management of intestinal obstruction
TRANSCRIPT
![Page 1: Management Of Intestinal Obstruction](https://reader035.vdocuments.mx/reader035/viewer/2022070521/58f9abd6760da3da068b8806/html5/thumbnails/1.jpg)
Intestinal Obstruction
![Page 2: Management Of Intestinal Obstruction](https://reader035.vdocuments.mx/reader035/viewer/2022070521/58f9abd6760da3da068b8806/html5/thumbnails/2.jpg)
![Page 3: Management Of Intestinal Obstruction](https://reader035.vdocuments.mx/reader035/viewer/2022070521/58f9abd6760da3da068b8806/html5/thumbnails/3.jpg)
Assessment
Investigations
Treatment
![Page 4: Management Of Intestinal Obstruction](https://reader035.vdocuments.mx/reader035/viewer/2022070521/58f9abd6760da3da068b8806/html5/thumbnails/4.jpg)
History-Onset, acute/chronic, bleeding, constipation, weight loss, anorexia, changes in bowel habits, associated features, previous surgery, drug usage.
Physical examination- General physical, vital signs, abdominal distention/mass, tenderness/guarding, auscultation (Bowel sounds)-high pitched, tinkling sounds.
![Page 5: Management Of Intestinal Obstruction](https://reader035.vdocuments.mx/reader035/viewer/2022070521/58f9abd6760da3da068b8806/html5/thumbnails/5.jpg)
Complete blood count- A raised white cell count will indicate an infection. A raised hematocrit may indicate hemoconcentration while a decreased hematocrit will signify blood loss.
Serum Urea & electrolytes- Derangements may be seen with vomiting & diarrhea. Dehydration will be reflected in raised serum urea & creatinine.
![Page 6: Management Of Intestinal Obstruction](https://reader035.vdocuments.mx/reader035/viewer/2022070521/58f9abd6760da3da068b8806/html5/thumbnails/6.jpg)
Liver function test- Elevated serum bilirubin & alkaline phosphatase point towards an obstructed cause.
Serum amylase It is a non-specific test & may be raised in
cases of small intestinal obstruction.
![Page 7: Management Of Intestinal Obstruction](https://reader035.vdocuments.mx/reader035/viewer/2022070521/58f9abd6760da3da068b8806/html5/thumbnails/7.jpg)
Erect chest x-ray- Free air under the diaphragm, without recent abdominal surgery, shows perforated viscus.
Supine abdominal x-ray- It may show abnormal bowel pattern (dilation of bowel loops in case of obstruction or sentinel loop). It may also show masses.
Erect Film- It shows fluid levels in case of obstructed bowel.
![Page 8: Management Of Intestinal Obstruction](https://reader035.vdocuments.mx/reader035/viewer/2022070521/58f9abd6760da3da068b8806/html5/thumbnails/8.jpg)
Ultrasound- It is less useful but may indicate presence of intraparitoneal fluid or mass. It can also detect gallstones or other biliary diseases.
CT- It is performed with oral or Intravenous contrast. Lower abdomen CT is useful in detection of acute appendicitis, acute diverticulitis, intestinal obstruction, aortic aneurysm & mesentric ischaemia.
![Page 9: Management Of Intestinal Obstruction](https://reader035.vdocuments.mx/reader035/viewer/2022070521/58f9abd6760da3da068b8806/html5/thumbnails/9.jpg)
Supportive NPO Rehydration & urine output monitoring Cross-match blood & transfusion if required Pass NG tube( diagnostic/therapeutic purpose) I.V antibiotics if indicated
Symptomatic Analgesia after confirming diagnosis
Specific Therapy directed at underlying disease
![Page 10: Management Of Intestinal Obstruction](https://reader035.vdocuments.mx/reader035/viewer/2022070521/58f9abd6760da3da068b8806/html5/thumbnails/10.jpg)
![Page 11: Management Of Intestinal Obstruction](https://reader035.vdocuments.mx/reader035/viewer/2022070521/58f9abd6760da3da068b8806/html5/thumbnails/11.jpg)
Investigations- Plain X-ray Duodenal obstruction- stomach & proximal
duodenum are distended- “double bubble” Jejunal & ileal obstruction- air fluid levels
present
![Page 12: Management Of Intestinal Obstruction](https://reader035.vdocuments.mx/reader035/viewer/2022070521/58f9abd6760da3da068b8806/html5/thumbnails/12.jpg)
Treatment: Correct electrolyte & fluid deficits Duodenal atresia requires
duodenojejuostomy & spliting of the anastomosis with a feeding tube.
