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Intestinal obstruction

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Shivay Gupta

This document discusses intestinal obstruction, including its causes, symptoms, diagnosis, and treatment. Mechanical obstruction is caused by lesions or masses that physically block the intestines, while paralytic ileus involves loss of normal bowel motility. Common symptoms are abdominal pain, vomiting, constipation and distension. Diagnosis involves medical history, physical exam finding bowel sounds or masses, and imaging tests. Treatment focuses on fluid replacement, decompressing the bowel, and timely surgery to resolve the obstruction if it has not resolved on its own.

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Intestinal obstruction
When there is pathological interference with the normal progression of intestinal luminal contents distally the condition is called as Intestinal obstruction Such obstruction may be due to mechanical causes (Mechanical obstruction) or Paralytic ileus Definition
Aetiology Mechanical obstruction Paralytic ileus
Mechanical obstruction Obstruction in the lumen Lesions of the bowel wall Congenital Traumatic Inflammatory Neoplastic Lesions extrinsic to the bowel Adhesive band constriction External hernia Volvulus Extrinsic masses
.
Paralytic ileus Abdominal causes Systemic causes Intestinal distension Electrolyte imbalance Peritonitis Retroperitoneal lesions * Retroperitoneal haemorrhage * Retroperitoneal sarcoma * Distension of ureter (Hypokalaemia)
Classification Simple mechanical obstruction Acute obstruction Strangulated obstruction Chronic obstruction Closed loop obstruction Acute-on-chronic obstruction
Pathology Bowel motility Distension Fluid and electrolyte imbalance Intestinal gas Strangulation Onset of gangrene Transmigration of bacteria and toxins
Bowel motility When the intestine obstructed part above the intestine shows vigorous peristalsis to overcome the obstruction. It remains about 2-6 days More distal is the obstruction more the peristalsis is and longer does it remains. For few hours intestines distal to the obstruction shows normal peristalsis and absorption later on it becomes immobile If the obstruction not relieved peristalsis ceases and intestines becomes flaccid and paralysed
Distension Accumulation of fluid and gas proximal to the intestinal obstruction causes intestinal distension Ingested fluid Digestive secretions Intestinal gas Plays major role in the distension
Fluid and electrolyte imbalance Large amount of fluid enters in to the gut daily (nearly 8000 ml/day) Saliva : 1500 ml Gastric juice : 2500 ml Bile & Pancreatic juice : 1000 ml and Intestinal juice : 3000 ml In intestinal obstruction distension causes increased intestinal secretion and decreased absorption Accumulation of such huge amount of fluid along with repeated vomiting causes severe electrolyte imbalance
Intestinal gas Much of the distension caused by the accumulation of gas in the intestine proximal to the obstruction. It contributes :- 1) Gas swallowed by atmospheric air 2) Diffusion of gas from blood in to lumen of the bowel (Carbon dioxide) 3) Organic gases : Hydrogen sulphide Ammonia Amines Hydrogen As O2 and CO2 are absorbed and Nitrogen is not absorbed, Nitrogen is highest content among the intestinal gases
Composition of various gases Nitrogen : 70% Oxygen : 12% Carbon dioxide : 8% Remaining : 10 % Hydrogen sulphide Ammonia and amines Hydrogen 5% 4% 1%
Strangulation When the blood circulation of affected intestine occluded strangulation develops. This frequently occurs in Adhesive band obstruction Hernia Volvulus Intussusception When the venous return is completely occluded it develops gangrene. Intestines becomes purple and then black. And transmition of bacteria and toxins occurres in peritoneum
