Professional Documents
Culture Documents
Abdominal Operations
Maingots Edisi 11
McGraw-Hills Srgery
By:
Resti Fratiwi Fitri
DEFINITION
WHAT IS BOWEL OBSTRUCTION??
The
occur.
WHERE?
the small intestine (small bowel obstruction), the large intestine (large
bowel obstruction), or via systemic alterations (generalized ileus)
DEFINITION
Mech
anical
Bowel
Obstr
c.
Intestinal obstruction
caused by either
paralysis or
dysmotility of
intestinal peristalsis
intestinal obstruction
caused by a physical
blockage of the
intestinal lumen
Functi
onal
Bowel
Obstr
c.
DEFINITION
LESIONS EXTRINSIC
LESIONS INTRINSIC
ADHESIONS:
Post-operative, Congenital, Post-inflammatory
CONGENITAL:
Intestinal atresia, Meckels diverticulum, duplications
HERNIA:
H. External abdominal wall, H. Internal, H. Incisional
INFLAMMATORY:
Chrons disease, eosinophilic granuloma
CONGENITAL:
Annular pancreas, malrotation, Omphalomesenteric duct
remnant
INFECTIONS:
Tuberculosis, actinomycosis, complicated diverticulitis
NEOPLASTIC:
Carcinomatosis, Extraintestinal neoplasm
NEOPLASTIC:
Primary or metastatic neoplasms, appendicitis
INFLAMMATORY:
Intra-abdominal abscess, Starch peritonitis
MISCELLANEOUS:
Intussusception, endometriosis, radiation stricture,
intramural hematoma, ischemic stricture
MISCELLANEOUS:
Volvulus, Gossypiboma, Superior mesentric artery
syndrome
INTRALUMINAL/OBTURATOR OBSTRUCTION:
Gallstone, enterolith, phytobezoar, parasite infestaion,
swallowed foreign body
DEFINITION
OBSTRUCTION
PARTIAL
OBSTR.
SIMPLE
OBSTR.
COMPLETE
OBSTR.
CLOSEDLOOP OBSTR.
STRANGULATION OBSTR.
increase in intraluminal
pressure secondary
DEFINITION
EXTRA-ABDOMINAL
CAUSES
CAUSES
INTRAPERITONEAL PROBLEMS:
peritonitis, intra-abdominal abscess, post-operative
, chemical (gastric juice, bile, blood), Autoimmune
(Serositis, vasculitis) & Intestinal ischemia (arterial
or venous, sickle
disease)
Thecell
most
common cause is
METABOLIC ABNORMALITIES:
Electrolyte imbalance, sepsis, lead poisoning,
porphyria, hyperglicemia, hypothiroidsm, uremia
RETROPERITONEAL
PROBLEMS: ILEUS
THORACIC PROBLEMS:
POST-OPERATIVE
Urolithiasis,
pyelonefphritis,
metastasis,
Myocardial
It is correlate
with
the degree of
surgical trauma as well
as the infarction, congestive heart failure,
pancreatitis, retroperitoneal
pneumonia, thoracic trauma
type of trauma
operation.
MEDICINES:
opiates,
Different anatomic segments of the gastrointestinal
tractanti-cholinergic, alpha-adrenergik
agonists,
also recover at different rates after manipulation
and antihistamines
trauma.
MISCELLANEOUS:
Spinal cord injury, pelvic fracture, head trauma,
radiation therapy, renal
The small bowel recovers within several hourschemotherapy,
posttransplantation
EPIDEMIOLOGY
frequency in
>
PHATOPHYSIOLOGY
the pathophysiology of bowel obstruction remains
incompletely understood.
PATOPHYSIOLOGY
DISTENTION,
ABSORPTION & SECRETION
BOWEL DISTENTION ??
Early phases of obstruct, accumulates gas from
nitrogen).