Atretic segments in the jejunum or ileum may produce dilated proximal loops that require tapering prior to anastomosis.
![Page 13: Management Of Intestinal Obstruction](https://reader035.vdocuments.mx/reader035/viewer/2022070521/58f9abd6760da3da068b8806/html5/thumbnails/13.jpg)
Investigation: Plain x-ray of the small bowel gas shows
malrotation & level of obstruction.
![Page 14: Management Of Intestinal Obstruction](https://reader035.vdocuments.mx/reader035/viewer/2022070521/58f9abd6760da3da068b8806/html5/thumbnails/14.jpg)
Treatment: The volvulus is reduced, the
transduodenal band(Ladd’s band) divided, the duodenum mobilised & the mesentry freed.
Appendicectomy is routinely performed to avoid diagnostic difficulty with appendicitis in the future.
Infarcted bowel necessitates resection.
![Page 15: Management Of Intestinal Obstruction](https://reader035.vdocuments.mx/reader035/viewer/2022070521/58f9abd6760da3da068b8806/html5/thumbnails/15.jpg)
Investigation Differential white cell count is raised A Merkel’s radioisotope scan will reveal acid
producing gastric mucosa.
![Page 16: Management Of Intestinal Obstruction](https://reader035.vdocuments.mx/reader035/viewer/2022070521/58f9abd6760da3da068b8806/html5/thumbnails/16.jpg)
Treatment: Excision of the inflammed diverticulum Presence of gastric mucosa requires the
resection of the ileal loop containing the diverticulum to ensure complete excision of all acid producing mucosa.
![Page 17: Management Of Intestinal Obstruction](https://reader035.vdocuments.mx/reader035/viewer/2022070521/58f9abd6760da3da068b8806/html5/thumbnails/17.jpg)
Plain x-ray Shows small dilated bowel loops Gastrograffin enema (in the absence of
acute obstruction) shows up the meconium & excludes Hirshsprung’s disease.
![Page 18: Management Of Intestinal Obstruction](https://reader035.vdocuments.mx/reader035/viewer/2022070521/58f9abd6760da3da068b8806/html5/thumbnails/18.jpg)
Treatment: Colonic washouts may restore patency Proximal ileum is anastomosed end to side
to the colon with a distal ileostomy to clear the obstruction.
![Page 19: Management Of Intestinal Obstruction](https://reader035.vdocuments.mx/reader035/viewer/2022070521/58f9abd6760da3da068b8806/html5/thumbnails/19.jpg)
Gastrograffin enema demonstrates unhindered flow of contrast upto the cecum & beyond
Relief of constipation requires bowel washouts or manual evacuation.
Counselling
![Page 20: Management Of Intestinal Obstruction](https://reader035.vdocuments.mx/reader035/viewer/2022070521/58f9abd6760da3da068b8806/html5/thumbnails/20.jpg)
Investigations: Double contrast Gastrograffin enema (‘claw
sign’ of ileocolic intussusception) In adults, a contrast CT scan of the
abdomen or barium enema is confirmatory.
![Page 21: Management Of Intestinal Obstruction](https://reader035.vdocuments.mx/reader035/viewer/2022070521/58f9abd6760da3da068b8806/html5/thumbnails/21.jpg)
Rx: The diagnostic enema may be used to
reduce the intussusception by hydrostatic pressure (in children)
Surgical reduction by taxis; bowel resection if there is gross edema preventing reduction or vascular compromise.
![Page 22: Management Of Intestinal Obstruction](https://reader035.vdocuments.mx/reader035/viewer/2022070521/58f9abd6760da3da068b8806/html5/thumbnails/22.jpg)
Investigations: Plain x-ray may be diagnostic -Large gas-filled, ‘kidney bean-shaped’
swelling in the right upper zone: Sigmoid volvulus
-Large gas-filled, ‘kidney bean-shaped’ swelling in the left lower zone: Caecal volvulus.
