INTRODUCTION

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

CLASSIFICATION
DYNAMIC
(MECHANI
CAL)

Peristalsis is
working
against a
mechanical
obstruction

ADYNAM
IC
(FUNCTI
ONAL)
Result
from atony of the
intestine with loss of
normal peristalsis, in the
absence of a mechanical
cause.
or it may be present in a
non-propulsive form (e.g.
mesenteric vascular
occlusion or pseudoobstruction)

CAUSES OF I.O (DYNAMIC)

Intraluminal

Impaction
Foreign bodies
Bezoars
Gallstone

Intramural

Extramural

Congenital atresia Bands/

adhesion(40%)
Stricture
Malignancy(15%) Hernia (12%)
Volvulus
Intussusception
Tumorbenign/malignant

Pathophysiology:

Proximal
bowel
dilated &
develops
altered
motility
dilate
reduce
peristaltic
strength

flaccidity
&
paralysis
(prev.
vascular
damage
due to
increasing
intralumin
al
pressure

Distal to
obs. Bowel
exhibits
normal
peristalsis
&
absorbtion
become
empty
contract &
become
immobile

Distention
is by gas &
fluid
-Gas:
aerobic &
anaerobic
growth
-Fluid:
Digestive
juices &
retarded
absorption

Dehydratio
n&
electrolyte
s loss:
Reduced
oral intake,
defective
intestinal
absorption,
loses from
vomiting &
sequestrati
on in bowel
of lumen.

LARGE BOWEL OBSTRUCTION

DISTINGUISHING ILEUS FROM MECHANICAL OBSTRUCTION IS
CHALLENGING
CAECUM 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
2. BENIGN STRICTURE:
DUE TO DIVERTICULAR DISEASE, ISCHEMIA, INFLAMMATORY
BOWEL DISEASE.
3. VOLVULUS:
SIGMOID VOLVULUS/ CAECAL VOLVULUS
4. HERNIA.
5. CONGENITAL :
HIRSCHPRUNG, ANAL STENOSIS

CLINICAL FEATURES
High small bowel obstruction
vomiting occurs early and is
profuse with rapid dehydration.
Distension is minimal with little
evidence of fluid levels on
abdominal radiography

CARDINAL FEATURES:
Colicky pain
Vomiting
Abd distention
Constipation

Low small bowel obstruction

pain is predominant with central
distension.
Vomiting is delayed.
Multiple central fluid levels are
seen on radiography

Large bowel obstruction

distension is early and pronounced.
Pain is mild and vomiting and
dehydration are late.
The proximal colon and caecum are
distended on abdominal
radiography

OTHER FEATURES:
Dehydration
Hypokalaemia
Pyrexia
Abd tenderness

PHYSICAL EXAMINATION
INSPECTION
Abdominal distention, scars, visible peristalsis,
darm contour
PALPATION
Mass, tenderness
PERCUSSION
Tymphanic, dullness
AUSCULTATION
Bowel sound are high pitch and increase in
frequency

INVESTIGATIONS:

Lab:
Leukocytosis/ leucopeni
Arterial blood gasses
Ur & Cr
Na, K, LFT and glucose

Radiological:
Plain abdominal x-ray
Abdominal CT Scan , MRI, Contrast
studies)

Fluid levels with gas

above; stepladder
pattern. Ileal
obstruction by adhesions;
patient erect.

Supine radiograph from a

patient with complete small
bowel obstruction shows
distended small bowel
loops in the central
abdomen with prominent
valvulae conniventes (small
white arrow)

Figure 3. Lateral
decubitus view of the
abdomen, showing
air-fluid levels
consistent with
intestinal obstruction
(arrows).

