Intestinal Obstruction

Definition Classification Defined as arrest of downward propulsion of intestinal contents According to its dynamicity: 1. Dynamic: peristalsis is working against mechanical obstruction. The obstructing lesion may be: Intraluminal: impacted feces, foreign bodies, gallstones Intramural: malignant or inflammatory strictures Extramural: intraperitoneal bands & adhesions, hernias, volvulus, intussusception 2. Adynamic: peristalsis is absent (e.g. paralytic ileus) or it may present in a non propulsive forms (e.g. pseudo -obstruction) According to the pathological nature of cause : 1. Simple mechanical: caused by organic block which produces acute abdominal pain. 2. Strangulation: Characterized by significant impairment of blood supply of the involved bowel segment (ischemia) Ischemia may result from i) Twisting of intestinal bl. supply upon itself; volvulus. ii) Constriction of the bl. flow by a tight band or hernia opening . iii) Thrombosis or embolism of the mesenteric vessels. Strangulation >6h will lead to gangrene 3. Paralytic ileus: due to loss of propulsive power of the bowel leading to functional obstruction. According to the level of obstruction : 1. High small bowel obstruction (jejunul) 2. Low small bowel obstruction (ileal) 3. Large bowel obstruction (colonic) According to the onset & course of obstruction : 1. Acute: rapid course & symptoms develop rapidly . 2. Chronic: insidious course & slowly progressive; patient has constipation & distension. May also develop acute on top of chronic obstruction. Etiology According to anatomical site : 1. In the lumen: fecal implication, gallstone, parasitic infection. 2. In the wall: congenital atresia, tumors, Chrons disease, chronic diverticulitis, mesenteric vascular occlusion. 3. Outside the wall: adhesions (commonly post -operative), strangulated hernia, volvulus. According to age: 1. Neonates: congenital atresia, volvulus neonatorum, anorectal malformations, mechonium ileus, Hirschsprungs disease. 2. Infants: ileocecal intussusception, Hirschsprungs disease, strangulated hernia. 3. Adults: adhesion, strangulated hernia 4. Elderly: colon carcinoma, strangulated hernia The most common cause of small bowel obstruction in adults (adhesion), children (strangulated hernia) & the most common cause of large bowel obstruction is colon cancer.

Pathology

Simple obstruction: 1. Distal to obstruction, intestine empties & collapsed. Proximal to intestine absorption ceases. Gaseous distension is due to swallowed air (68%), diffusion from congested vessels (22%) & bacterial fermentation (10%) 2. The stretched smooth muscles undergo hyperperistalsis in an attempt to overcome the obstruction. 3. Distension impairs bl. supply which may end in ulc eration & perforation; perforation may also occur from the pressure of an adhesion band or the edge of a hernia defect on the bowel wall, producin g local ischemic necrosis. Strangulation obstruction: in addition to the above 1. Bacteria & toxins in the lumen can transgress ischemia bowel to the peritoneal cavity. Unrelieved strangulation can lead to septicemic shock. 2. Mucosa is the 1 s t layer to suffer from ischemia producing acute ulceration & intraluminal bleeding. If a long bowel segment is involved, bl. loss may be substantial. 3. Unrelieved strangulation is followed by gangrene of the ischemia bowel with perforation & peritonitis. General lethal effects: 1. Fluid & electrolytes loss from vomiting & from accumulation in the proximal bowel. 2. Septicemia from peritonitis.

Clinical features & Examination

Cardinal symptoms but not necessarily present in all cases: 1. Pain: Caused by hyperperistalsis Colicky in character: continue for about 1 min & free for about 3 -4 min If pains continue, severe & not relieved by suction

2. Distension:

3. Absolute constipation: Early in colon obstruction, late in high obstruction. 4. Vomiting: Early in high obstruction, late or absent in colon obstruction

5. Dehydration: Early in high obstruction, late in colonic obstruction Caused by vomiting, transudation of fluid & no intake of food EXAMINATION 1. General examination: evidence of dehydration as tachycardia, oliguria, dry tongue or hypotension. 2. Abdominal inspection: Hernia: strangulated ext hernia Scar of previous operation may denote intraabdominal adhesions Distension Visible peristalsis due to dehydration & hyperperistalsis 2