![Page 23: Management Of Intestinal Obstruction](https://reader035.vdocuments.mx/reader035/viewer/2022070521/58f9abd6760da3da068b8806/html5/thumbnails/23.jpg)
Rx: Sigmoid volvulus may be relieved at right
sigmoidoscopy. Emergency laprotomy & resection of the
volvulus for strangulated or recurrent cases. Gangrenous bowel is exteriorised &
resected, with the formation of a ‘double barrel’ colostomy (Paul-Mikulicz procedure).
![Page 24: Management Of Intestinal Obstruction](https://reader035.vdocuments.mx/reader035/viewer/2022070521/58f9abd6760da3da068b8806/html5/thumbnails/24.jpg)
Investigations: White cell count: >20×109 /L Serum amylase: slightly raised (>200IU)Mesentric angiography
Rx: Laparotomy: superior mesentric
embolectomy; Resection of areas of non-viable bowel.‘second look’ laprotomy at 24 hours for further
resection of non-viable bowel.
![Page 25: Management Of Intestinal Obstruction](https://reader035.vdocuments.mx/reader035/viewer/2022070521/58f9abd6760da3da068b8806/html5/thumbnails/25.jpg)
Treatment: Surgical bypass of occlusion.
![Page 26: Management Of Intestinal Obstruction](https://reader035.vdocuments.mx/reader035/viewer/2022070521/58f9abd6760da3da068b8806/html5/thumbnails/26.jpg)
Investigations:Plain x-ray abdomen: Characteristics of the
distended bowel from which the level of obstruction is identified
Contrast enhanced CT: Delineates the type & level of obstruction
![Page 27: Management Of Intestinal Obstruction](https://reader035.vdocuments.mx/reader035/viewer/2022070521/58f9abd6760da3da068b8806/html5/thumbnails/27.jpg)
Treatment: Nasogastric decompression of stomach &
bowel proximal to the obstruction. I/v Fluids & electrolyte therapy Analgesia Antibiotics( inflammatory or infectious
causes) Emergency surgery * Post operative adhesion obstruction usually
resolves on conservative measures.
![Page 28: Management Of Intestinal Obstruction](https://reader035.vdocuments.mx/reader035/viewer/2022070521/58f9abd6760da3da068b8806/html5/thumbnails/28.jpg)
Operative procedures vary according to cause of obstruction.
Resection- The diseased part of the small intestine (ileum) is removed. The two healthy ends are then sewn back together and the incision is closed.
Indications Gangrenous bowel
![Page 29: Management Of Intestinal Obstruction](https://reader035.vdocuments.mx/reader035/viewer/2022070521/58f9abd6760da3da068b8806/html5/thumbnails/29.jpg)
In cases of strangulated Inguinal/femoral hernias the standard groin incision is given & the weakness repaired using hernioplasty or herniorrhaphy, with bowel resection if required.
![Page 30: Management Of Intestinal Obstruction](https://reader035.vdocuments.mx/reader035/viewer/2022070521/58f9abd6760da3da068b8806/html5/thumbnails/30.jpg)
In adhesive obstructed cases, laproscopic adhesiolysis (adhesive band lysis) maybe performed in selected patients or using open procedure through an incision dictated by scar from previous surgery.
Bypass: Anastomosis of proximal small bowel or large intestine distal to the obstruction may be a good procedure in some cases of carcinoma or radiation injury.
![Page 31: Management Of Intestinal Obstruction](https://reader035.vdocuments.mx/reader035/viewer/2022070521/58f9abd6760da3da068b8806/html5/thumbnails/31.jpg)
Decompression-Done by use of gastrostomy or jejunostomy tube where adhesions can’t be freed & bypass can’t be done. Parentral nutrition is provided that
allows spontaneous resolution.
The tube can be passed orally orBy needle aspiration through the bowel wall.
![Page 32: Management Of Intestinal Obstruction](https://reader035.vdocuments.mx/reader035/viewer/2022070521/58f9abd6760da3da068b8806/html5/thumbnails/32.jpg)
![Page 33: Management Of Intestinal Obstruction](https://reader035.vdocuments.mx/reader035/viewer/2022070521/58f9abd6760da3da068b8806/html5/thumbnails/33.jpg)
Short Practice of surgery- Bailey & love’s Acute surgical management- Hwang Nian
Chi Current surgery Medlineplus