Prof Bachtiar Surya SpB.

KBD
Bagian Bedah FK-USU / RSUP HAM
Medan

Definition
Intestinal obstruction involves a partial or complete blockage of
the bowel that results in the failure of the intestinal contents to
pass through.

Causes :
1. no "mechanical" (anatomic)
2. mechanical

Paralytic ileus, also called pseudo-obstruction,

is one of the major causes of obstruction in
infants and children.
The causes of paralytic ileus may include the
following:
Medications, especially narcotics
Intraperitoneal infection
Mesenteric ischemia (decreased blood supply
to the support structures in the abdomen)
Injury to the abdominal blood supply
Complications of intra-abdominal surgery
Kidney or thoracic disease
Metabolic disturbances (such as decreased
potassium levels)

Mechanical obstruction
Mechanical obstruction occurs when movement of material
through the intestines is physically blocked.
The mechanical causes of obstruction are numerous and may
include the following:
Hernias
Postoperative adhesions or scar tissue
Impacted feces (stool)
Gallstones
Tumors blocking the intestines
Granulomatous processes (abnormal tissue growth)
Intussusception
Volvulus (twisted intestine)
Foreign bodies (ingested materials that obstruct the
intestines)

Symptoms

Abdominal fullness, gaseous

Abdominal distention
Abdominal pain and cramping
Vomiting
Failure to pass gas or stool (constipation)
Diarrhea
Breath odor

Signs and tests

High-pitched bowel sounds at the onset of mechanical
obstruction.
If the obstruction has persisted for too long or the bowel
has been significantly damaged, bowel sounds
decrease, eventually becoming silent.
Early paralytic ileus is marked by decreased or absent
bowel sound.
Tests that show obstruction include:

Barium enema
Abdominal CT scan
Upper GI and small bowel series
Abdominal film

Treatment
Decompress the intestine with suction, using a
nasogastric (NG) tube inserted into the stomach or
intestine.
Surgery to relieve the obstruction may be necessary if
decompression by NG tube does not relieve the
symptoms, or if tissue death is suspected.

Complications
Infection
Gangrene of the bowel
Perforation (hole) in the intestine

Mechanical Intestinal
Obstruction
For clinical purposes, mechanical
obstruction is divided into obstruction of
the small bowel, including the duodenum,
and the large bowel.

Etiology
Common causes of mechanical obstruction are
adhesions, hernias, tumors, foreign bodies (including
gallstones), inflammatory bowel disease (Crohn's
disease), Hirschsprung's disease, fecal impaction, and
volvulus.
Obstruction of the small bowel:
Small-bowel (jejunoileal) obstruction is commonly
caused by incarceration in hernias or by adhesions and
is less commonly caused by tumors (primary or
metastatic), obturation by foreign bodies, a Meckel's
diverticulum, or Crohn's disease.

Obstruction of the duodenum:

Duodenal obstruction is usually caused by cancer, primarily in
the duodenum or head of the pancreas.
In neonates, duodenal obstruction is most commonly caused by
atresia, volvulus, bands, congenital esophageal webs, and
annular pancreas. In rare instances, congenital webs persist
into adult life and lead to deformities (eg, the so-called
intraluminal diverticula associated with obstruction).
Obstruction of the large bowel:
Large-bowel obstruction is caused by tumors, diverticulitis,
volvulus, and fecal impaction. Tumors include cancer that
blocks the lumen and rare benign lesions (eg, lipomas, large
polyps) that can lead to intussusception. Obstructing cancer
occurs most often at the splenic and sigmoid flexures,
diverticulitis usually obstructs in the sigmoid, and volvulus is
most common in the sigmoid or cecum.