3. Abdominal palpation: No tenderness & rigidity, if have it may denote:

Mass may be felt: tumor or intussusception 4. Percussion: Shifting dullness: strangulation because there is devitalisation of lumen Hyperresonance Tympanitic resonance 5. Auscultation: accentuated intestinal sounds 6. Rectal examination: Fingers should be clean May feel tumor mass, head of intussusception or currant jelly stools (in children) May also reveals an empty rectum Strangulation is suspected with certain findings (urgent surgical intervention): 1. Toxic patient, tachycardia, fever, leukocytosis 2. Evidence of blood loss as pallor, tachycardia, hypotension 3. Pain that is not relieved by nasogastric suction 4. Marked tenderness, rebound tenderness & rigidity Course: 1. Acute: obstruction is confined to small intestine 2. Chronic: obstruction is confined to colo nic segment 3. Acute on top of chronic: starts by colonic obstruction which ends in small intestinal obstruction; it occurs when ileocecal valve is incompetent (produces feculent vomiting)

Investigation

1. Plain X-ray abdomen Standing: multiple fluid-gas level Supine: known by the gas pattern of the distended proximal intestine; Distended jejunal loops: circular mucosal folds (valvulae conniventes) crossing from one side of the lumen to the other. Distended ileal loops: featureless tubes with no mucosal pattern. Colon full of gas shows haustrations that do not appear to reach the other side of lumen. 2. Double enema test: the 2 n d enema should come without feces, flatus. 3. Blood urea & electrolytes 4. Blood picture 5. US: reveal distended bowel loops or a mass of intussusception. 6. CT scan + contrast: 80-90% sensitivity

Treatment

Main objective: urgent relief of obstruction usually by surgery after adequate preoperative preparation. OPERATIVE MANAGEMENT Pre-Operative Management 1. Correction of dehydration, electrolyte disturbances & acid -base balance 2. Put Ryles tube: values Relieve pain & vomiting Removal of bacterial endotoxin Facilitate operations & closure of the abdomen 3. Antibiotics are given if there is possibility of strangulation. 4. A Foleys catheter is inserted to check the urine output. Operative Management, the Algorithm 1. During exploration of the abdomen , localize the site of obstruction. Initially inspect the cecum

Cecum is collapsed It is SI obstruction, so trace the ileal upward until reaching the site of obstruction

Cecum is distended It means colonic obstruction

Check the sigmoid

Sigmoid is distended Rectal obstruction

Sigmoid is collapsed Obstruction is between sigmoid & cecum

2. Deal with the obstruction Adhesive band: adhesolysis Volvulus: untwist Intussusception: reduction of it Tumor mass: according to its oncological principle 3. After relieve, check the viability of the intestine Characters of non-viable intestine Peritoneal lusterless Flappy (paralyze) No peristalsis, no mesenteric pulsation Colour changes: greenish or black bowel is non -viable, white purple may still recover Non-

CONSERVATIVE MANAGEMENT 1. Adhesive obstruction: relieved by IV drip & nasogastric suction 2. Ileocecal intussusception: hydrostatic effect of a barium enema & reduction is radiologically monitored. 3. Sigmoid volvulus: untwisting using rectal tube passed thru a sigmoidoscope. 4. Fecal impaction: enema to dissolve the obstructing hard fecal mass.

Special Forms of Intestinal Obstruction

Intestinal Volvulus Definition Pathology Defined as a complete twisting of a loop of intestine around its mesenteric attachment site. When the twisting is complete, it forms a closed loop of obstruction with resultant ischemia 2ry to vascular occlusion . Produce a combination of obstruction of the closed-loop type and occlusion of the main vessels at the base of the involved mesentery (strangulation) . In a closed-loop, the pressure rises rapidly which further increase the risk of gangrene & perforation. Commonest in sigmoid colon, may also affect caecum, stomach & small intestine . It may be primary or secondary: The 1ry form occurs secondary to congenital malformation of the gut, abnormal mesenteric attachments or congenital bands . The 2ry form occurs due to actual rotation of a piece of bowel around an acquired adhesion or stoma . Predisposing factors & Etiology Occur more commonly in elderly ch ronically constipated males. Midgut volvulus: usually in infants predisposed because of congenital intestinal malformation. Segmental volvulus: in patients of any age with a predisposition because of abnormal intestinal contents (e.g. meconium ileus) & adh esion. Volvulus of caecum, transverse or sigmoid colon : usually in adults, with a predispose factor of redundant intestinal tissue & constipation. Anatomically, the predisposing factors of sigmoid volvulus are: Long sigmoid colon Narrow base of sigmoid mesocolon A heavily loaded sigmoid (as a result of chronic constipation) Adhesion at the apex of the sigmoid lo op which facilitate the twist of the loop Types Volvulus neonatorum Due to arrest gut rotation & narrow mesentery of small bowel & caecum Repeated vomiting, rapid dehydration & abdominal distension Volvulus of small intestine Occurs primarily or secondarily; usually in lower ileum Occur spontaneously or secondary Treatment: reduction of the twist & directed to the underlying cause s Caecal volvulus Occurring primarily or as a part of volvulus neonatorum A clockwise twist Female > Male 25% has tympanic swelling at the midline or left side of abdomen Sigmoid volvulus Anti-clockwise twist Occurring spontaneously in adult (most common) Chronic constipation is a predisposing factors

