INTESTINAL OBSTRUCTION

SYAHBUDDIN HARAHAP

INTESTINAL OBSTRUCTION
SYAHARA

NEUROGENIC paralytic
MECHANICAL
MECHANICAL :
- Simplex
- Stranggulata
Aetilogy:
-In the lumen
-In the wall
-Outside the wall
Site :
- High
- Low
Speed of onset :
- Acute
- Chronic

What Causes Intestinal Strangulation?

Intestinal strangulation (cutting off of the blood supply to the intestine)

usually results from one of three causes.

MECHANICAL INTESTINAL
OBSTRUCTION
Common causes of obtruction at each age group

Neonate -Congenital atresia

-Volvulus neonatum
-Meconeum ileus
-Hirschsprungs disease
-Imperforate anus
-Stranggulated inguinal hernia
Infant
-Intussuception
-Complication of Meckels diverticulum
-Hischsprungs diseases

 Young adult

-Adhesions and bands

-Strangulated ing.hernia

Middle age

-Adhesesion and band

-Strangulated Ing.hernia
-Strangulated fem.hernia
-Carcinoma colon
-Volvulus

Elderly

-Adhesion and bands

-Strangulated Ing.hernia
-Strangulated fem.hernia
-Carcinoma colon
-Volvulus
-Impacted faeces

Incidence
May occur at any age
70 percent small bowel,
30 percent large bowel

Physiologic and Pathologic

Derangement
Fluid and electrolyte disturbances
-8 10 L of fluid are secreted
-Sequestration within the dilated loop--

hypovolumic shock --> SIRS MODS

Bacteriology
-Rapid colonisation
Pathology
-High intra luminar pressure- oedematous--
cyanosis intraperitoneal exudation necrosis
perforation--peritonitis -> SIRS -> MODS

Clinical Manifestations
Sign - the classic quartet->pain,vomiting,constipation,abd
dist

Abdominal pain is colicky

-On Auscultation -borborygmi

-metalic sound
Vomiting
- Consists food and gastric chyme- bile faeculent
Absolute constipation
Abdominal distension - ACS
-Inspection distended visible peristalsis and colicky pain
Scars-- Adhesion or Band
Vital Sign---Pulse - SBP RR Temp-- hypovolumic shock ?
Palpation--- palpable mass - DRE

Diagnoctic Studies

Laboratory test--fecal occult blood test

Sigmoidoscopy
X ray examination
Plain X ray --- Erect and lying down -
routinely
Follow-through studies after ingestion of
radiopague meal --- gastrografin
Barium enema X ray

Treatment

NGT
Rehydration
Foley bag Catheter
Antibiotics
Informed concent
Exploratory laporotomy

Exploratory Laparotomy
Inspected and palpated the Caecum
-Distended--- colon obstruction
-Collapsed--- small bowel obstruction
Distended SBO - Prevent Abd.Comp.syndrom
-Retrograde milkingby Jones and Matheson(1968)
-canula inserted + pursetring suture ?
-Enterostomy
Distended LBO- Prevent Abd.Comp.Syndrom
-canula inserted + pursestring suture
-Caecostomy

Emergency Intestinal obstruction due

to Colon Cancer

Right Hemicolectomy
Extended Right Hemicolectomy
Hartmants procedures
Proximal colostomy
By Pass
On-table antegrade irigation of the large

bowel-- one staged colon operation ?

Emergency Intestinal obstruction due

to Sigmoid volvulus

The upper limb of the loop descends

in front of the lower, twisting on its

mesenteric axis from one half to two
turns in counterclock-wise direction
Predisposing condition-long and
freely movable meso sigmoid

Radiologic Examination
Plain abdominal foto --Bent inner tube sign 0r

Coffe bean apperance

Barium enema ---Bird beak apperance
- Contrast agent and air fills rectum and distal
sigmoid colon.
- The contrast agent stops abruptly at the
point of
torsion.
(Courtesy of Dina F. Caroline, M.D., Ph.D., Temple
University Hospital.)

Plain film of sigmoid volvulus.

Note appearance of

bent inner tube.

(Courtesy of Dina F.
Caroline, M.D.,
Ph.D., Temple
University Hospital.)

Coffe bean

appearance

Barium enema of sigmoid

volvulus.
Contrast agent and

air fills rectum and

distal sigmoid colon.
The contrast agent
stops abruptly at
the point of torsion.
(Courtesy of Dina F.
Caroline, M.D.,
Ph.D., Temple
University Hospital

Treatment
Consevative
- Barium enema
- LLD + general anestesi -
sigmoidocopy rectal tube lubbricated
- left in place 48 hours
Operative
- Resection Hartmantns operation
- After conservative bowel preparation-
resection end to end
anastomosis

Emergency Intestinal obstruction

due to Caecum volvolus

The caecum passing upward and

then to the left , twist 90 degrees to

as many as three complete twist a
clock wise direction
Mobile caecum

Radiologic examination

Plain abdominal foto

Barium enema

Caecum Volvulus
The contrast stops abruptly
at the proximal end of the
hepatic flexure
(arrowhead). The dilated,
air-filled cecum crosses the
midline of the abdomen
toward the left upper
quadrant (arrows).
(Courtesy of Dina F.
Caroline, M.D., Ph.D.,
Temple University
Hospital.)

Treatment

Caecopexy
Rigth Hemicolectomy

Emergency Intestinal obstruction due to

ADHESIONS AND BANDS

Classification :
- Congenital
- Acquired

Aetiology :
1. infection -> fibrin --- fibroblast -fibrous
adhesion
2. tissue ischaemia -vascular collateral
fibrous
matrix-- fibrous adhesion
3. corpus alienum

A. fibrin --- fibroblast -fibrous adhesion

B. tissue ischaemia -vascular collateral fibrous matrix--

fibrous adhesion

Attempts to Prevent Adhesions

To prevent Fibrin deposit --Anti coagulan
Dextran , Trasylol
Remove fibrin exudat Peritoneal lavage
Separate bowel surfaces - peristalsis
Inhibit fiboblast proliferation - Anti
histamin , Steroid

Treatment
Trial of conservative --- Spontaneus
remmision

Exploratory laporotomy
- simple lysis
- resection
- by pass
- plication

Plication small bowel seromuscular

complete small bowel obstruction.

Upright film shows

multiple, short, airfluid levels arranged

in a stepwise
pattern. (Courtesy
of Melvyn H.
Schreiber, M.D., The
University of Texas
Medical Branch

complete small bowel obstruction.

Supine film

shows dilated
loops of small
bowel in an
orderly
arrangement,
without evidence
of colon gas.

Surgical management of carcinoma of the small

bowel
. A, Malignant tumors should

be resected with a wide

margin of normal bowel and a
wedge of mesentery to
remove the immediate
draining lymph nodes.
B, End-to-end anastomosis of
the small bowel and repair of
the mesentery.
(Adapted from Thompson JC:
Atlas of Surgery of the
Stomach, Duodenum and
Small Bowel. St. Louis, Mosby
Year Book, 1992, p 299.)

constricting carcinoma.
Barium enema

demonstrating
apple core or
napkin ring
lesion, caused by a
constricting
carcinoma.

polypoid carcinoma
Barium enema

demonstrating a
polypoid carcinoma
arising in the cecum of
a 35-year-old woman
(arrows). (Courtesy of
Dina F. Caroline, M.D.,
Ph.D., Temple
University Hospital.)