ALVA’S HOMOEOPATHIC MEDICAL COLLEGE MIJAR

MOODABIDRI

SURGERY SEMINAR
Sai Bhuvan Kottary – 54

DEPARTMENT OF SURGERY

HOD - DR. SHIVAKUMAR M K

ASSISTANT PROFESSOR - DR. MAHALASA KAMATH
Patient comes with complaints of ….
• abdominal pain (Colicky) (Once in 4-5 mins)
• Nausea
• Vomiting (yellow-green vomitus)
• Abdominal distention
• Constipation

H/O :

abdominal surgery / diarrhea

INTESTINAL
OBSTRUCTIO
N
Objectives…

• Adhesive obstruction
• Strangulation
• Closed-loop obstruction
 OBSTRUCTION
means
Blockage of a structure that prevents it from functioning
normally.
 OBSTRUCTION
INTESTINAL
means
Partial or complete blockage of lumen of the large or
small intestine.
ILEUS refers to intestinal obstruction when there is loss
of the forward flow of intestinal contents.
 Intussusception tuberculosis
Duplications
Endometriosis Radiation enteropathy
Crohns disease
Intraabdominal Abscess Adhesions
Carcinomatosis paralytic ileus
Stercoliths phytobezoars
Extraintestinal neoplasia
trichobezoars Food
Volvulus
hematoma
intestinal neoplasia ischemic strictures
neoplasms
Malrotation Gallstones cysts Hernia

diverticulitis Worms
actinomycosis
Regional Classification…
1. Small bowel obstruction (~80%)
2. Colon obstruction
Classification
Intestinal obstruction maybe primarily classified as

1. DYNAMIC OBSTRUCTION
In which peristalsis is working against a mechanical obstruction

2. ADYNAMIC OBSTRUCTION
Here peristalsis is absent or inadequate with no mechanical obstruction
(Like paralysis)
In DYNAMIC OBSTRUCTION it can be
further classified into -
1. Extramural lesions / Obstruction from Extraluminal
causes.

2. Intramural lesions / Obstructions from lesions

Intrinsic to the bowel wall.

3. Intraluminal, Obturator Obstruction.

 ?
Extramural lesions Intramural lesions

Intraluminal, Obturator Obstruction

1. Obstruction from Extraluminal causes/ Extramural
lesions.
1. Adhesions (usually postoperative) (~60%)
2. Hernia (~10% sbo)
External – inguinal, femoral, umbilical & ventral
Internal – congenital mesenteric defects - like paraduodenal, foramen of Winslow.
3. Neoplastic (~20% sbo)
Carcinomatosis
Extraintestinal neoplasia
4. Intraabdominal Abscess
5. Volvulus
Adhesive
intestinal
obstruction
Adhesive intestinal obstruction
Adhesions are fibrous band which holds parts together that are
normally separated.

• Any source of peritoneal irritation results in local fibrin production,

which produces adhesions between apposed surfaces.

• Early fibrinous adhesions may disappear when the cause is removed

or they may become vascularized and be replaced by mature fibrous
tissue.
Adhesions can be of 2 types ;

1. Fibrinous - ‘easy’ flimsy ones

2. Fibrous - ‘difficult’ dense ones

Band
Adhesion
Adhesive
intestinal
obstruction
Hernia
Hernia
2. Obstructions from lesions Intrinsic to the bowel
wall / Intramural lesions
1. Congenital – Malrotation, Duplications, cysts.
2. Inflammatory (entric strictures) (15% - bo)
Crohns disease (5% - sbo)
Infections – tuberculosis, actinomycosis, diverticulitis
3. Neoplastic (~20% sbo)– primary neoplasms, metastatic neoplasms
4. Traumatic –hematoma, ischemic strictures
5. Miscellaneous (~5% sbo)
Intussusception
Endometriosis
Radiation enteropathy
The slipping of one part of
an intestine into another
part just below it; becoming
ensheathed.
INTRALUMINAL, Obturator Obstruction (8% - bo)
1. Gallstones
2. Food
3. Bezoar – trichobezoars and phytobezoars
4. Stercoliths/ Enteroliths
5. Worms – Ascaris Lumbricodes
enteroliths
phytobezoars
trichobezoars
Worms – Ascaris Lumbricodes
The common causes of intestinal obstruction and their relative frequencies

miscellaneous
5%
pseudo-obstruction
5%
faecal impaction
8%

adhesions
40%
carcinoma
15%

inflammatory
15% obstructed hernias
 3 Levels of Intestinal Obstruction
1. Simple Mechanical Obstruction
2. Strangulation
3. Closed-loop obstruction
Simple Mechanical Obstruction
• It is a simple form of dynamic obstruction .
• Here the blood supply to the intestines is not hindered.
Strangulation
• Intestinal obstruction are not immediately life-threatening,
unless there is superimposed Strangulation.