Clinical pictures

Features of that acute colonic obstruction Cardinal symptoms but not necessarily present in all cases: 6. Pain: colicky, caused by hyperperistalsis 7. Distension: Mainly in flanks Marked in sigmoid volvulus, less in high obstruction Central abdominal distention in low small bowel obstruction 8. Absolute constipation: Early in colon obstruction , late in high obstruction. 9. Vomiting: Early in high obstruction, late or absent in colon obstruction In neglected cases: vomiting become greenish, then later become brown & offensive 10. Neglected cases of sigmoid volvulus shows evidence of peritonitis

Investigation

1. Plain X-ray: huge gas-filled sigmoid loop (omega loop) 2. Urea, electrolyte & blood picture

Treatment

Conservative: Indicated in early cases with no evidence of gangrene gush of gases & fluid stools The tube is left in place & patient is prepared for later elective resection of the long sigmoid (to prevent recurrence) Surgery: Indicated in 1) Failure of conservative management 2) Late presentation The gangrenous bowel is resected The proximal colon end is brought out to the skin as a terminal colostomy & the distal end is closed by sutures (Hartmanns procedure) for later elective anastomosis Viable sigmoid is untwisted & either fixed to the posterior abdominal wall or resected as for gangrenous case

Intussusception Definition An invagination of an intestinal segment (intussusceptum) into the lumen of an adjacent one (intussuscepiens). Composed of 2 parts: Inner tube & returning tube (intussusceptum) Outer tube (intussuscepiens) The bl. supply of the inner layers of the intussusception is liable to b e impaired at the neck of the intussusception. Types 1. Ileo-ileal: part of ileum invaginated itself into adjacent ileal loop 2. Ileo-cecal: terminal ileum invaginates into colon with ileo -cecal valves repressing the apex of the intussusception. Commonest & usually affects infant 3. Ileo-colic: ileal loop invaginates into an ileal loop, and then passes to the colon thru the ileocecal valve. The bl. supply is tightly compressed by the valve. 4. Colo-colic: a loop of colon invaginates into adjacent colonic segment.

Etiology

1. Infants: idiopathic; adenovirus causes the swelling of the lymphoid follicles in the distally along the gut. This explains the frequent occurrence of intussusception at the age of weaning & the peak of incide 2. Adult: in minority cases, evid ent causes at the head of the intussusceptum: Meckers diverticulum, Submucous hematoma in a patient with Henoch -Schonlein purpura.

Clinical picture of Infantile Intussusception

Symptoms 1. Usually affects well-nourished infants at the age of 3 -12 months (age of weaning). 2. Male: females 2: 1 . 3. Infants awaken from sleep by severe abdominal colics, scream & draw his knees up onto the abdomen. It alternate with intervals of apparent well -being. 4. Associated symptoms of pain: pallor, apathy & lethargy . 5. Vomiting following the attacks of colic (85% cases) . 6. Passes mucous & blood per rectum (red currant jelly stools) . Signs 1. Emptiness in Rt. iliac fossa (Sign de Dance). 2. Distension: absent in early cases, if occur denotes possible perforation/gangrene. 3. Mass: sausage shaped. 4. Digital rectal examination: bloody mucous (60% cases), head of intussusception may be felt.

