LARGE BOWEL OBSTRUCTION

&

ACPO

LARGE BOWEL OBSTRUCTION

INTERRUPTION IN THE PASSAGE OF LARGE

INTESTINAL CONTENTS

CLASSIFICATION OF LBO

Depending on nature of obstruction

Depending on the blood supply

Depending Upon Presentation

Depending Upon In Relation To Lumen

DEPENDING ON THE NATURE OF OBSTRUCTION

DYNAMIC OBSTRUCTION• Carcinoma colon

• Volvulus

• Diverticulosis

• Intussusceptions

• Adhesions

ADYNAMIC OBSTRUCTION• Ogilvie’s syndrome

• Toxic mega colon

• Metabolic (hypokalemia)

• Post-op ileus

• Inflammatory disorder

• Hirschsprung’s disease

DEPENDING ON THE BLOOD SUPPLY

• Simple obstruction

• Strangulated obstruction

• Closed loop obstruction

DEPENDING UPON PRESENTATION• Acute Obstruction : volvulus /obstructed

hernia

• Chronic obstruction : carcinoma colon / diverticulosis

• Acute on chronic obstruction : ca colon

DEPENDING IN RELATION TO LUMEN

• Outside the wall

• Inside the wall

• Inside the lumen-Foreign body,Fecal impaction

DEPENDING IN RELATION TO LUMEN

OUTSIDE THE WALL

• Volvulus

• Hernias

• Tumour in adjacent organs

• Intra abdominal abscess

• Colonic obstructions

INSIDE THE WALL

• Carcinoma• Inflammation

(diverticulosis,crohn’s disease,LGV,schistosomiasis,TB)

• Hirschsprung’s disease• Ischemia• Radiation• Intussusceptions• Anatomical stricture

MOST COMMON CAUSES OF LBO

• Colorectal cancer-65%

• Colonic volvulus-15%

• Diverticulitis-10%

• Others-10% Hernia Intussusceptions

MOST COMMON CAUSES OF LBO

PATHOGENESIS OF INTESTINAL OBSTRUCTION

Changes proximal to bowel obstrucion

Changes at the site of obstruction

Closed loop obstruction

Changes in the bowel distal to obstruction-Inactive and collapsed

CHANGES PROXIMAL TO BOWEL OBSTRUCTION

Intestinal obstruction

Increased peristalsis

Vigorous peristalsis

If obstruction not relieved Cessation of peristalsis

Cessation Of Peristalsis

Flaccid, Paralysed Bowel

Dilated Bowel

CHANGES AT THE SITE OF OBSTRUCTION

Intestinal obstruction Distension

Venous compression

Congestion and edema

Progressive arterial compromise

Loss of shineness, Blackish discolouration Loss of peristalsis

Gangrene & Perforation

Bacteria and toxins migrate into peritoneum

Peritonitis

CLOSED LOOP OBSTRUCTION

Growth in the right colon with competent ileocaecal valve

Pressure increases in the caecum Stercoral ulcer in the caecum

Gangrene&Perforation

Fecal peritonitis

CLINICAL FEATURES OF LARGE BOWEL OBSTRUCTION

• Symptoms : Abdominal Distension Abdominal Pain Obstipation Vomiting Nausea / Anorexia

SIGNS OF LARGE BOWEL OBSTRUCTION

• General signs of dehydration • Abdominal findings :

Distension Tympanitic Note

Rt To Lt Colonic PeristalsisBorborygmi

SIGNS OF STRANGULATION

Features of septic shock : fever/hypotension/ renal failure/respiratory signs

Rebound tendernessGuarding / rigidityAbsent bowel soundsConstant pain / severe painFever / tachycardia / leucocytosis

INVESTIGATIONS • Blood : CBC / RBS / RFT / LFT / Electrolytes/ grouping

typing / ABG• Imaging

1.upright chest x ray2.supine / upright abdominal x ray3.barium enema (single/ double contrast)

(gastrografin)4.USG abdomen5.CT with oral water soluble contrast / IV

contrast / rectal contrast6.colonoscopy / sigmoidoscopy

MANAGEMENT OF LARGE BOWEL OBSTRUCTION

Sun should not be both rise and set

PRINCIPLES

• Aspiration (ryles tube)• Bowel care / blood transfusion• Charts (temp,PR,RR,I/O,)/ critical care• Drugs : antibiotics• Exploratory laparotomy• Fluids : IVF

PRINCIPLES OF EXPLORATORY LAPAROTOMY

• Ideally done 6 – 8 hrs• Long midline incision• Check viability of bowel – if not viable resection

& anastomosis• Adhesion – release • Bands – divide • Volvulus – untwist / resection• Obstructed hernia – reduce • Stricture – resection / stricturoplasty