The next phases, gas arise from the
fermentation of sugars ,
10
PATOPHYSIOLOGY
DISTENTION,
ABSORPTION & SECRETION
Dilatation &
inflammation bowel
Activated
Activated
neutrophils &
macrophages
macrophages
Accumulate
Accumulate within
within
muscular layer of
the
the bowel
bowel wall
wall
Damage
By release of reactive proteolytic enzymes,
Damage to
to secretory
secretory
&
& motor
motor processess
processesscytokines & other locally substances
11
PATOPHYSIOLOGY
DISTENTION,
ABSORPTION & SECRETION
12 hours of
obstruct.
Water
Water &
&
electrolytes
electrolytes
accumulate
accumulate
secondary
secondary
Decrease
Decrease
absorption
absorption
24 hours of
obstruct.
water
water &
&
electrolytes
electrolytes
accumulate
accumulate
more
more rapidly
rapidly
Decrease
Decrease in
in
absorption
flux
absorption flux
Mucosal injury
Increase
Increase
intestinal
intestinal
secretion
secretion (flux)
(flux)
Increased
Increased
permeability
permeability
Intraluminar leakage plasma,
12
PATOPHYSIOLOGY
DISTENTION,
ABSORPTION & SECRETION
DEHYDRATION
OBSTRUCTED BOWEL
WITH SECRETORY FLUX
Bile
vasoavasoac
tive intestinal
polypeptide
prostaglandins
Intraluminar
bacteria toxins
Oxygen
Free
radical
13
PATOPHYSIOLOGY
INTESTINAL MOTILITY
Early phase of bowel obstruction,
Intestinal contractile activity increases propel intraluminal contents past
the obstruction
Later phase of bowel obstruction,
The contractile activity diminishes intestinal wall hypoxia
autonomic
parasympathetic (vagal) and sympathetic splanchnic
innervation.
14
PATOPHYSIOLOGY
CIRCULATORY CHANGES
Distention of the bowel lumen with a concomitant results in
increased transmural pressure on capillary blood flow
within the wall of the bowel risk
of ischemic.
15
PATOPHYSIOLOGY
MICROBIOLOGY &
BACTERIAL TRANSLOCATION
Upper small intestine gram-positive
concentrations, <10 6 colonies/mL.
and
anaerobic organisms
in the presence of obstruction, a rapid proliferation of bacterial
organisms occurs consisting predominantly of fecal-type organisms.
reaching a plateau of 10 91010 colonies/mL after 1248 hours of an
established obstruction.
Bacterial toxins have an important role in the mucosal response to bowel
obstruction.
16
ETIOLOGY
ADHESIONS
HERNIA
MALIGNANT BOWEL OBSTRUCTION
GRANULOMATOUS DISEASE AND CHROHNS
DISEASE
INTUSSUSCEPTION
VOLVULUS
OTHER CAUSE
17
DIAGNOSIS
The diagnosis of bowel obstruction is suspected clinically
based on the presence of classic signs and symptoms and then
18
HISTORY &
DIAGNOSIS
PHYSICAL EXAMINATION
Abdominal pain & distention precede the appearance
of NAUSEA & VOMITING by several hours
The more Proximal the obstruction,
the earlier and more prominent are the
nausea & vomiting, distention usually less.
DISTENTI
DISTENTI
ON
ON
The location
CRAMPY
CRAMPY
ABDOMINAL
ABDOMINAL PAIN
PAIN
and
character of pain may be
helpful in differentiating
mechanical bowel obstruction and
ileus.
19
HISTORY &
DIAGNOSIS
PHYSICAL EXAMINATION
MECHANICAL SMALL BOWEL
OBSTRUCTION
VISCERAL PAIN
POORLY LOCALIZED
CRAMPY WITH RECCURENT
PAROXYSMS occuring short (30
seconds to 2 minutes)
20
HISTORY &
DIAGNOSIS
PHYSICAL EXAMINATION
FEVER??
infectious cause or strangulations
VITAL
VITAL SIGNS
SIGNS
POTENSIAL
ABD.
HYDRATION
ABD.
RECTAL
AUSCULTA-TION
PALPATION
INSPECION
HERNIA
EXAMS
STATUS
DEFECT
POTENSIAL
ABD.
HYDRATION
ABD.
