INTESTINALOBSTRUCTION

ADHESIONS

Aetiology

Iatrogenic (Post operative) : Individual susceptibilityMay be induced by talc (powder from

gloves), cotton or linen (surgical mops, suture material)

Inflammatory / Infections : Following appendicitis and PIDFollowing peritonitis (specially biliary)Plastic type of peritoneal tuberculosis

Ischaemia :

Arterial or venous occlussionOccurs at sites of anastomosesIschaemia due to mobilisation of peritoneum

Irradiation : Radiation enteritis

Drugs : Practolol

Types

Fibrinous :EarlyEasy to do adhesiolysis / flimsyMay reduce over time

Fibrous : Occurs laterDifficult to do adhesiolysis / denseNo tendency to improve over timeOccurs due to associated ischaemia and

vascular ingrowth and replacement with mature fibrous tissue

Treatment - Medical

Monitor the vital signs : TPR / BP / IO / Abdominal girth chart

Nil Per Oral

Nasogastric tube (Ryle’s tube) insertion anddependent drainage. Intermittent (fourthhourly) aspiration

IV fluid supplement : Ringer’s lactate orNormal saline

Antibiotics if strangulation suspected

Reassess periodically

Treatment – Surgical

Indications :

When conservative treatment for 3 to 5days does not result in resolution

When strangulation is suspected / cannotbe ruled out

Treatment – Surgical Emergency exploratory laparotomy

Adhesiolysis / EnterolysisResect the strangulated bowel and do

end to end anastomosis

• Handle the bowel carefully (less abrasion)• Do not produce ischaemia of peritoneum• Do not mobilize and suture peritoneum• Do thorough peritoneal lavage with saline• Instillation of inhibitors - controversial

Treatment for recurrent intestinal obstruction due to adhesions

Repeat Adhesiolysis / Enterolysis Noble’s plication Charles – Phillips transmesentric plication Intestinal intubation

BANDS

Aetiology

Congenital :

Ladds bandsObliterated vitellointestinal duct

Mesodiverticular band

Inflammatory :A string band following bacterial peritonitis

Greater omentum adherent to the parietes

Gall Stone ileus

Definition

• Gall stone obstructing the lumen of bowel, usually the small intestine

Pathogenesis

• Gall stone erodes the wall of the gall balder and enters the duodenum

• Impaction 60 cm proximal to ileo-cecal junction

Clinical Features• Elderly female • Severe colicky pain • Recurrent attacks –ball valve

obstruction • Vomiting • Distension • Usually no constipation

Investigations

• Routine • Plain x-ray abdomen

–Air fluid level with Air in the biliary tree- pneumobilia (diagnostic)

– Gall stone may or may not be seen

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• CT scan

• CT scan

Treatment

• General measures

• Laparotomy – Explore by palpating bowel– Crush the stone without opening bowel– Enterotomy and removal

Do not explore gall bladder

Intussusception

Definition:

Invagination of one portion of the gut within the other and it is usually proximal into the distal bowel;

Rarely retrograde.

- Telescoping

Etiology:Primary - Idiopathic • Seen in children; no lead point• Peak incidence 3 - 9 months• Hyperplasia of Payer’s patches in the terminal ileum - Secondary to weaning - URTI due to adenovirus or rotavirusAdults – Secondary • Meckel’s diverticulum, HS Purpura• Polyp (Peutz – Jegher syndrome)• Submucous lipoma , submucous haemorrhage• Malignancy of the colon - Lead point always

Types:

• Simple - Ileocolic, ileoileal, colocolic• Retrograde - Jejunogastric• Compound - Ileoileocolic• Multiple

• Chronic intussusception• Recurrent intussusception

Parts of the intussusception:

• Intussusceptum:Proximal bowel which enters inside – inner tube

• Intussuscipiens:Distal bowel which receives the intestine – outer tube

• Apex: Starting point or the part which advances• Neck:Narrowest portion

INTUSSUSCEPTUM

INTUSSUSCIPIENS NECK

APEXLEAD POINT

Pathology:• As the intussusception progresses the mesentery is

dragged through the neck• Mucosal ulcers and hemorrhages• Venous engorgement with oedema of the wall • Blood and mucous from the wall and will be discharged per

rectally – red currant jelly• Arteries get occluded and gangrene sets in • Perforation and peritonitis

• Strangulating obstruction (compound obstruction )

• Gangrene sets in at the neck • Inner layer blood supply get impaired

Clinical features

• Male child between 3 -9 months of age commonly affected• Colicky pain abdomen - onset is sudden and the child

screams with drawing up of the legs• Attack lasts for few minutes, recur every 15 minutes and

becomes progressively severe.• Vomiting may or may not be there• Facial pallor• Red current jelly stools• Dehydration, tachycardia

On examination

Abdomen• Visible peristalsis• Lump may be felt under the right or left coastal margin• Sausage shaped lump with the concavity towards the umbilicus;

mass may disappear• Sign - de – Dance, Right iliac fossa is empty Per rectal• Blood stained mucous• Apex of the intussusception may be felt• Intussusception may protrude from the anus

Investigations

• Haemogram• Plain X ray abdomen• Barium enema -

Diagnostic and therapeutic

Pincer shaped filling defect

( Claw sign / meniscus sign / coiled

spring appearance)

CT SCAN –YIN YANG SIGN

• Ultra sound– Concentric rings

of high and low echogenicity (Target Sign)

Treatment:• Nil per orally• IV fluids• Ryle’s tube aspiration• Electrolytes, Antibiotics

Hydrostatic reductionContraindicated in Presence of obstruction Peritonitis Gangrene Symptoms more than 48 hrs

• Hydrostatic reduction -–Selected cases –Barium enema – Infants –50% success

• Hydrostatic reduction -–Enema can at height –Push barium rapidly –Confirm with x-ray

Surgical treatment• Laparotomy and reduction of intussusception• Reduction is done by squeezing the distal part proximally ( Do

not pull)• Last part of the intussusception is the most difficult part to

reduce• Free the adhesions between neck & distal bowel• Appedicectomy is done• If the intestine is gangrenous then resection and end to end

anastomosis is done

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