FEATURES OF VIABLE BOWEL

• Normal peristalsis

• Normal peritoneal sheen is present

• Normal pulsation are visible or felt at mesentery

• Normal pink colour is present

IN DOUBTFUL VIABILITY

• Warm saline soaked mop is placed over the doubtful areas with 100% oxygen for 10 min

if colour become normal with peristalsis

Bowel is viable

PRINCIPLES OF EXPLORATORY LAPAROTOMY

• Ideally done 6 – 8 hrs• Long midline incision• Check viability of bowel – if not viable resection

& anastomosis• Adhesion – release • Bands – divide • Volvulus – untwist / resection• Obstructed hernia – reduce • Stricture – resection / stricturoplasty

COMPLICATIONS OF INTESTINAL OBSTRUCTION

• Peritonitis• Hypovolemia & septic shock• Renal failure• ARDS• Intra abdominal abscess formation

POST SURGICAL COMPLICATIONS

• Pelvic abscess• Subphrenic abscess• Biliary or fecal fistula• Burst abdomen• Bands and adhesion• Incisional hernia

MANAGEMENT OF MALIGNANT LARGE BOWEL OBSTRUCTION

• Primary goal: Decompression of obstructed segment to prevent perforation

• Secondary goal : Removal of the malignant lesion

OBSTRUCTING LESION OF THE RIGHT COLON

Stable patient:

Resection And Ileotransvese Anastomosis In Single Stage

OBSTRUCTING LESION OF THE RIGHT COLON

• Unstable patient & bowel perforation1st stage:

Resection Of Lesion But No Primary Anastomosis

Terminal Ileostomy And Transverse Colon Mucus Fistula

2nd Stage:Ileotransverse Anastomosis

OBSTRUCTING LESION OF THE RIGHT COLON

Non - resectable lesion : (Fixed To Posterior Abdominal Wall ,

Common Iliac Vessels)

Palliative: Ileotransverse Anastomosis Caecosigmoidostomy

OBSTRUCTING LESION OF THE TRANSVERSE COLON

• Treatment :Extended Rt Hemicolectomy + Removal Of Whole Omentum, Transverse Colon+

Ileocolic Anastomosis (Distal Transverse Colon Or Proximal Descending Colon)

OBSTRUCTING LESIONS OF THE LEFT COLON

Treatment options:

Three stage operation- Unstable Patient

Two stage operation- Unstable Patient

Single stage operation- Stable Patient

Sub total colectomy and ileorectal anastomosis - Unhealthy proximal colon

THREE STAGE OPERATION Transverse colostomy

After 3 – 6 weeks Elective resection of tumour with an anastomosis After 8 weeks

Colostomy closure

TWO STAGE OPERATION

Hartmann’s Operation

After Six weeks

Restoration Of Bowel Continuity

SINGLE STAGE OPERATION

Stable Patient: Left Hemicolectomy & Colorectal

Anastomosis

UNRESECTABLE LESION

External diversion: colostomy

Internal diversion: caecosigmoidostomy

COLONIC STENTS

Decompression Of The Obstruction

Emergency Situation Elective Setting

COLONIC STENTS

COLONIC VOLVULUS

SIGMOID VOLVULUS – 53%

CECAL VOLVULUS - <42%

TRANSVERSE COLON-3%

SPLENIC FLEXURE-2%

SIGMOID VOLVULUS

SIGMOID VOLVULUS

• Predisposing factors Long mesentery of the pelvic colon

Narrow attachment at the base

Long, redundant and pendulous sigmoid

Loaded colon due to residue diet

Diverticulitis with band/adhesions

CLINICAL FEATURES OF SIGMOID VOLVULUS

• Acute sigmoid volvulusAbdominal pain

Absolute constipation

Abdominal distension-tympanitic abdomen

Tyre like feel

Features of peritonitis

CHRONIC RECURRENT SIGMOID VOLVULUS

• Clinical features

Recurrent left lower abdominal pain

Abdominal distension

Relieved by passage of large amount of flatus

INVESTIGATIONS Contrast Enema

Bird’s beak sign

Bird of prey sign

Ace of spade sign

CT AbdomenWhirl pattern

X- Ray Abd Erect

Omega sign

Coffee bean sign

Bent inner tube sign

SIGMOID VOLVULUS

INTRA-OPERATIVE INTRA-OPERATIVE

MANAGEMENT

• Non operative managementResuscitation Endoscopic Decompression Using

Flatus Tube/Sigmoidoscopy/ Flexible Colonoscopy

If Obstruction Relieved If Not

Elective Surgery Emergency After One Week Laparotomy

Non operative management

NON OPERATIVE MANAGEMENT-FLATUS TUBE

OPERATIVE MANAGEMENT

If Bowel Is Gangrenous Single Stage- Resection And End To End Anastomosis Hartmann’s Operation Exteriorisation Of Bowel

If Bowel Is Not Gangrenous Single Stage- Resection and End To End AnastomosisSigmoidopexy