Pathophysiology
In simple mechanical obstruction, blockage occurs without

vascular or neurologic compromise. Ingested fluid and food,

digestive secretions, and gas accumulate in excessive amounts if
obstruction is complete. The proximal bowel distends, and the distal
segment collapses. The normal secretory and absorptive functions
of the mucous membrane are depressed, and the bowel wall
becomes edematous and congested. Severe intestinal distention is
self-perpetuating and progressive, intensifying the peristaltic and
secretory derangements and increasing the risks of dehydration,
ischemia, necrosis, perforation, peritonitis, and death.

In strangulating obstruction, infarction of the bowel is most

commonly associated with hernia, volvulus, intussusception, and

vascular occlusion. Strangulation usually begins with venous
obstruction, which may be followed by arterial occlusion, resulting in
rapid ischemia of the bowel wall. The bowel becomes edematous
and infarcted, leading to gangrene and perforation.

Symptoms, Signs, and Diagnosis

Obstruction of the small bowel:
Diagnosis of simple obstruction is based on a triad of symptoms:
(1) Abdominal cramps are centered around the umbilicus or in the epigastrium;
(2) Vomiting starts early with small-bowel and late with large-bowel obstruction.
(3) Obstipation occurs with complete obstruction, but diarrhea may be present with
partial obstruction.

Abdominal x-ray in both the supine and upright positions

A ladderlike series of small-bowel loops usually is typical but also occurs with an
obstructing lesion of the right colon.
Fluid levels in the bowel can be seen in upright views.
Distended loops may be absent with an obstruction of the upper jejunum.
With closed-loop strangulating obstructions (as may occur with volvulus),
A barium enema can usually rule out colonic lesions.
In questionable cases of small-bowel obstruction, oral barium can be given but is
contraindicated if obstruction is believed to be in the colon.

Physical examination

Typically shows a distended abdomen with loud borborygmi. There

is no tenderness, and the rectum is usually empty.

Unlike in small-bowel obstruction, adhesions rarely obstruct the

colon. Strangulation (except with volvulus) is rare. Perforation of a
tumor or of a diverticulum also may occur at the obstruction site.

If the cecum is dilated to a diameter of 13 cm, the danger of rupture

is high and immediate operation is indicated.

Preliminary endoscopy or barium enema should be performed for

precise location of the obstruction.

Cecal volvulus can be diagnosed on abdominal x-ray by a large gas

bubble in the midabdomen or the left upper quadrant.

Sigmoidal volvulus usually occurs in the elderly. With both cecal and
sigmoidal volvulus, a barium enema shows the site of obstruction by
a typical bird-beak deformity at the site of the twist.

Treatment

Obstruction of the small bowel :

A nasogastric tube is inserted and placed on suction.
Most surgeons favor early laparotomy, although often it
is delayed 2 or 3 h to improve the status and obtain a
urine output in a very ill, dehydrated patient.
An inlying bladder catheter helps monitor urinary output.
IV fluids (preferably lactated Ringer's solution) and
electrolytes are started.
Procedures to prevent recurrence should be performed,
including repair of hernias, removal of foreign bodies,
and complete lysis of adhesions.

 Obstructing gallstones are removed by

lithotomy; cholecystectomy can be
performed either simultaneously or later
Treatment of obstruction of the duodenum
in adults consists of resection or, if the
lesion cannot be removed, palliative
gastrojejunostomy

Obstruction of the large bowel:

Treatment is essentially the same as for small-bowel obstruction.

Nasogastric suction, IV fluids and electrolytes, and a urinary
catheter are needed before emergency operation.

Obstructing cancers of the colon can often be treated by a singlestage resection and anastomosis.

Other options include a diverting colostomy and anastomosis.

Treatment of cecal volvulus consists of either resection and

anastomosis of the involved segment or fixation of the cecum in its
normal position by cecostomy.

In sigmoidal volvulus, a typical distended loop of the sigmoid can be

seen on the abdominal x-ray. The endoscope or a long rectal tube
can usually decompress the loop, and resection and anastomosis
may be deferred for a few days. Without a resection, recurrence is
almost inevitable.