Clinical aspect of intestinal obstruction Ritasman Baisya Medical College kolkata
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Transcript of Clinical aspect of intestinal obstruction Ritasman Baisya Medical College kolkata
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