Intestinal Obstruction

Ahmed Badrek-Amoudi
FRCS

The common Scenario

A 50 year old gentleman presents with abdominal pain, distension and absolute constipation. With repeated episodes of vomiting. His vital sign were stable, abdomen distended with diffuse tenderness but minimal peritonism. Bowel Sounds are hyperactive. The plain abdominal xray was taken on admission.

What are your objectives?

You should be able to address the following questions 1. Is this bowel obstruction or ileus? 2. Is this a small or large bowel obstruction? 3. Is this proximal or distal obstruction? 4. What is the cause of this obstruction? 5. Is this a complex or simple obstruction? 6. How should I start investigating my patient? 7. What is the role of other supportive investigations? 8. What is my immediate/ intermediate treatment plan? 9. What are the indications for surgery? 10. What are the medico-legal and ethical issues that I should address?

Introduction and Definitions

Accounts for 5% of all acute surgical admissions Patients are often extremely ill requiring prompt assessment, resuscitation and intensive monitoring Obstruction A mechanical blockage arising from a structural abnormality that presents a physical barrier to the progression of gut contents. Ileus is a paralytic or functional variety of obstruction

Obstruction is:

Partial or complete Simple or strangulated

Patho-physiology I

8L of isotonic fluid received by the small intestines (saliva, stomach, duodenum, pancreas and hepatobiliary ) 7L absorbed 2L enter the large intestine and 200 ml excreted in the faeces Air in the bowel results from swallowed air ( O2 & N2) and bacterial fermentation in the colon ( H2, Methane & CO2), 600 ml of flatus is released Enteric bacteria consist of coliforms, anaerobes and strep.faecalis. Normal intestinal mucosa has a significant immune role
Distension results from gas and/ or fluid and can exert hydrostatic pressure. In case of BO Bacterial overgrowth can be rapid If mucosal barrier is breached it may result in translocation of bacteria and toxins resulting in bactaeremia, septaecemia and toxaemia.

Patho-physiology II
Obstruction results in:
1. 2. 3. 4. 5. 6. 7. 8. Initial overcoming of the obstruction by increased paristalsis Increased intraluminal pressure by fluid and gas Vomiting sequestration of fluid into the lumen from the surrounding circulation Lymphatic and venous congestion resulting in oedematous tissues Factors 3,4,5 result in hypovolaemia and electrolyte imbalance Further: localised anoxia, mucosal depletion necrosis and perforation and peritonitis. Bacterial over growth with translocation of bacteria and its toxins causing bacteraemia and septicaemia.

Decompress with NGT Replace lost fluid Correct electrolyte abnormalities Recognise strangulation and perforation Systemic antibiotics.

Causes- Small Bowel

Luminal F. Body Bezoars Gall stone Food Particles
A. lumbricoides

Mural Neoplasims lipoma polyps leiyomayoma hematoma lymphoma carcimoid carinoma secondary Tumors Crohns TB Stricture Intussusception Congenital

Extraluminal Postoperative adhesions Congenital adhesions Hernia Volvulus

Small Bowel Adhesions

Accounts for 60-70% of All SBO Results from peritoneal injury, platelet activation and fibrin formation. Associated with starch covered gloves, intraperitoneal sepsis, haemorrhage and wash with irritant solutions iodine and other foreign bodies. As early as 4 weeks post laparotomy. The majority of patients present between 1-5 years
Colorectal Surgery 25% Gynaecological 20% Appendectomy 14%

70% of patients had a single band Patients with complex bands are more likely to be readmitted Readmission in surgically treated patients is 35%

ADHESIVE INTESTINAL OBSTRUCTION

ADHESIVE INTESTINAL OBSTRUCTION

ADHESIVE INTESTINAL OBSTRUCTION

ADHESIVE INTESTINAL OBSTRUCTION

ADHESIVE INTESTINAL OBSTRUCTION

Hernia
Accounts for 20% of SBO Commonest 1. Femoral hernia 2. ID inguinal 3. Umbilical 4. Others: incisional and internal H. The site of obstruction is the neck of hernia The compromised viscus is with in the sac. Ischaemia occurs initially by venous occlusion, followed by oedema and arterialc ompromise. Attempt to distinguish the difference between:
Incaceration Sliding Obstruction Persistent pain Discolouration Tenderness Constitutional symptoms

Strangulation is noted by:

Other causes

Intussusception

Gall stone Ileus

IBD

INTUSSUSCEPTION
Inversion of the bowel upon itself secondary to a leading point Juvenile Intussusception most often idiopathic Also secondary to Meckel"s diverticulum Presents 6 months to 2 years of age As early as 1 month Acute painful episodes followed by periods of lethargy When incarcerated progress to continuous lethargy May or may not have currant-jelly stool But often stool is heme positive Rule out with a left lateral Decubitus film

Bad Intussusception

Intussusception

Large Bowel Obstruction

Distinguishing ileus from mechanical obstruction is challenging According to Leplacs law: maximum pressure is at the its maximum diameter. Cecum is at the greatest risk of perforation Perforation results in the release of formed feaces with heavy bacterial contamination Aetiology: 1. Carcinoma:

The commonest cause, 18% of colonic ca. present with obstruction 2. Benign stricture: Due to Diverticular disease, Ischemia, Inflammatory bowel disease. 3. Volvulus: 1. Sigmoid Volvulus: Results from long redundant, faecaly loaded colon with a narrow pedicle 2. Caecal Volvulus 4. Hernia. 5. Congenital : Hirschusbrung, anal stenosis and agenesis

Sigmoid Volvulus

Colonic Obstruction

Radiological Evaluation
Normal Scout Always request: Supine, Erect and CXR Gas pattern:
1. 2. 3. 4. Gastric, Colonic and 1-2 small bowel Gastric 1-2 small bowel Caecal Hepatobiliary Free gas under diaphragm Rectum