Clinical features Abdominal pain 1 Vomiting 2 Constipation 3 Distension 4
Abdominal pain This is first symptom and usually starts suddenly Cramping type of abdominal pain with hyper-peristalsis Central abdominal pain : Small intestinal obstruction 4-5 minutes interval in : Proximal obstruction 15-20 minutes interval in : Distal obstruction Patient is free from pain in between the attacks
Sr.No. Origin / Nature of the pain Site of obstruction 1. Diffuse, poorly localized and felt across the upper abdomen High obstruction 2. At the level of umbilicus Low ileal obstruction 3. Lower abdomen Colon obstruction 4. Perineum Recto-sigmoid obstruction 5. Continuous severe pain without any quiescent period s/o Strangulation
Vomiting High intestinal obstruction : Vomiting is more frequent and copious and relieved by decompression Lower intestinal obstruction : Vomiting is not so frequent and doesnt get relief by decompression and faeculent afterwards In the colon obstruction there is no vomiting until the occurrence of incompetency of valve. Vomiting is absent in colon obstruction until the ilio-caecal valve is competent
Constipation Bowel present early distal to the obstruction is evacuated and then constipation develops. Constipation is early in distal bowel obstruction while it is late in proximal bowel obstruction In few conditions of intestinal obstruction constipation is not presenting symptom for e.g.: Richters hernia, Intestinal obstruction in pelvic abscess, Mesenteric vascular occlusion
Distension Is absent in early stages Is much less in high small bowel obstruction Is centrally placed but late in low small bowel obstruction
.
.
Physical examination Inspection :- Visible peristalsis in early cases Abdominal distension later on Fluid thrill Shifting dullness and fullness in flanks All the hernial orifices must be inspected to rule out Hernia as cause of obstruction
Palpation Abdomen should thoroughly palpated to exclude presence of any mass which may be found in case of neoplasm, Abscess, intussusception Muscle guarding may be present during colic Tenderness and rigidity at the site of obstruction suggestive of strangulation Rebound tenderness suggests peritonitis and like hood strangulation All the hernial sites are well palpated
Auscultation Is having great value Sr.No. Auscultation of bowel sounds Diagnosis 1. Loud, High pitched and metallic Simple mechanical obstruction 2. Isolated bowel sound occasionally Paralytic ileus 3. Complete absence of B.S. Strangulation
Importance of rectal examination It should be done in all cases of intestinal obstruction. Presence of mass within or outside the lumen gives clue to diagnose Absence of faeces in the rectum suggestive of higher intestinal obstruction and vice versa Most of the rectal cancer are within the reach of examining finger.
Special investigations Blood examination Straight X-ray Barium enema Intravenous urography WBC count is very useful to differentiate type of strangulation Normal / Slight rise in WBC : Simple mechanical obstruction Moderate rise (15,000-20,000) :- Strangulation Very high rise (30,000-40,000) :- Primary mesenteric vascular occlusion Serum amylase level is often elevated (due to entry of Amylase in to blood by regurgitation from pancreas due to back pressure of duodenum)
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Management Principle Fluid and electrolyte therapy Decompression of bowel Timed surgical intervention
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Intestinal obstruction

