Ivano-Frankivsk state medical university

Acute intestinal obstruction

Departments of surgery 1

Intestinal obstruction is a complete or partial violation of intestinal function due to many causes.

Mortality/Morbidity
Mortality and morbidity are dependent on the early recognition and correct diagnosis of obstruction. If untreated, strangulated obstructions cause death in 100% of patients. If surgery is performed within 36 hours, the mortality rate decreases to 8%. The mortality rate is 25% if the surgery is postponed beyond 36 hours in these patients.
In United States AIO accounts for 20% of all acute surgical admissions.

Etiology
Adhesions of abdominal cavity after traumas, wounds, previous operations and inflammatory diseases of organs of abdominal cavity and pelvis; Long mesentery of small intestine or colon, that predetermines consid erable mobility of their loops; Tumours of abdominal cavity and retroperitoneal space.

Pathogenesis
Obstruction of the small bowel leads to proximal dilatation of the intestine due to accumulation of GI secretions and swallowed air. This bowel dilatation stimulates cell secretory activity resulting in more fluid accumulation. This leads to increased peristalsis both above and below the obstruction with frequent loose stools and flatus early in its course. Vomiting occurs if the level of obstruction is proximal. Increasing small-bowel distention leads to increased intraluminal pressures. This can cause compression of mucosal lymphatics leading to bowel wall lymphedema. With even higher intraluminal hydrostatic pressures, increased hydrostatic pressure in the capillary beds results in massive third spacing of fluid, electrolytes, and proteins into the intestinal lumen. The fluid loss and dehydration that ensue may be severe and contribute to increased morbidity and mortality.

 Strangulated AIO are most commonly associated with adhesions and occur when a loop of distended bowel twists on its mesenteric pedicle. The arterial occlusion leads to bowel ischemia and necrosis. If left untreated, this progresses to perforation, peritonitis, and death. Bacteria in the gut proliferate proximal to the obstruction. Microvascular changes in the bowel wall allow translocation to the mesenteric lymph nodes. This is associated with an increase in incidence of bacteremia due to Escherichia coli, but the clinical significance is unclear.

Classification
Acute intestinal obstruction is divided: I. According to morphofunctorial signs. 1. Dynamic intestinal obstruction: paralytic; spastic; hemostatic (embolic, thrombophlebitic). 2. Mechanical intestinal obstruction: strangulated, volvulus, jamming; obturation (closing of bowel lumen, squeezing from outside); mixed (Intussusceptions (invagination), spike intestinal obstruction). II. According to clinical features. Acute. Chronic.

III. According to the degree of loss of intestinal function. Small intestinal. Large intestinal: high; low. IV. According to the passing of intestinal maintenance. Complete. Partial. V. According to the origin. Innate. Acquired. VI. According to development of pathological process. 1. Stage of acute violation of intestinal motility. 2. Stage of hemodynamic disorders of bowel wall and its mesentery. 3. Stage of peritonitis.

strangulated AIO

obturation

mixed

CLINICAL

 The pain in the abdomen is intermittent and is seen in all forms of mechanical intestinal obstruction. However, some types of strangulated intestinal obstruction (node formation, volvulus of small intestine and colons) can be accompanied by permanent pain

 Distension of abdomen, the delay of emptying and gases are observed in 8590% patients, mainly, with the high forms of obstruction (volvulus of small intestine, spike intestinal obstruction).

 Nausea and vomiting are present in 75-80 % patients with severe forms of high level intestinal obstruction (node formation, volvulus of small intestine, obstruction). At obturation obstruction and invagination they are not observed so often. There is increased thirst which can be considered as an early symptom. Besides, the higher intestinal obstruction, the greater is the complain of thirst.

During palpation the abdomen is soft sometimes there is slight resistance over theomterior abdominal wall, Percussion - high tympanitis.

On auscultation at the beginning of the disease there is increased peristalsis, then gradually the peristalsis disappeares(the Mondor's symptom, "sounds of onset beginning, quietness of end")

other signs pathognomic for intestinal obstruction

The Vala's sign is the elastic sausage shaped deformity of the bowel. The Sklarov's sign is the sound of intestinal splash. The Kywul's sign is the sound above the exaggerated bowel. The Schlange's sign is the peristalsis of bowel, that arises after palpation of abdomen. The Spasokukotsky's sign is "sound of falling drop". The Hochenegg's sign - incompletely closed anus in combination with balloon expansion of ampulla of rectum.

Investigations
Anamnesis and physical methods of examination (auscultation,palpation of abdomen, percussion and others like that). General analysis of blood, urine and biochemical blood test, coagulogram. X-Rays organs of abdominal cavity. Electrocardiography. Irrigography.

X-rays
On roentgenoscopy or roentography of the abdominal cavity: liquid and gas are observed in bowels - the Klojber's bowl

CT scanning

Ultrasonography

Differential diagnosis
Pain in abdomen +Distension of abdomen + Vomiting
Appendicitis Cholangitis Cholecystitis and Biliary Colic Perforation Gastroenteritis Inflammatory Bowel Disease Mesenteric Ischemia Pancreatitis Diabetic Ketoacidosis

Treatment
In the first 1,5-2 hours after hospitalization of patient intensive conservative therapy is started on lines of differential diagnosis and simulteneously preoperative preparation is conducted.

Treatment is directed
to prevent the complications, related to pain shock, correction of homeostasis and, attempt to correct intestinal obstruction by unoperative methods.

1.The measures directed against abdominal pain shock include use of neuroleptan algesia, procaine paranephric block and introduction of spasmolytics. In patients with the expressed pain syndrome and spastic intestinal obstruction positive effect can be attained by epidural anaesthesia also.

 2. Correction of hypovolemia by correction of electrolyte, carbohydrate and albumin exchange is achieved by introduction of salt blood substitutes, 5-10 % solution of glucose, gelatinol, albumen and plasma of blood.

 3. Correction of hemodynamic indexes, microcirculation and disintoxication therapy is achieved by intravenous infusion.

 4. Decompression of intestinal tract is achieved by nasogastric drainage and stomach wash, and also by giving of siphon enema.

Correction of the intestinal obstruction by such conservative methods is succesfulleded in 50-60 % of the patients with mechanical intestinal obstruction.

Principles of surgical treatment

In middle laparotomy novocaine blockade of the mesentery of small and large intestine The revision of organs of abdominal cavity Correction of causes of obstruction Decompression of intestine .

Thank you for your attention