Fluid Levels:

Check gasses in 4 areas:

Look for calcification Look for soft tissue masses, psoas shadow Look for fecal pattern

The Difference between small and large bowel obstruction

Large bowel Peripheral ( diameter 8 cm max) Presence of haustration Small Bowel Central ( diameter 5 cm max) Vulvulae coniventae Ileum: may appear tubeless

Symptoms
The four cardinal features of intestinal obstruction:
-abdominal pain -vomiting -distension -constipation
Vary according to:location of obstruction age of obstruction underlying pathology intestinal ischemia

Symptoms
Abdominal pain
colicky in nature, around the umbilicus in SBO while in the lower abdomen in LBO if it becomes continuous, think about perforation or strangulation

Vomiting
-starts early in SBO and late in LBO -vomitus starts with clear color then becomes thick, brown and foul ( faeculent) -more with lower or complete obstruction -diarrhea may be present with partial obstruction

Distension
-more with lower obstruction

Symptoms
Constipation
-more with lower or complete obstruction -diarrhea may be present with partial obstruction -either absolute (no feces or flatus)<-cardinal in absolute IO or relative (flatus passed)

Distension
-more with lower obstruction

Symptoms
In strangulation:
severe constant abdominal pain distended abdomen fever tachycardia tender abdomen

Role of CT

Used with iv contrast, oral and rectal contrast (triple contrast). Able to demonstrate abnormality in the bowel wall, mesentery, mesenteric vessels and peritoneum.

It can define the level of obstruction The degree of obstruction The cause: volvulus, hernia, luminal and mural causes The degree of ischaemia Free fluid and gas
Ensure: patient vitally stable with no renal failure and no previous alergy to iodine

Role of barium gastrografin studies

Barium should not be used in a patient with peritonitis As: follow through, enema Limited use in the acute setting Gastrografin is used in acute abdomen but is diluted Useful in recurrent and chronic obstruction May able to define the level and mural causes. Can be used to distinguish adynamic and mechanical obstruction

How to initially investigate your patient

Lab:
CBC (leukocytosis, anaemia, hematocrit, platelets) Clotting profile Arterial blood gasses U& Crt, Na, K, Amylase, LFT and glucose, LDH Group and save (x-match if needed) Optional (ESR, CRP, Hepatitis profile Plain xrays USS ( free fluid, masses, mucosal folds, pattern of paristalsis, Doppler of mesenteric vasulature, solid organs) Other advanced studies (CT, MRI, Contrast studiessenior decision)

Radilogical:

ECG and other investigations for co-morbid factors

Understanding the clinical findings

Clinical Findings

1. History

The Universal Features

Colicky abdominal pain, vomiting, constipation (absolute), abdominal distension. Complete HX ( PMH, PSH, ROS, Medication, FH, SH)

High
Pain is rapid Vomiting copious and contains bile jejunal content Abdominal distension is limited or localized Rapid dehydration

Distal small bowel

Pain: central and colicky Vomitus is feculunt Distension is severe Visible peristalsis May continue to pass flatus and feacus before absolute constipation

Colonic
? Preexisting change
in bowel habit Colicky in the lower abdomin Vomiting is late Distension prominent Cecum ? distended

Persistent pain may be a sign of strangulation Relative and absolute constipation

Clinical Findings

2. Examination
General Vital signs: P, BP, RR, T, Sat dehydration Anaemia, jaundice, LN Assessment of vomitus if possible Full lung and heart examination

Abdominal
Abdominal distension and its pattern Hernial orifices Visible peristalsis Cecal distension Tenderness, guarding and rebound Organomegaly Bowel sounds
High pitched Absent

Others
Systemic examination If deemed necessary. CNS Vascular Gynaecological muscuoloskeltal

Rectal examination

Initial Management in the ER

Resuscitate:
Air way (O2 60-100%) Insert 2 lines if necessary IVF : Crytloids at least 120 ml/h. (determined by estimated fluid loss and cardiac function). Add K+ at 1mmmol/kg

Draw blood for lab investigations Inform a senior member in the team. NPO. Decompress with Naso-gastric tube and secure in position Insert a urinary catheter (hourly urinary measurements) and start a fluid input / output chart Intravenous antibiotics (no clear evidence) If concerns exist about fluid overloading a central line should be inserted Follow-up lab results and correction of electrolyte imbalance The patient should be nursed in intermediate care Rectal tubes should only be used in Sigmoid volvulus.

Indications for Surgery

Immediate intervention: Evidence of strangulation (hernia.etc) Signs of peritonitis resulting from perforation or ischemia
In the next 24-48 hours Clear indication of no resolution of obstruction ( Clinical, radiological). Diagnosis is unclear in a virgin abdomen

Intermediate stage The cause has been diagnosed and the patient is stabalised

Legal issues and consent

Ileus
Associated with the following conditions:
Postoperative and bowel resection Intraperitoneal infection or inflammation Ischemia Extra-abdominal: Chest infection, Myocardia infarction Endocrine: hypothyroidism, diabetes Spinal and pelvic fractures Retro-peritoneal haematoma Metabolic abnormalities: Hypokalaemia Hyponatremia Uraemia Hypomagnesemia Bed ridden Drug induced: morphine, tricyclic antidepressants

Is this an ileus or obstruction

Clinical features Is there an under lying cause? Is the abdomen distended but tenderness is not marked. Is the bowel sounds diffusely hypoactive.
Radiological features: Is the bowel diffusely distended Is there gas in the rectum Are further investigasions (CT or Gastrografin studies) helpful in showing an obstruction. Does the patient improve on conservative measures

Example of ileus