  • 2. When there is pathological interference with the normal progression of intestinal luminal contents distally the condition is called as Intestinal obstruction Such obstruction may be due to mechanical causes (Mechanical obstruction) or Paralytic ileus Definition
  • 4. Mechanical obstruction Obstruction in the lumen Lesions of the bowel wall Congenital Traumatic Inflammatory Neoplastic Lesions extrinsic to the bowel Adhesive band constriction External hernia Volvulus Extrinsic masses
  • 5. .
  • 6. Paralytic ileus Abdominal causes Systemic causes Intestinal distension Electrolyte imbalance Peritonitis Retroperitoneal lesions * Retroperitoneal haemorrhage * Retroperitoneal sarcoma * Distension of ureter (Hypokalaemia)
  • 7. Classification Simple mechanical obstruction Acute obstruction Strangulated obstruction Chronic obstruction Closed loop obstruction Acute-on-chronic obstruction
  • 8. Pathology Bowel motility Distension Fluid and electrolyte imbalance Intestinal gas Strangulation Onset of gangrene Transmigration of bacteria and toxins
  • 9. Bowel motility When the intestine obstructed part above the intestine shows vigorous peristalsis to overcome the obstruction. It remains about 2-6 days More distal is the obstruction more the peristalsis is and longer does it remains. For few hours intestines distal to the obstruction shows normal peristalsis and absorption later on it becomes immobile If the obstruction not relieved peristalsis ceases and intestines becomes flaccid and paralysed
  • 10. Distension Accumulation of fluid and gas proximal to the intestinal obstruction causes intestinal distension Ingested fluid Digestive secretions Intestinal gas Plays major role in the distension
  • 11. Fluid and electrolyte imbalance Large amount of fluid enters in to the gut daily (nearly 8000 ml/day) Saliva : 1500 ml Gastric juice : 2500 ml Bile & Pancreatic juice : 1000 ml and Intestinal juice : 3000 ml In intestinal obstruction distension causes increased intestinal secretion and decreased absorption Accumulation of such huge amount of fluid along with repeated vomiting causes severe electrolyte imbalance
  • 12. Intestinal gas Much of the distension caused by the accumulation of gas in the intestine proximal to the obstruction. It contributes :- 1) Gas swallowed by atmospheric air 2) Diffusion of gas from blood in to lumen of the bowel (Carbon dioxide) 3) Organic gases : Hydrogen sulphide Ammonia Amines Hydrogen As O2 and CO2 are absorbed and Nitrogen is not absorbed, Nitrogen is highest content among the intestinal gases
  • 13. Composition of various gases Nitrogen : 70% Oxygen : 12% Carbon dioxide : 8% Remaining : 10 % Hydrogen sulphide Ammonia and amines Hydrogen 5% 4% 1%
  • 14. Strangulation When the blood circulation of affected intestine occluded strangulation develops. This frequently occurs in Adhesive band obstruction Hernia Volvulus Intussusception When the venous return is completely occluded it develops gangrene. Intestines becomes purple and then black. And transmition of bacteria and toxins occurres in peritoneum
  • 15. Clinical features Abdominal pain 1 Vomiting 2 Constipation 3 Distension 4
  • 16. Abdominal pain This is first symptom and usually starts suddenly Cramping type of abdominal pain with hyper-peristalsis Central abdominal pain : Small intestinal obstruction 4-5 minutes interval in : Proximal obstruction 15-20 minutes interval in : Distal obstruction Patient is free from pain in between the attacks
  • 17. Sr.No. Origin / Nature of the pain Site of obstruction 1. Diffuse, poorly localized and felt across the upper abdomen High obstruction 2. At the level of umbilicus Low ileal obstruction 3. Lower abdomen Colon obstruction 4. Perineum Recto-sigmoid obstruction 5. Continuous severe pain without any quiescent period s/o Strangulation
  • 18. Vomiting High intestinal obstruction : Vomiting is more frequent and copious and relieved by decompression Lower intestinal obstruction : Vomiting is not so frequent and doesnt get relief by decompression and faeculent afterwards In the colon obstruction there is no vomiting until the occurrence of incompetency of valve. Vomiting is absent in colon obstruction until the ilio-caecal valve is competent
  • 19. Constipation Bowel present early distal to the obstruction is evacuated and then constipation develops. Constipation is early in distal bowel obstruction while it is late in proximal bowel obstruction In few conditions of intestinal obstruction constipation is not presenting symptom for e.g.: Richters hernia, Intestinal obstruction in pelvic abscess, Mesenteric vascular occlusion
  • 20. Distension Is absent in early stages Is much less in high small bowel obstruction Is centrally placed but late in low small bowel obstruction
  • 21. .
  • 22. .
  • 23. Physical examination Inspection :- Visible peristalsis in early cases Abdominal distension later on Fluid thrill Shifting dullness and fullness in flanks All the hernial orifices must be inspected to rule out Hernia as cause of obstruction
  • 24. Palpation Abdomen should thoroughly palpated to exclude presence of any mass which may be found in case of neoplasm, Abscess, intussusception Muscle guarding may be present during colic Tenderness and rigidity at the site of obstruction suggestive of strangulation Rebound tenderness suggests peritonitis and like hood strangulation All the hernial sites are well palpated
  • 25. Auscultation Is having great value Sr.No. Auscultation of bowel sounds Diagnosis 1. Loud, High pitched and metallic Simple mechanical obstruction 2. Isolated bowel sound occasionally Paralytic ileus 3. Complete absence of B.S. Strangulation
  • 26. Importance of rectal examination It should be done in all cases of intestinal obstruction. Presence of mass within or outside the lumen gives clue to diagnose Absence of faeces in the rectum suggestive of higher intestinal obstruction and vice versa Most of the rectal cancer are within the reach of examining finger.
  • 27. Special investigations Blood examination Straight X-ray Barium enema Intravenous urography WBC count is very useful to differentiate type of strangulation Normal / Slight rise in WBC : Simple mechanical obstruction Moderate rise (15,000-20,000) :- Strangulation Very high rise (30,000-40,000) :- Primary mesenteric vascular occlusion Serum amylase level is often elevated (due to entry of Amylase in to blood by regurgitation from pancreas due to back pressure of duodenum)
  • 28. .
  • 30. .
  • 31. .

Editor's Notes

  • #5: Potassium induced stricture
  • #28: What exact difference between strangulation and primary mesenteric vascular occlusion ?