• When strangulation occurs, the blood supply is

compromised and the bowel becomes ischaemic
Strangulation -
Causes of strangulation
Direct pressure on the bowel wall
● Hernial orifices
● Adhesions/bands
Interrupted mesenteric blood flow
● Volvulus
● Intussusception
Increased intraluminal pressure
● Closed-loop obstruction
Closed-loop obstruction
• This occurs when the bowel is obstructed at both the proximal and
distal point.

• The distension is principally confined to the closed loop; and the

distension of the proximal segment is less marked
• Closed loop obstructions are classically in the presence of malignant
structure of the colon with competent ileocaecal valve

• This ultimately increases the luminal pressure, (more in the caecum)

causing impairment of blood flow to the wall... Untreated may result
in necrosis and perforation
Pathology

Early in the course of an obstruction, intestinal motility and contractile activity

increase in an effort to propel luminal contents past the obstructing point. The
increase in peristalsis that occurs early in the course of bowel obstruction is
present above and below the point of obstruction; this process can account
for the finding of diarrhea that may accompany partial or even complete small
bowel obstruction in the early period. Later in the course of obstruction, the
intestine becomes fatigued and dilates, with contractions becoming less
frequent and less intense.
As the bowel dilates, water and electrolytes accumulate intraluminally and in the bowel wall itself. This
massive third-space fluid loss accounts for the dehydration and hypovolemia. The metabolic effects of
fluid loss depend on the site and duration of the obstruction. With a proximal obstruction, dehydration
may be accompanied by hypochloremia, hypokalemia, and metabolic alkalosis associated with
increased vomiting. Distal obstruction of the small bowel may result in large quantities of intestinal
fluid into the bowel; however, abnormalities in serum electrolyte levels are usually less dramatic.
Oliguria, azotemia, and hemoconcentration can accompany the dehydration. Rarely, hypotension and
shock can ensue. Other consequences of bowel obstruction include increased intraabdominal
pressure, decreased venous return, and elevation of the diaphragm, compromising ventilation. These
factors can serve to potentiate the effects of hypovolemia.
As the intraluminal pressure increases in the bowel, a decrease in mucosal
blood flow can occur. This alteration is particularly noted in patients with
a closed loop obstruction, in which greater intraluminal pressures are
attained. A closed loop obstruction, produced commonly by a twist of the
bowel, can progress to arterial occlusion and ischemia if it is left untreated
and may potentially lead to bowel perforation and peritonitis.
In the absence of intestinal obstruction, the jejunum and proximal ileum have only 103 to 105
colony-forming units per milliliter (CFU/mL) of bacteria. With obstruction, however, the flora of
the small intestine changes dramatically, in both the type of organism (most commonly
Escherichia coli, Streptococcus faecalis, and Klebsiella spp.) and the quantity, with organisms
reaching concentrations of 109 to 1010 CFU/mL. Studies have shown an increase in the number
of indigenous bacteria translocating to mesenteric lymph nodes and even systemic organs.
Bacterial translocation amplifies the local inflammatory response in the gut, leading to
intestinal leakage and subsequent increase in systemic inflammation. This inflammatory
cascade may result in systemic sepsis and multiorgan failure if it is unrecognized and untreated
 E
Increased motility & contractility.
a Leading to symptoms like diarrhoea.
r Gets fatigued and dilates.
l
y Third spacing - intraluminal water and electrolytes accumulation.
• Proximal obstruction- dehydration, hypochloremia, hypokalemia, and
Obstructive
metabolic alkalosis.
i • Distal obstruction- much more fluid loss with less electrolyte loss.
s
c • In closed loop obstruction As the intraluminal pressure increases in the
h bowel, there is decrease in mucosal blood flow.
e
m • Leads to arterial occlusion and ischemia and may cause bowel
i perforation and peritonitis.
cL
• Drastic increase in intraluminal bacteria and its translocation to
a
t
mesenteric lymph nodes
e • intestinal leakage and subsequent increase in systemic inflammation
leading to systemic sepsis and multiorgan failure
ADYNAMIC OBSTRUCTION
Paralytic Ileus
It may be defined as the state in which there is failure of transmission
of peristaltic waves secondary to neuromuscular failure.

