INTESTINAL OBSTRUCTION

SYAHBUDDIN HARAHAP
 INTESTINAL OBSTRUCTION
SYAHARA
NEUROGENIC paralytic
MECHANICAL

MECHANICAL :
- Simplex
- Stranggulata
Aetilogy:
-In the lumen
-In the wall
-Outside the wall
Site :
- High
- Low
Speed of onset :
- Acute
- Chronic
 What Causes Intestinal Strangulation?

Intestinal strangulation (cutting off of the blood supply to the intestine)

usually results from one of three causes.
 MECHANICAL INTESTINAL OBSTRUCTION
Common causes of obtruction at each age group

Neonate -Congenital atresia

-Volvulus neonatum
-Meconeum ileus
-Hirschsprungs disease
-Imperforate anus
Infant -Stranggulated inguinal hernia
-Intussuception
-Complication of Meckels diverticulum
-Hischsprungs diseases
 Young adult -Adhesions and bands
-Strangulated ing.hernia

Middle age -Adhesesion and band

-Strangulated Ing.hernia
-Strangulated fem.hernia
-Carcinoma colon
-Volvulus

Elderly -Adhesion and bands

-Strangulated Ing.hernia
-Strangulated fem.hernia
-Carcinoma colon
-Volvulus
-Impacted faeces
Incidence
May occur at any age
70 percent small bowel,
30 percent large bowel
Physiologic and Pathologic
Derangement
Fluid and electrolyte disturbances
-8 10 L of fluid are secreted
-Sequestration within the dilated loop--
hypovolumic shock --> SIRS MODS
Bacteriology
-Rapid colonisation
Pathology
-High intra luminar pressure- oedematous--
cyanosis intraperitoneal exudation necrosis
perforation--peritonitis -> SIRS -> MODS
Clinical Manifestations

Sign - the classic quartet->pain,vomiting,constipation,abd dist

Abdominal pain is colicky

-On Auscultation -borborygmi
-metalic sound
Vomiting
- Consists food and gastric chyme- bile faeculent
Absolute constipation
Abdominal distension - ACS
-Inspection distended visible peristalsis and colicky pain
Scars-- Adhesion or Band
Vital Sign---Pulse - SBP RR Temp-- hypovolumic shock ?
Palpation--- palpable mass - DRE
Diagnoctic Studies
Laboratory test--fecal occult blood test
Sigmoidoscopy
X ray examination
Plain X ray --- Erect and lying down -
routinely
Follow-through studies after ingestion of
radiopague meal --- gastrografin
Barium enema X ray
Treatment
NGT
Rehydration
Foley bag Catheter
Antibiotics
Informed concent
Exploratory laporotomy
Exploratory Laparotomy
Inspected and palpated the Caecum
-Distended--- colon obstruction
-Collapsed--- small bowel obstruction
Distended SBO - Prevent Abd.Comp.syndrom
-Retrograde milkingby Jones and Matheson(1968)
-canula inserted + pursetring suture ?
-Enterostomy
Distended LBO- Prevent Abd.Comp.Syndrom
-canula inserted + pursestring suture
-Caecostomy
 Emergency Intestinal obstruction due to
Colon Cancer
Right Hemicolectomy
Extended Right Hemicolectomy
Hartmants procedures
Proximal colostomy
By Pass
On-table antegrade irigation of the large
bowel-- one staged colon operation ?
 Emergency Intestinal obstruction due to
Sigmoid volvulus

The upper limb of the loop descends in

front of the lower, twisting on its
mesenteric axis from one half to two turns
in counterclock-wise direction
Predisposing condition-long and freely
movable meso sigmoid
Radiologic Examination
Plain abdominal foto --Bent inner tube sign 0r Coffe
bean apperance
Barium enema ---Bird beak apperance
- Contrast agent and air fills rectum and distal
sigmoid colon.
- The contrast agent stops abruptly at the point of
torsion.
(Courtesy of Dina F. Caroline, M.D., Ph.D., Temple
University Hospital.)
 Plain film of sigmoid volvulus.

Note appearance of
bent inner tube.
(Courtesy of Dina F.
Caroline, M.D., Ph.D.,
Temple University
Hospital.)

Coffe bean
appearance
 Barium enema of sigmoid volvulus.

Contrast agent and

air fills rectum and
distal sigmoid colon.
The contrast agent
stops abruptly at the
point of torsion.
(Courtesy of Dina F.
Caroline, M.D., Ph.D.,
Temple University
Hospital
Treatment
Consevative
- Barium enema
- LLD + general anestesi -
sigmoidocopy rectal tube lubbricated
- left in place 48 hours
Operative
- Resection Hartmantns operation
- After conservative bowel preparation-
resection end to end anastomosis
 Emergency Intestinal obstruction due
to Caecum volvolus

The caecum passing upward and then to

the left , twist 90 degrees to as many as
three complete twist a clock wise direction
Mobile caecum
 Radiologic examination

Plain abdominal foto

Barium enema
 Caecum Volvulus
The contrast stops abruptly at
the proximal end of the
hepatic flexure (arrowhead).
The dilated, air-filled cecum
crosses the midline of the
abdomen toward the left upper
quadrant (arrows). (Courtesy
of Dina F. Caroline, M.D.,
Ph.D., Temple University
Hospital.)
 Treatment

Caecopexy

Rigth Hemicolectomy
 Emergency Intestinal obstruction due to
ADHESIONS AND BANDS
Classification :
- Congenital
- Acquired

Aetiology :
1. infection -> fibrin --- fibroblast -fibrous
adhesion
2. tissue ischaemia -vascular collateral fibrous
matrix-- fibrous adhesion
3. corpus alienum
A. fibrin --- fibroblast -fibrous adhesion
B. tissue ischaemia -vascular collateral fibrous matrix-- fibrous
adhesion
 Attempts to Prevent Adhesions

To prevent Fibrin deposit --Anti coagulan

Dextran , Trasylol
Remove fibrin exudat Peritoneal lavage
Separate bowel surfaces - peristalsis
Inhibit fiboblast proliferation - Anti histamin ,
Steroid
Treatment
Trial of conservative --- Spontaneus
remmision

Exploratory laporotomy
- simple lysis
- resection
- by pass
- plication
Plication small bowel seromuscular
 complete small bowel obstruction.

Upright film shows

multiple, short, air-
fluid levels arranged
in a stepwise pattern.
(Courtesy of Melvyn
H. Schreiber, M.D.,
The University of
Texas Medical Branch
 complete small bowel obstruction.

Supine film shows

dilated loops of
small bowel in an
orderly
arrangement,
without evidence
of colon gas.
 Surgical management of carcinoma of the small bowel

. A, Malignant tumors should be

resected with a wide margin of
normal bowel and a wedge of
mesentery to remove the
immediate draining lymph nodes.
B, End-to-end anastomosis of the
small bowel and repair of the
mesentery.
(Adapted from Thompson JC:
Atlas of Surgery of the Stomach,
Duodenum and Small Bowel. St.
Louis, MosbyYear Book, 1992, p
299.)
 constricting carcinoma.

Barium enema
demonstrating apple
core or napkin ring
lesion, caused by a
constricting
carcinoma.
polypoid carcinoma
Barium enema
demonstrating a polypoid
carcinoma arising in the
cecum of a 35-year-old
woman (arrows).
(Courtesy of Dina F.
Caroline, M.D., Ph.D.,
Temple University
Hospital.)