RECTAL
AUSCULTA-TION
PALPATION
INSPECION
HERNIA
EXAMS
STATUS
DEFECT
21
HISTORY &
DIAGNOSIS
PHYSICAL EXAMINATION
VITAL
VITAL SIGNS
SIGNS
POTENSIAL
ABD.
HYDRATION
ABD.
RECTAL
AUSCULTA-TION
PALPATION
INSPECION
HERNIA
EXAMS
STATUS
DEFECT
POTENSIAL
ABD.
HYDRATION
ABD.
RECTAL
AUSCULTA-TION
PALPATION
INSPECION
HERNIA
EXAMS
STATUS
DEFECT
DEHYDRATION??
Tachycardia +
Hypotension + Oligouria
22
HISTORY &
DIAGNOSIS
PHYSICAL EXAMINATION
VITAL
VITAL SIGNS
SIGNS
POTENSIAL
ABD.
HYDRATION
ABD.
RECTAL
AUSCULTA-TION
PALPATION
INSPECION
HERNIA
EXAMS
STATUS
DEFECT
POTENSIAL
ABD.
HYDRATION
ABD.
RECTAL
AUSCULTA-TION
PALPATION
INSPECION
HERNIA
EXAMS
STATUS
DEFECT
23
HISTORY &
DIAGNOSIS
PHYSICAL EXAMINATION
VITAL
VITAL SIGNS
SIGNS
POTENSIAL
ABD.
HYDRATION
ABD.
RECTAL
AUSCULTA-TION
PALPATION
INSPECION
HERNIA
EXAMS
STATUS
DEFECT
POTENSIAL
ABD.
HYDRATION
ABD.
RECTAL
AUSCULTA-TION
PALPATION
INSPECION
HERNIA
EXAMS
STATUS
DEFECT
PERITONITIS??
Rebound, localized tenderness,
involuntary guarding that herald
vascular or perforations
24
DIAGNOSIS
LABORATORY
Completed
Completed blood
blood cell
cell count
count &
& diff
diff
Electrolyte
Electrolyte panel
panel
Blood
Blood urea
urea nitrogen
nitrogen
Creatine
Creatine serum
serum
Urinalysis
Urinalysis
25
DIAGNOSIS
RADIOLOGIC FINDINGS
Flat & upright (supine)
abdominal radiographs
Contrast studies
Computed tomography
ultrasonography
26
DIAGNOSIS
RADIOLOGIC FINDINGS
Flat & upright (supine)
abdominal radiographs
Contrast studies
Computed tomography
ultrasonography
27
DIAGNOSIS
RADIOLOGIC FINDINGS
Flat & upright (supine)
abdominal radiographs
Contrast studies
valuable tool in the diagnosis of bowel
Computed tomography
ultrasonography
28
DIAGNOSIS
RADIOLOGIC FINDINGS
Flat & upright (supine)
abdominal radiographs
Contrast studies
Computed tomography
ultrasonography
29
MANAGEMENT
SMALL BOWEL OBSTRUCTION
Focus on aggressive fluid
aspiration.
Resuscitation
Aspiration
Guided by urine
output,hemodyna
mically stable
and normal renal
function.
Use functioning
NGT for
nasogastric
decompression to
prevent swallowed
air.
Use Crystalloid.
LARGE BOWEL
OBSTRUCTION
SURGICAL Intervention!!!
surgical exploration should be
undertaken as soon as possible after
appropriate resuscitation.
30
MANAGEMENT
Aggresive
resuscitatio
n
Electrolyte
replacement
MANAGEMENT
Physic
Exam.
Localized
tenderness
Continous
abdominal
pain
Peritonitis
Lab.
leukocytosis
Minimal 3
sign & symptomp
WHEN?
Non-operative management
can be continued longer
than 48 hours with the
understanding that delaying
invitable
operative
treatment.
MANAGEMENT
beta-blockers
to patient with
cardiovascular
cormorbidities
Antibiotic preoperatif
Correction
electrolyte
abnormalities
Use
nasogastric
tube
MANAGEMENT
MANAGEMENT
TERIMAKASIH
36