Intestinal Obstruction

Ahmed Badrek-Amoudi

FRCS

The common Scenario

A 50 year old gentleman presents
with abdominal pain, distension and
absolute constipation. With
repeated episodes of vomiting.
His vital sign were stable, abdomen
distended with diffuse tenderness
but minimal peritonism. Bowel
Sounds are hyperactive.
The plain abdominal xray was taken
on admission.

?What are your objectives

You should be able to address the following questions
1. Is this bowel obstruction or ileus?
2. Is this a small or large bowel obstruction?
3. Is this proximal or distal obstruction?
4. What is the cause of this obstruction?
5. Is this a complex or simple obstruction?
6. How should I start investigating my patient?
7. What is the role of other supportive investigations?
8. What is my immediate/ intermediate treatment plan?
9. What are the indications for surgery?
10. What are the medico-legal and ethical issues that I
should address?

Introduction and Definitions

Accounts for 5% of all acute surgical admissions
Patients are often extremely ill requiring prompt
assessment, resuscitation and intensive
monitoring
Obstruction A mechanical blockage arising from a
structural abnormality that presents a
physical barrier to the progression of gut
contents.
Ileus
is a paralytic or functional variety of
obstruction

Obstruction is:

Partial or complete
Simple or strangulated

Patho-physiology I

8L of isotonic fluid received by the small intestines (saliva,

stomach, duodenum, pancreas and hepatobiliary )
7L absorbed
2L enter the large intestine and 200 ml excreted in the
faeces
Air in the bowel results from swallowed air ( O 2 & N2) and
bacterial fermentation in the colon ( H 2, Methane & CO2),
600 ml of flatus is released
Enteric bacteria consist of coliforms, anaerobes and
strep.faecalis.
Normal intestinal mucosa has a significant immune role
Distension results from gas and/ or fluid and can exert
hydrostatic pressure.
In case of BO Bacterial overgrowth can be rapid
If mucosal barrier is breached it may result in translocation of
bacteria and toxins resulting in bactaeremia, septaecemia and
toxaemia.

Patho-physiology II
Obstruction results in:
1.
2.
3.
4.
5.
6.
7.
8.

Initial overcoming of the obstruction by increased paristalsis

Increased intraluminal pressure by fluid and gas
Vomiting
sequestration of fluid into the lumen from the surrounding
circulation
Lymphatic and venous congestion resulting in oedematous
tissues
Factors 3,4,5 result in hypovolaemia and electrolyte
imbalance
Further: localised anoxia, mucosal depletion necrosis and
perforation and peritonitis.
Bacterial over growth with translocation of bacteria and its
toxins causing bacteraemia and septicaemia.

Decompress with NGT

Replace lost fluid
Correct electrolyte abnormalities
Recognise strangulation and perforation
Systemic antibiotics.

Causes- Small Bowel

Luminal

Mural

F. Body
Neoplasims
Bezoars
lipoma
Gall stone
polyps
Food
leiyomayoma
Particles
hematoma
A. lumbricoides
lymphoma
carcimoid
carinoma
secondary
Tumors
Crohns
TB
Stricture
Intussusception

Extralumina
l
Postoperati
ve
adhesions
Congenital
adhesions
Hernia
Volvulus

Small Bowel Adhesions

Accounts for 60-70% of All SBO

Results from peritoneal injury, platelet activation and fibrin
formation.
Associated with starch covered gloves, intraperitoneal sepsis,
haemorrhage and wash with irritant solutions iodine and other
foreign bodies.
As early as 4 weeks post laparotomy. The majority of patients
present between 1-5 years

Colorectal Surgery 25%

Gynaecological
20%
Appendectomy
14%

70% of patients had a single band

Patients with complex bands are more likely to be readmitted
Readmission in surgically treated patients is 35%

Hernia

Accounts for 20% of SBO

Commonest 1. Femoral hernia
2. ID inguinal
3. Umbilical
4. Others: incisional and internal H.
The site of obstruction is the neck of hernia
The compromised viscus is with in the sac.
Ischaemia occurs initially by venous occlusion,
followed by oedema and arterialc ompromise.
Attempt to distinguish the difference between:

Incaceration
Sliding
Obstruction

Strangulation is noted by:

Persistent pain
Discolouration
Tenderness
Constitutional symptoms

Other causes

Intussusception

Gall stone Ileus

IBD

Large Bowel Obstruction

Distinguishing ileus from mechanical obstruction is challenging
According to Leplacs law: maximum pressure is at the its
maximum diameter. Cecum is at the greatest risk of perforation
Perforation results in the release of formed feaces with heavy
bacterial contamination
Aetiology:
1. Carcinoma:

The commonest cause, 18% of colonic ca. present

with obstruction
2. Benign stricture: Due to Diverticular disease, Ischemia,
Inflammatory bowel disease.
3. Volvulus:
1. Sigmoid Volvulus: Results from long redundant,
faecaly loaded colon with a narrow pedicle
2. Caecal Volvulus
4. Hernia.
5. Congenital :
Hirschusbrung, anal stenosis and agenesis

Sigmoid Volvulus

Colonic Obstruction

Radiological Evaluation
Normal Scout
Always request: Supine, Erect and CXR
Gas pattern:

Gastric,
Colonic and 1-2 small bowel

Fluid Levels:

Gastric
1-2 small bowel

Check gasses in 4 areas:

1.
2.
3.
4.

