Intestinal Obstruction

Assessment

Investigations

Treatment

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.

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.

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.

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.

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.

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

Investigations- Plain X-ray

Duodenal obstruction- stomach & proximal
duodenum are distended- double bubble
Jejunal & ileal obstruction- air fluid levels
present

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.

Investigation:
Plain x-ray of the small bowel gas shows
malrotation & level of obstruction.

Treatment:
The volvulus is reduced, the
transduodenal band(Ladds
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.

Investigation
Differential white cell count is raised
A Merkels radioisotope scan will reveal acid
producing gastric mucosa.

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.

Plain x-ray
Shows small dilated bowel loops
Gastrograffin enema (in the absence of
acute obstruction) shows up the meconium
& excludes Hirshsprungs disease.

Treatment:
Colonic washouts may restore patency
Proximal ileum is anastomosed end to side
to the colon with a distal ileostomy to clear
the obstruction.

Gastrograffin enema demonstrates

unhindered flow of contrast upto the cecum
& beyond

Relief of constipation requires bowel

washouts or manual evacuation.

Counselling

Investigations:
Double contrast Gastrograffin enema (claw
sign of ileocolic intussusception)
In adults, a contrast CT scan of the
abdomen or barium enema is confirmatory.

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.

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.

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).

Investigations:
White cell count: >2010 /L
Serum amylase: slightly raised (>200IU)
Mesentric angiography
9

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.

Treatment:
Surgical bypass of occlusion.

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

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.

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

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.

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.

Decompression-Done by use of gastrostomy

or jejunostomy tube where adhesions cant
be freed & bypass cant be done. Parentral
nutrition is provided that
allows spontaneous resolution.

The tube can be passed orally or

By needle aspiration through the
bowel wall.

Short Practice of surgery- Bailey & loves

Acute surgical management- Hwang Nian
Chi
Current surgery
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