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Small bowel obstruction supine
Small bowel obstruction, upright
On plain x-rays, a ladderlike series of distended small-bowel loops is
typical of small-bowel obstruction, but may also occur with obstruction
of the right colon. Fluid levels in the bowel can be seen in upright
views. Similar, although perhaps less dramatic, x-ray findings and
symptoms occur in ileus (paralysis of the intestine without obstruction);
clear cut differentiation can be difficult. Distended loops and fluid
levels may be absent with an obstruction of the upper jejunum or with
closed-loop strangulating obstructions (as may occur with volvulus).
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Infarcted bowel may produce a mass effect on x-ray. Gas in the bowel
wall (pneumatosis intestinalis) indicates gangrene. In large-bowel
obstruction, abdominal x-ray shows distention of the colon proximal
to the obstruction. In cecal volvulus, there may be a large gas bubble
in the mid-abdomen or left upper quadrant. With both cecal and
sigmoidal volvulus, a contrast enema shows the site of obstruction by
a typical “bird-beak” deformity at the site of the twist; the procedure
may actually reduce a sigmoid volvulus. If contrast enema is not done,
colonoscopy can be used to decompress a sigmoid volvulus but rarely
works with a cecal volvulus.
Acute intestinal obstruction:
The cardinal features of intestinal intestinal obstruction are: colicky
pain, vomiting, distention and constipation They vary according to:
- The location of obstruction
- The duration of obstruction
- The underlying pathology
- The presence or absence of intestinal ischemia
Late manifestations of acute intestinal obstruction are: dehydration,
oliguria, hypovolumic shock, pyrexia, septicemia, respiratory failure,
and peritonism
N.B in any case of suspected intestinal obstruction all the hernial
orifices should be examined
Pain:
· It is the first symptom, it is usually sudden, sever, colicky in
nature, around the umbilicus in small bowel obstruction, and in the
lower abdomen in large bowel obstruction, it change to mild
constant pain with increasing distention. Sever pain may indicate
strangulation. The pain is absent in paralytic ileus
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Vomiting:
· The more distal the obstruction, the longer the interval between the
onset of symptoms and the appearance of nausea and vomiting. In
the beginning the vomitus is digested food then it become faeculent
material due to bacterial over growth
Distention:
· In small bowel the more distal the obstruction the greater the
distention, visible peristalsis may be seen in advanced cases. The
distention is delayed in large bowel obstruction and it is minimal
or absent in mesenteric vascular occlusion
Constipation:
· It can be absolute or relative constipation.
· Absolute constipation is cardinal feature of complete obstruction,
however, some patients pass flatus or faeces after the obstruction
due to evacuation of distal segment which is normal.
· It is not a feature of intestinal obstruction due to:
- Richter’s hernia
- Gall bladder stone obstruction
- Mesenteric vascular occlusion
- Obstruction associated with pelvic abscess
- Partial obstruction (faecal impaction, colonic carcinoma)
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Acute intestinal obstruction with abdominal distention
Dehydration:
· It is more common in small bowel obstruction
· Clinical features are: tachycardia, hypotension, dry skin and tongue,
poor venous filling, sunken eyes and oliguria
· Blood urea and haematocrit are raised
· It is not common feature of simple mechanical obstruction
Pyrexia:
· It may indicate: onset of ischemia, perforation or inflammation
associated with the obstructing disease
· Hypothermia indicate septic shock
Abdominal finding:
· Localized tenderness indicate bowel ischemia
· Peritonism indicate infarction or /and perforation
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Clinical features of Strangulation:
· The diagnosis is mainly clinical, and it should be differentiated
from non strangulating obstruction
· Presence of shock indicate bowel ischemia
· Strangulation always associated with pain (usually sever)
· Symptoms are sudden and recur regularly
· Localized tenderness with rigidity and rebound tenderness
· Generalized tenderness and rigidity are indications for early
laparotomy
· Persistent pain despite conservative measures, even in absence of
the above signs is diagnostic of strangulation
· In external hernia, the lump is tense, tender, irreducible, no cough
impulse and suddenly increase in size
· Frequent clinical assessment of patient with intestinal obstruction
is needed for early diagnosis of strangulation
Treatment of acute intestinal obstruction: (suck and drip)
2- Fluid and electrolyte replacement indicated in pre, intra and post
operative period
3- Relief of obstruction ( usually surgical ) the surgical treatment can
be delayed if there is no signs of strangulation or closed loop
obstruction
I- Supportive treatment:
i- Nasogastric decompression: by Ryle`s tube decompression proximal
to the obstruction reduce the risk of aspiration during operation
ii- Replacement of water and sodium loss by normal saline or
Hartmann`s solutions
iii- Antibiotics: not always mandatory in all patients undergoing
resection
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* Blood transfusion may be needed in cases of strangulation
II- Surgical treatment:
· Early surgical intervention is indicated in:
- Obstructed or strangulated external hernia
- Internal intestinal strangulation
- Acute obstruction
· in general early intervention is always advised unless the cause is
adhesions and patient has no pain nor tenderness despite of positive
x rays
· conservative management can be continued up to 72 hours with
close monitoring of the patient and it should be stop if there is any
sign of ischemia or there is no sign of improvement.
· adequate exposure is best achieved by mid line incision
· The operative assessment is directed to: Site and nature of obstruction
and the viability of the gut
· If the caecum is collapsed the obstruction in small bowel, if it is
dilated it indicate large bowel obstruction
· Dilated loops may require decompression if:
- they prevent good exposure
- Viability of the bowel is compromised
- Subsequent closure will be difficult
- And to remove the toxic material from the lumen
All the amount of fluid removed should be accurately and replaced
with normal saline and potassium.