The Difference between small

and large bowel obstruction
Small Bowel
Central ( diameter 3 cm
max)
Ileum: may appear
tubeless

Large bowel
Peripheral ( diameter 6
cm max)
Presence of haustration

TREATMENT OF INTESTINAL
OBSTRUCTION

SUPPORTIVE
1. Resuscitation
2. Decompression of proximal to the obstruction,
reduce subsequent aspiration during induction
of anesthesia and post extubation.
3. DC to decompression and observe urine
product
3. Electrolite corection
4. Broad spectrum antibiotic (not mandatory but
need in all patient undergoing surgery.

 SURGICAL
IND: obstructed / strangulated
external hernia, Internal
intestinal strangulation and
acute obstruction
1.Midline incision usually look on
CAECUM
2.Operative decompression
3.Look at viability of intestine
4.Large bowel obstruction:

INDICATIONS FOR
SURGERY
Absolute

Generalised peritonitis
Localised peritonitis
Visceral perforation
Irreducible hernia

Relative
Palpable mass lesion
'Virgin' abdomen
Failure to improve

Trial of conservatism

Incomplete obstruction
Previous surgery
Advanced malignancy
Diagnostic doubt - possible ileus

MANAGEMENT FOR
LARGE BOWEL
OBSTRUCTION
All patients require
Adequate resuscitation
Prophylactic antibiotics
Consenting and marking for potential stoma formation
Appropriate operations include:
Right sided lesions right hemicolectomy
Transverse colonic lesion extended right hemicolectomy
Left sided lesions various options

Three-staged procedure
Defunctioning colostomy
Resection and anastomosis
Closure of colostomy

Two-staged procedure
Hartmanns procedure
Closure of colostomy

One-stage procedure
Resection, on-table lavage and primary anastomosis
Three stage procedure will involve 3 operations!
Associated with prolonged total hospital stay
Transverse loop colostomy can be difficult to manage
With two-staged procedure only 60% of stomas are ever reversed
With one-stage procedure stoma is avoided
Anastomotic leak rate of less than 4% have been reported
Irrespective of option total perioperative mortality is about 10%

Complications
associated with
intestinal obstruction
repair
include
excessive bleeding

infection
formation of abscesses (pockets of
pus)
leakage of stool from an anastomosis
adhesion formation
paralytic ileus (temporary paralysis of
the intestines)
http://www.surgeryencyclopedia.com/Fi-La/Intestinal Source:
reoccurrence
of the obstruction.

COLOSTOMY TECHNIQUE
Single Colostomy
The single colostomy
technique can also be called
an 'end' or 'terminal'
colostomy. This tecnique
involves bring one end of the
colon out through an opening
made in the abdominal wall.
In this technique the
diseased part of the bowel is
removed, bt the rectal pouch
still remains.

Divided Colostomy
The Divided colostomy tecnique
involves two edges of the colon
being brought out through an
opening in the abdominal wall.
These two edges are seperate.
The edge which comes from the
digestive/proximal end is normally
active, therefore is known as the
colostomy. The other edge
brought through the abdominal
wall is known as the Distal end.
This tecnique is normally used
when spillages of faeces into the
bowel needs to be avoided.

 Loop Colostomy
The Loop colostomy Techniqe is when the
surgeon brings a loop of the bowel up
through the opening in the abdominal wall.
This loop is normally supported by a plastic
bridge, rod or plastic tubing. The surgeon
will cut two openings in the abdominal wall.
One opening is the proximal/afferent end,
and the other is the Distal/efferent end.
The afferent end is active and functioning
part of the colon,and will pass stools and
gas through the stoma. The efferent end is
the non active, non functioning part of the
colon. This tecnique is normally performed
in emergencies and will tend to be located
on transverse colon. A loop colostomy can
be temporary or permanent.

 Double - Barrelled Colostomy

This technique is very similar to
the loop colostomy in the way
that there is anproximal end
anddistal end which are both
brought up through an opening
in the abdominal wall.The
difference is that in the double
barrelled colostomy theproximal
end anddistal end are sutured
together for about 4 inches.
(Shown in diagram above).

THANK YOU