Caecal
Hepatobiliary
Free gas under diaphragm
Rectum

Look for calcification

Look for soft tissue masses, psoas shadow
Look for fecal pattern

The Difference between small

and large bowel obstruction
Large bowel
Peripheral ( diameter 8 cm max)
Presence of haustration

Small Bowel
Central ( diameter 5 cm max)
Vulvulae coniventae
Ileum: may appear tubeless

Role of CT

Used with iv contrast, oral and

rectal contrast (triple contrast).
Able to demonstrate
abnormality in the bowel wall,
mesentery, mesenteric vessels
and peritoneum.

It can define

the level of obstruction

The degree of obstruction

The cause: volvulus,

hernia, luminal and mural
causes

The degree of ischaemia

Free fluid and gas

Ensure: patient vitally stable

with no renal failure and no
previous alergy to iodine

Role of barium
gastrografin studies
Barium should not be used in
a patient with peritonitis

As: follow through, enema

Limited use in the acute
setting
Gastrografin is used in
acute abdomen but is
diluted
Useful in recurrent and
chronic obstruction
May able to define the level
and mural causes.
Can be used to distinguish
adynamic and mechanical
obstruction

How to initially investigate

your patient

Lab:

Radilogical:

CBC (leukocytosis, anaemia, hematocrit, platelets)

Clotting profile
Arterial blood gasses
U& Crt, Na, K, Amylase, LFT and glucose, LDH
Group and save (x-match if needed)
Optional (ESR, CRP, Hepatitis profile
Plain xrays
USS ( free fluid, masses, mucosal folds, pattern of paristalsis,
Doppler of mesenteric vasulature, solid organs)
Other advanced studies (CT, MRI, Contrast studiessenior
decision)

ECG and other investigations for co-morbid factors

Understanding the
clinical findings

Clinical Findings

1. History

The Universal Features

Colicky abdominal pain, vomiting, constipation (absolute), abdominal
.distension
Complete HX ( PMH, PSH, ROS, Medication, FH, SH)

High
Pain is rapid
Vomiting copious and
contains bile jejunal
content
Abdominal distension
is limited or localized
Rapid dehydration

Distal small bowel

Colonic

Pain: central and

colicky
Vomitus is feculunt
Distension is severe
Visible peristalsis
May continue to pass
flatus and feacus
before absolute
constipation

? Preexisting change
in bowel habit
Colicky in the lower
abdomin
Vomiting is late
Distension prominent
Cecum ? distended

Persistent pain may be a sign of strangulation

Relative and absolute constipation

Clinical Findings

2. Examination
General
Vital signs:
P, BP, RR, T, Sat
dehydration
Anaemia, jaundice,
LN
Assessment of
vomitus if possible
Full lung and heart
examination

Abdominal
Abdominal
distension and its
pattern
Hernial orifices
Visible peristalsis
Cecal distension
Tenderness,
guarding and
rebound
Organomegaly
Bowel sounds
High pitched
Absent

Rectal examination

Others
Systemic examination
If deemed necessary.
CNS
Vascular
Gynaecological
muscuoloskeltal

Initial Management in the ER

Resuscitate:

Air way (O2 60-100%)

Insert 2 lines if necessary
IVF : Crytloids at least 120 ml/h. (determined by estimated fluid
loss and cardiac function). Add K+ at 1mmmol/kg

Draw blood for lab investigations

Inform a senior member in the team.
NPO.
Decompress with Naso-gastric tube and secure in position
Insert a urinary catheter (hourly urinary measurements) and
start a fluid input / output chart
Intravenous antibiotics (no clear evidence)
If concerns exist about fluid overloading a central line should be
inserted
Follow-up lab results and correction of electrolyte imbalance
The patient should be nursed in intermediate care
Rectal tubes should only be used in Sigmoid volvulus.

Indications for Surgery

Immediate intervention:

Evidence of strangulation (hernia.etc)

Signs of peritonitis resulting from perforation or ischemia

In the next 24-48 hours

Clear indication of no resolution of obstruction ( Clinical,

radiological).

Diagnosis is unclear in a virgin abdomen

Intermediate stage
The cause has been diagnosed and the patient is stabalised

Legal issues and consent

Ileus

Associated with the following conditions:

Postoperative and bowel resection

Intraperitoneal infection or inflammation
Ischemia
Extra-abdominal: Chest infection, Myocardia infarction
Endocrine: hypothyroidism, diabetes
Spinal and pelvic fractures
Retro-peritoneal haematoma
Metabolic abnormalities:
Hypokalaemia
Hyponatremia
Uraemia
Hypomagnesemia
Bed ridden
Drug induced: morphine, tricyclic antidepressants

Is this an ileus or
obstruction
Clinical features

Is there an under lying cause?

Is the abdomen distended but tenderness is not marked.

Is the bowel sounds diffusely hypoactive.

Radiological features:

Is the bowel diffusely distended

Is there gas in the rectum

Are further investigasions (CT or Gastrografin studies) helpful

in showing an obstruction.
Does the patient improve on conservative measures

Example of ileus