· The type of procedure indicated depends on the cause: division of
adhesion, excision, bypass or proximal decompression
· After relief of obstruction the viability of the segment should be
carefully evaluated.
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· Clearly infarcted bowel is obvious: dark coloured, dull peritoneal
covering, flappy thin and friable, no bleeding from its mesentery
and no pulsation this segment of bowel should be resected
where viability is not sure:
bowel resuscitation measures should be done:
· Bowel should wrapped in a warm, moist packs
· Pure oxygen 100% should be given to the patient special attention
should be paid to pressure rings after 10 minutes
viability should be clear.
· if there is multiple ischemic patches (mesenteric vascular occlusion) a
second look laparotomy at 24-48 hrs is indicated small patches of
doubtful viability should be infolded by seromuscular suture and
covered with omentum.
Chronic intestinal obstruction:
The clinical picture due to the underlying pathology the subsequent
Obstruction
1. Organic causes:
· Intramural: fecal impaction
· Mural: colorectal cancer, diverticulitis, stricture (Cohn’s ischemia),
anastomotic stenosis
· Extramural: adhesions (small bowel), metastatic deposits, endometriosis
2. Functional causes:
· Hirschsprung`s disease, congenital megacolon, pseudo obstruction
Clinical features:
· Constipation: first symptom, relative then absolute
· Abdominal distention: more at the caecal area
· Lower abdominal pain
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· Vomiting is late and therefore dehydration is late
· O/E: abdominal distention,peritonism in late cases P/R: palpable
mass or fecal impaction
Investigations:
Plain x ray: large bowel obstruction
Single contrast water soluble enema can rule out functional lesion
Colonoscopy differentiate organic from functional causes
Treatment:
Functional: conservative measures, colonoscopic decompression
Organic: treatment according to the cause
Treatment of intestinal obstruction.
1. Nasogastric suction
2. IV fluids
3. IV antibiotics if bowel ischemia suspected
Patients with possible intestinal obstruction should be hospitalized.
Treatment of acute intestinal obstruction must proceed simultaneously
with diagnosis. A surgeon should always be involved.
Supportive care is similar for small- and large-bowel obstruction:
nasogastric suction, IV fluids (0.9% saline or lactated Ringer's solution
for intravascular volume repletion), and a urinary catheter to monitor
fluid output. Electrolyte replacement should be guided by test results,
although in cases of repeated vomiting serum Na and K are likely to
be depleted. If bowel ischemia or infarction is suspected, antibiotics
should be given (e.g. 3rd-generation cephalosporin, such as cefotetan
2 g IV) before laparotomy.
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Specific measures:
Obstruction of the duodenum in adults is treated by resection or, if the
lesion cannot be removed, palliative gastrojejunostomy. Complete
obstruction of the small bowel is preferentially treated with early
laparotomy, although surgery can be delayed 2 or 3 h to improve fluid
status and urine output in a very ill, dehydrated patient. The offending
lesion is removed whenever possible. If a gallstone is the cause of
obstruction, it is removed through an enterotomy, and cholecystectomy
need not be done.
Procedures to prevent recurrence should be done, including repair of
hernias, removal of foreign bodies, and lysis of the offending adhesions.
In some patients with early postoperative obstruction or repeated
obstruction caused by adhesions, simple intubation with a long intestinal
tube (many consider a standard NGT to be equally effective), rather
than surgery, may be attempted in the absence of peritoneal signs.
Disseminated intraperitoneal cancer obstructing the small bowel is a
major cause of death in adult patients with gastro-intestinal tract cancer.
Bypassing the obstruction, either surgically or with endoscopically
placed stents, may palliate symptoms briefly.
Obstructing colon cancers can often be treated by a single-stage resection
and anastomosis. Other options include a diverting ileostomy or protective
colostomy and distal anastomosis in cases with peritonitis and risk for
anastomosis. Occasionally, a diverting colostomy with delayed resection
is required.
When diverticulitis causes obstruction, perforation is often present.
Removal of the involved area may be very difficult but is indicated if
perforation and general peritonitis are present. Resection and colostomy
are done, and anastomosis is postponed.
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Fecal impaction usually occurs in the rectum and can be removed
digitally and with enemas. However, a fecal concretion alone or in a
mixture (i.e. with barium or antacids) that causes complete obstruction
(usually in the sigmoid) requires laparotomy.
Treatment of cecal volvulus consists of resection and anastomosis of
the involved segment or fixation of the cecum in its normal position
by cecostomy in the frail patient. In sigmoidal volvulus, an endoscope
or a long rectal tube can often decompress the loop, and resection and
anastomosis may be deferred for a few days. Without a resection,
recurrence is almost inevitable.
Ileus (Paralytic Ileus; Adynamic Ileus; Paresis)
Ileus is a temporary arrest of intestinal peristalsis. It occurs most
commonly after abdominal surgery, particularly when the intestines have
been manipulated. Symptoms are nausea, vomiting, and vague abdominal
discomfort. Diagnosis is based on x-ray findings and clinical impression.
Treatment is supportive, with nasogastric suction and IV fluids.
Etiology.
In addition to postoperative causes, ileus also results from intraperitoneal
or retroperitoneal inflammation (e.g., appendicitis, diverticulitis, perforated
duodenal ulcer), retroperitoneal or intra-abdominal hematomas (e.g.,
ruptured abdominal aortic aneurysm, lumbar compression fracture),
metabolic disturbances (e.g., hypokalemia, or drugs (e.g., opioids,
anticholinergics, sometimes Ca channel blockers). Ileus sometimes
occurs in association with renal or thoracic disease (e.g., lower rib
fractures, lower lobe pneumonias, myocardial infarction).
Gastric and colonic motility disturbances after abdominal surgery are
common. The small bowel is typically least affected, with motility and
absorption returning to normal within hours after surgery. Stomach
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