COMPOUND VOLVULUS

Ileo Sigmoid KnottingDue To Presence Of Long Pelvic Mesocolon Allows The Ileum To Twist Around The Sigmoid ColonPresents As Acute Intestinal ObstructionX-ray : Dilated Both Ileal And Sigmoid LoopsTreatment: Resuscitation Decompression f/b Resection And Anastomosis or Exteriorisation Of Bowel

COMPOUND VOLVULUS

ILEO SIGMOID KNOTTING

CECAL VOLVULUS

• Due to failure of fixation of the ileal and caecal mesentery to the posterior abdominal wall

• Predisposing factors: Previous surgeryPregnancyObstructing lesion of left colonMalrotation

INVESTIGATIONS • Plain Xray Abdomen Erect

Comma Shaped Dilated Ceacum In Left Upper Abdomen

Single Long Fluid Level

Dilated Small Bowel Right Of The Distended Caecum

Contrast Enema: Tapering Of

Ascending ColonCT Abdomen:

Dilated Caecum With Fluid Level

CAECAL VOLVULUS

CAECAL VOLVULUS

MANAGEMENT

Right hemicolectomy with primary anastomosis

Caecostomy/Caecopexy

Endoscopic decompression/derotation not advisable

INTUSSUSCEPTION

• Defined as the Invagination of one segment of intestine into the adjacent segment

• Types: Antigrade:

Simple: Ileocolic, ileoileal, colocolicCompound: IleoileocolicRetrograde: Jejunogastric intususception

Ileocolic-iss

PARTS OF INTUSSUSCEPTION

Intussuscipiens:Distal bowel which receives the intestine

Intussusceptum:Proximal bowel which enter into distal segment

Apex:Is the part which advances

Lead point

CAUSES OF INTUSSUSCEPTION

In Infants

Change in diet during weaning period

Upper respiratory tract viral infection

In Adults

Intestinal polypsSubmucous lipomasMeckel's diverticulumCarcinomaLeomyoma of intestinePurpuric submucosal haemorrhages-HSP

CLINICAL FEATURES OF INTUSSUSCEPTION

Symptoms

Severe cramping abdominal pain

Vomiting

Red current jelly stool

SignsSausage shaped mass in umbilical region

Right iliac fossa empty

Step ladder peristalsis

Features of peritonitis

PR shows blood stained mucus-Red current jelly

INVESTIGATIONS PlainX-ray:Multiple air fluid levels

Barium enema:Claw Sign Or Coiled Spring Sign Or Meniscus Sign

Ultrasound abdomen :– Target sign– Psuedokidney sign– Bull’s eye sign

Doppler Study :

To Check Blood Supply Of Bowel It Shows Mass With Doughnut Sign

CT Abdomen Target sign

MANAGEMENT

• Non operative management: Hydrostatic reduction – Contrast enema – Air enema– Warm salineContraindications:

Perforation Profound shock and known pathological lesion

SURGICAL MANAGEMENT OF ISS

• Laparotomy and reduction of intussusception milking method

If Reduction possible If not possible

check the viability & Resection and suture terminal ileum anastomosisto ascending colon

SURGICAL MANAGEMENT OF ISS

• Laparotomy and reduction of intussusception milking method

If Reduction possible If not possible

check the viability & Resection and suture terminal ileum anastomosisto ascending colon

ACUTE COLONIC PSEUDO OBSTRUCTION-ACPO

• Defined as Massive Colonic Distension In The Absence Of Mechanically Obstructing Lesion

• Etiology: Primary pseudo-obstruction

• Familial visceral myopathy• Sporadic visceral myopathy

SECONDARY PSEUDO OBSTRUCTION

Smooth muscle disorders: Collagen vascular disorders

Scleroderma, DermatomyositisMuscular dystrophy- Myotonic dystrophyAmyloidosis

Neurological disorders– Chaga's disease– Parkinsonism– Spinal cord injury

SECONDARY PSEUDO OBSTRUCTION

Drugs- Phenothiazines, Tricyclic antidepressants and opioids

Metabolic-Uremia, Hypokalemia, Diabetes, Myxoedema, Hypoparathyroidism

Viral infections

CLINICAL FEATURES OF ACPO

Medically ill patient suddenly develops abdominal distension

Tympanitic abdomen

Not tender

Bowel sounds present

INVESTIGATIONS

• Plain Xray Abdomen Erect : Shows Distension Of Colon• Water Soluble Contrast Enema:IOC Differentiates ACPO From Mechanically

Obstructing Lesions• Colonoscopy Not Advisable

Plain Xray Abdomen Erect-acpo

MANAGEMENT

Non operative:– Injection Neostigmine 2.5mg iv over 3 minutes – Epidural anaesthesia – Colonoscopic decompressionOperative:Emergency Laparotomy– If there is no ischemia or perforation-loop colostomy– If there is ischemia or perforation-Resection and

ileostomy with mucus fistula

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