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INTESTINAL OBSTRUCTION Dr. Mohammad Jamil Alhashlamon Intestinal Obstruction Causes • Adhesions or Bands – Resulting from previous surgery or intraperitonial infection ( rarely congenital band) • Strangulated external hernia – Femoral or inguinal or umbilical • Tumors • Volvulus of small or large bowel – A mobile or distended loop of bowel rotates causing obstruction at its neck • Inflammatory stricture – e.g. diverticular disease , crohns disease ( obstruction usually incomplete ) • Bolus obstruction – e.g. impacted faeces , foreign body , gaalstone . • Internal hernia • Itussusception – Usually initiated by a mass in the bowel Pathophysiology • Obstruction lead to dilation of bowel proximally and disrupt peristalsis . • Presentation depend on : – Level of obstruction – Completeness of obstruction Symptoms of intestinal obstruction • Vomiting – The more proximal the obstruction the earlier it develops . – Nature of vomitus give important clues to the level of obstruction . – Change to faeculent vomiting usually take place gradually after about 24 hours of complete obstruction . • Pain – Fluid and swallowed air proximal to the obstruction together with continuing peristalsis cause the pain . – Usually mild m colicky . – Small intestine obstruction cause central abdominal pain . – Large intestine obstruction cause suprapupic abdominal pain . • Constipation – Absolute constipation or obstipation – The lower the obstruction the earlier the obstipation develops . • Symptoms develops more gradually in the large bowel obstruction • If the ileocecal valve remain competent , the caecum will progressively distend and eventually rupture . • The ileocaecal valve become incompetent in 50% of the cases and this allow small intestine distension and delay the onset of symptoms . Incomplete obstruction • If the bowel partially obstructed , the clinical features are less clearly defined . • The pain is often accompanied by visible peristalsis ( this is the hallmark of partial obstruction ) • The most common cause is slowly growing cancer in the colon . Physical signs of intestinal obstruction • • • • • Dehydration Abdominal distension Visible peristalsis Signs of primary cause . Lack of tenderness “except in strangulation “ • Mass “ if it is the cause “ • Bowel sounds will be “ loud , frequent , high pitched and tinkling “ • Succession splash may be positive Investigation of suspected obstruction • Plane abdominal X-Ray • Abdominal X-Ray with contrast Adynamic intestinal obstruction • Temporary disruption of normal peristaltic activity without mechanical blockage . • If happened in the small intestine called “paralytic ileus “ • If happened in the large intestine called “psudo-obstruction of the colon “ Paralytic ileus • Most commonly post surgery . • May also happened in : – Hypokalemia – Side effect of anti-parkinson medications Psudo-obstruction of the colon • Caused by : – Retroperitonial inflammation or hemorrhage – Neurological illnesses – Anticholenergics – Pregnancy – Orthopedic injuries and surgery • Physical signs : similar to those of the mechanical obstruction except the absence of bowel sounds Management of intestinal obstruction • • • • Keep NPO IV fluid and correct electrolytes NG tube Treat the underlying pathology Bowel Strangulation • Segment of the bowel trapped so that the lumen becomes obstructed and its blood supply compromised • If unrelieved , this progress into infarction and eventually perforation . • This happened mostly in hernia and volvulus . symptoms and signs of strangulation • Signs and symptoms of obstruction • Abdominal tenderness • The patient more unwell and tachycardia and lucocytosis • Management : – If it is diagnosed or even suspected immediate surgery . THANK YOU