big is the problem? 2010
• Chung et al. Minimizing recurrence after sigmoid volvulus. 1997
• Törer N, Nursal TZ, Tufan H, Can F, Bal N, Tarim A, Moray G, Haberal M. Effect of manual bowel
decompression (milking) in the obstructed small bowel. 2008
• Ezer A, Torer N, Colakoglu T, Colakoglu S, Parlakgumus A, Yildirim S, Moray G. Clinical outcomes of
manual bowel decompression (milking) in the mechanical small bowel obstruction: a prospective
randomized clinical trial. 2012
• Eli Avisar, MD, Harry B. Abramowitz, MD, FACS, and Omri Z. Lernau, MD, FACS. Elective
Extraperitonealization for Sigmoid Volvulus: An Effective and Safe Alternative. 1997
• Hok-Kwok Choi et al. Therapeutic Value of Gastrografin in Adhesive Small Bowel Obstruction
After Unsuccessful Conservative Treatment: A Prospective Randomized Trial. 2002
116
References
Text books

117
Thank You!

118