The resultant stasis leads to accumulation of fluid and gas within the
bowel , with the classical symptoms of dynamic obstruction BUT
WITHOUT ANY BOWEL SOUNDS.
Varieties
1.postoperative: it is self limiting with a variable duration 25- 72 hrs,
but may prolong in the presence of hypoproteinaemia or metabolic
abnormalities
2. Infections: intra-abdominal sepsis may cause localised or generalised
ileus
3. Reflex ileus: due to spinal injuries or retroperitoneal trauma causing
over stimulation of sympathetic reflex
4. Metabolic: uraemia and hypokalaemina are the most common
contributors
Clinical features
• Signs and Symptoms
• Physical Examination
The presentation may vary on the basis of …
• Location of obstruction

• Duration since the obstruction

• Underlying pathology

• Presence or absence of intestinal ischaemia

Clinically it can be classified under
• Acute intestinal obstruction
• Here there is complete obstruction
• All the cardinal symptoms and signs may be present

• Chronic intestinal obstruction

• Here there is incomplete obstruction
• They may lack the cardinal symptoms and signs and maybe
are intermittent
• These are also referred to as partial or subacute intestinal
obstruction
The 4 cardinal Sign and symptoms are

1. Abdomen pain
2. Vomiting
3. distension
4. Absolute constipation
ABDOMINAL PAIN
• It is the 1st symptom, the onset is sudden and severe.
• It a localised, non radiating, colicky type of pain.
(small bowel – centred to the umbilicus)
(large bowel – towards the hypogastrium)
• Severity of 10/10 in pain scale.
• Pain coincides with every peristalsis.
• Pain gets worsened as the abdomen continues to distend.
• Pain is less frequent in distal bowel obstruction.
• Pain usually is not be present in PARALYTIC ILEUS
Vomiting
• More common in higher obstruction
• The more distal the obstruction, the longer the interval between the
onset of symptoms and the appearance of nausea and vomiting.
Vomitus
• Bilious vomitus is usually seen
• As obstruction progresses the character of the vomitus alters from
digested food to faeculent material,
(more distal the obstruction -> more faeculant the vomitus)
Abdominal distension
• Distension occurs proximal to the obstruction .

• Degree of distension depends on the site of the obstruction.

• Peristalsis maybe visible in thin patients, and can be sometimes
provoked by flicking the abdomen.
Constipation
• 2 types of constipations
Absolute & relative constipation
Absolute Constipation
• Absolute constipation is the cardinal feature of COMPLETE bowel
obstruction.

• History of diarrhoea is just secondary to increased peristalsis in initial

stage during obstruction.
Later on other symptoms are seen -
• Dehydration symptoms like – dry tongue and skin, poor venous filling,
sunken eyes with oliguria
• Blood urea level may increase and there maybe haematocrit rise,
secondary to polycythaemia
• Hypokalaemia symptoms maybe seen weakness and irritability with
muscular hypotonia and weakness maybe seen
• Presence of fever indicates - onset of ischaemia (especially in
strangulation), intestinal perforation, inflammation or abscess with
the obstructing disease
Ischaemic small
and large bowel
in a strangulated
incisional hernia
• Hypothermia indicates septic shock or neglected case of long duration
On Physical Examination
On general physical examination
• Increased Pulse rate
• Fall in Blood pressure
• Fever in strangulation
Inspection
• Look for abdominal distension, where peristalsis maybe visible in
early course

• Look for previous surgical scars on abdomen

 Visible peristalsis.
Intestinal obstruction
due to a strangulated
right femoral hernia
Palpation
• Localised tenderness indicates impending ischaemia.
• Peritonism or peritonitis may indicate infarction or perforation
Auscultation
• In early stages High pitched sound of hyperactive bowel can be heard
as “rushing“ with vigorous peristalsis (borborygmic).

• Later in obstructive course there maybe minimal or no bowel sounds.

Investigations and diagnosis
• Laboratory tests
• Radiographic imaging
Laboratory finding
• It is useful in assessment of level of dehydration and not for the actual
diagnosis.
• Leucocytosis is seen in strangulation.
• Increase in lactic acid and procalcitonin maybe seen after bowel
ischaemia and necrosis.
Radiographic finding
X ray maybe taken on
• Upright position or on left lateral decubitus position
• Supine or prone position
• Barium study
 Supine film shows
dilated loops of small
A
bowel in an orderly
arrangement, without
evidence of colonic
gas
Upright film shows
multiple, short air-
fluid levels arranged
in a stepwise pattern.
Fluid levels with gas above;
‘stepladder pattern’. Ileal
obstruction caused by
adhesions (erect abdominal
radiograph)
Barium study
demonstrates
jejunojejunal
intussusception.

barium studies can precisely demonstrate

the level of the obstruction as well as the
cause of the obstruction in certain cases
Stepladder pattern of
paralytic ileus
Other investigations like
• CT scan
• MRI
• USG (in pregnant females)
Can help diagnose and can help in finding out the cause of obstruction.
Differential diagnosis
• Appendicitis
• Diverticulitis
• Gastroenteritis
• Mesenteric adenitis

• Pancreatitis
• peritonitis
• Peptic ulceration