Intestinal ObstructionDr Hatem El GoharyLecturer of General Surgery

Types

• Dynamic peristalsis is working against a mechanical obstruction.

• Adynamic peristalsis may be absent.

CausesDynamic

■ IntraluminalImpactionForeign bodiesBezoarsGallstones

■ IntramuralStrictureMalignancy

■ ExtramuralBands/adhesionsHerniaVolvulusIntussusception

Adynamic ■Paralytic ileus

■Mesenteric vascular

occlusion

Mechanism of Dynamic obstruction

• Proximal loop dilatation (Gas and Fluid) + increased peristalsis.• Distal loop normal peristalsis and

absorption until it become empty collapse immotile.

STRANGULATION• The venous return is compromised before the

arterial supply.

• Edema and accumulation of toxic fluid Impaired arterial supply infarction.

• viability of the bowel is compromised there is marked translocation and systemic exposure to anaerobic organisms with their associated toxins.

Clinical features of strangulation

■ Constant pain ■ Tenderness with rigidity ■ Shock

Acute intussusception• Definition:One portion of the gut becomes invaginated within an immediately adjacent segment (the proximal into the distal) due to lead point.

• commonly in children.

• Pathological lead point such as Meckel’s diverticulum, polyp.

• Ilio –colic is the most common.• blood supply of the inner layer is usually impaired

strangulation.

Parts of intussusception.

Acute Volvulus

• Definition: twisting or axial rotation of a portion of bowel around its mesentery.• Causes: -Primary congenital bands. -Secondary Sigmoid volvulus.

Sigmoid vovulous

CLINICAL FEATURES OF INTESTINAL OBSTRUCTION• General Dehydration – Fever.

• Local pain, distension, vomiting and absolute constipation.

Small bowel vomiting early + distension minimal. Large bowel vomiting late + distension is evident.

INVESTIGATIONS•Plain x ray abdomen ERECT Multiple air – fluid levels.

Supine Dilated bowel loops (small intestinal central-large intestinal peripheral).

Other Investigations

• Laboratory: CBC – Serum Electrolytes• Radiological: - Ultrasound abdomen and Pelvis Peritoneal collection. - CT abdomen and pelvis (may show obstructing tumor).

Treatment of intestinal obstruction

■Gastrointestinal drainage Nasogastric tube (Ryle).

■Fluid and electrolyte replacement.

■Surgical treatment is necessary for most cases of intestinal obstruction but should be delayed

until resuscitation is Complete except in STRANGULATION.

Surgical Operations for Intestinal Obstruction• Intussusception Reduction of the obstructed

loop.• Obstructed Hernia Reduction of the viable loops

+ Repair of Hernia.• Strangulated Gangrenous Hernia Resection

anastomosis of the non-viable loops + Repair of Hernia.• Volvulus Surgical Untwisting.• Obstructing Tumor Resection of the tumor

(resectable) or Bypass surgery (irresectable) + anastomosis or colostomy.