Intestinal obstruction- clinical aspects

Ritasman BaisyaRoll no – 85 8th semester

Factors affecting clinical feature

• Location of obstruction

• Age of the obstruction

• Underlying pathology

• Presence or absence of intestinal ischemia

Cardinal features

Abdominal pain

Distension Vomiting

Absolute constipation

Cardinal features of acute obstruction

Pain

• First symptom

• Onset -- Occurs suddenly and usually severe

• Site - Around umbilicus or lower abdomen

• Nature-Colicky in nature ,with increased distension ,pain becomes mild, constant ,diffuse

Contd. pain

• Special points –

• Very severe pain indicates strangulation

• Pain may not be significant in post operative simple mechanical obstruction

• Not present usually in paralytic ileus

Vomiting

• Onset – timing depends on site

• Character— alters from digested food, bile stained food to faeculent matter

• Nature – projectile

Distension

• Degree of distension depends on site of obstruction

• Visible peristalsis may be present

• Delayed in colonic obstruction & minimal /absent in mesenteric vascular occlusion

Few images of visible peristalsis in obstruction

Constipation

Types -- 1. absolute (neither feces nor flatus ) 2. relative (where only flatus is passed ) Absolute constipation is cardinal feature of

complete obstruction

Some patients pass feces or flatus due to distal bowel content

Exceptions

• Richter hernia

• Gallstone obturation

• Mesenteric vascular occlusion

• Obstruction associated with a pelvic abscess

• Partial obstruction where diarrhea may often occurs

Dehydration

• Mostly in small bowel obstruction due to repeated vomiting

• Dry tongue, dry skin , sunken eye , oliguria

• Secondary polycythemia…

Abdominal tenderness

Initially localised , later diffuse

Rebound phenomenon & guarding will not be present in simple obstruction

Temperature

• Fever signifies inflammation in bowel wall / ischemia / perforation

• Hypothermia -- when septicemia due to poor pyrogenic response

Bowel sounds

• High pitched metallic to metallic tinkling sound of dilated bowel

• Once fatigue– silent abdomen peritonitis

• In paralytic ileus no return of bowel sound on auscultation

Other features

• Pyrexia – onset of ischemia , intestinal perforation

• Hypokalemia

• Increase in serum amylase ,LDH

Features of strangulation

• Continuous severe pain

• Shock indicates underlying ischemia

• Symptoms commence suddenly and recur regularly

• Local tenderness associated with rigidity and rebound tenderness ( Blumberg sign )

Proximal small bowel

Distal small bowel Large bowel

Severe vomiting Moderate vomiting Late vomiting

Less distension Central distension Early distension , pronounced

Colicky pain Central abdominal pain Less pain

Constipation late Varies in appearance Constipation is early feature

Severe dehydration Moderate Less dehydration

Comparison of clinical aspects

Complications • Peritonitis• Shock• Renal failure• ARDS• Intra abdominal abscess• Moribund status