Investigation of Infantile Intussusception

1. Bl. picture: anemia 2. US 3. Barium enema: In cases of doubtful diagnosis Arrest of further progress of the contrast & cylindrical filling defect

Treatment of Infantile Intussusception

1. Resuscitation: IV infusion of dextrose & saline, antibiotics, nasogastric tube is inserted. 2. Early cases: a trial of hydrostatic reduction is performed; the pressure should not exceed 120cm of water Success of reduction is confirmed by free flow of barium into SI for >5cm & by prompt clinical improvement with no further colics The baby should be kept under observation for 24h Success rate of hydrostatic reduction is 75 -95% Contraindications to hydrostatic reduction: doubtful diagnosis, late cases or presence of abdominal distension/rigidity 3. Surgery: Needed when hydrostatic reduction fails or if the condition is advanced Laparotomy: Head of intussusception is squeezed backwards out of the containing colon The proximal ileum should never be pulled backwards to disengage the intussusception as this may lead to intestinal tears Presence of gangrene or irreducible intussusception is an indication for bowel resection & anastomosis

Prognosis of Infantile Intussusception

1. Mortality is high in gangrenous cases 2. Intussusception may recur in 2% of cases

Adhesive Intestinal Obstruction General Intraperitoneal adhesions constitute the commonest cause of intestinal obstruction in adults in developed countries. 1. Post-operative adhesions: commonest, resulting from prev abdominal surgery 2. Post-inflammatory adhesions: may follow previous septic or tuberculous peritonitis Pathology Adhesions may be multiple or solitary It bind one intestinal loop to another, or to abdominal wall It induce obstruction by kinking/by directly obstructing a small intestinal loop Strangulation may result from compression of the loops bl. supply. A band may induce localize ischemic necrosis by direct pressure on th e intestine at the level of block Adhesions have a tendency for recurrence producing recurrent intestinal obstruction Clinical features 1. Acute or recurrent acute small bowel obstruction: colicky abdominal pain, vomiting, distension & absolute constipation 2. Scar of previous abdominal surgery (almost always) 3. Physical findings of strangulation Treatment Conservative: in early cases, no evidence of strangulation 1. Naso-gastric suction & IV replacement 2. Close observation: success is indicated by Resolution of pain & distension Passage of flatus Retrieval of clear gastric aspirate 3. Should not be prolonged if there is no response in 48h Surgery: if the conservative management fails, evidence of strangulation or grangrene 1. Adhesions are divided 2. Bowel viability is assessed & dealt with

Etiology

Paralytic Ileus Definition A form of Adynamic obstruction in which there is failure of peristaltic waves of intestine due to failure of neuromuscular mechanism 1. Reflex inhibition of intestinal motility following abdominal cramps, spine fractures, hyperextension of spine (in plaster jacket), retroperitoneal hemorrhage 2. Metabolic abnormalities: hypokalemia, uremia, diabetic ketoacidosis 3. Peritonitis induces paralytic ileus due to direct toxic effect on the nerve plexuses of intestine 4. Drugs: anticholinergic (probantine), tricyclic antidepressants if taken in large doses Pathology Marked distension of the SI & LI with gas & fluid Patient suffers a severe loss of fluid & electrolytes in the distended bowel & thru vomiting Clinical features Most common occur after major abdominal surgery Symptoms: 1. Abdominal distension 2. Absolute constipation 3. Effortless vomiting 4. No colicky abdominal pain but there is only a sense of fullness & discomfort Signs: 1. Abdominal distension 2. Inaudible intestinal sounds (silent abdomen) 3. Evidence of localized/generalized peritonitis Investigation 1. Plain X-ray: multiple gas fluid levels; the gaseous distension includes the whole SI & LI 2. Bl. urea, electrolytes & bl. picture Prevention 1. Prevention & correction of biochemical disturbances : hypokalemia is treated by IV potassium 2. Gentle handling of intestine during surgery 3. For major abdominal surgery, naso -gastric tube is used to decompress the bowel post-operatively Treatment 1. IV replacement, electrolytes, naso -gastric suction 2. Correction of underlying metabolic abnormalities & hypoproteinemia 3. If a postoperatively ileus is unduly prolonged: one should think of peritonitis from a leaking intestinal anastomosis & of mechanical obst ruction from early fibrinous adhesions. Both conditions necessitate reoperation. 4. Parasympathomimetic (prostigmine) may be useful in resistant unsuccessful cases

Etiology