INTESTINAL OBSTRUCTION

A. VAYDA

department of surgery with urology and anesthesiology

Intestinal obstruction is a complete or partial disturbance of intestinal evacuation and peristalsis resulting from various causes which manifests by specific clinical course and morphologic changes

of involved part of the bowel

Intestinal obstruction occurs approximately in 9.4 % among urgent abdominal pathology, consisting 1.2 % of all surgical diseases.

Classification(by D.P.Chuhrienko)

1. Dynamic intestinal obstruction:a) paralytic;b) spastic.2. Mechanical intestinal obstruction:a) strangulation;b) obturation;c) mixed (invagination).II. According to the course of pathological process.1. Stage of acute disturbance of intestinal evacuation and peristalsis.2. Stage of hemodynamic disorders of the bowel wall and its mesentery.3. Stage of peritonitis.

Etiologic and contributing factors

•Adhesions (50 %).•Tumours.•Bile stones.•Inflammatory infiltrates in the abdominal cavity.•Internal hernias.•Increasing of abdominal pressure.•Defects of the peritoneum.•Long mesentery of the bowel.

Pathogenesis

Transudation of intestinal juice

Vomiting

Intestinal block

Accumulation of intestinal contents

Distention of intestinal wall

Loss of electrolytes, dehydratation, loss of potassium, loss of proteins

Necrosis of the bowelPeritonitis

Intoxication, hemodynamic disturbances

More higher the obstruction, more severe the pathologic changes

Pathogenesis

Peculiarities of strangulated intestinal obstruction

•Transfusion of large quantity of proteins;•Transfusion of erythrocytes and decreasing of volume of circulating blood;•Severe dehydratation, caused by additional edema of the bowel wall;•Rapid necrosis of intestinal wall with subsequent peritonitis and intoxication.

Clinical manifestation

It depends on the level of the block, type and degree of obstruction and its cause.

1. Acute onset of the disease.2. Periodic acute diffuse pain of wavelike character which results in shock.3. Constant vomiting and nausea without any relief.4. Signs of dehydratation and intoxication (The patient looks anxious, with drawn features, hollowed-eyed, his lips and tongue are dry, with brown fur).5. Retention of stool and gases.

Objective examination

1. Signs of shock.2. Distended and asymmetric abdomen.3. Splashing sound (Sklyarov’s sign).4. Increased peristalsis in early period with further absence.5. Wahl’s sign - high tympanic sound over the distended bowel.6. PR: empty and distended anus and rectal ampoule - (Grekov’s sign).7. In intestinal strangulation and advanced cases of obstruction - peritoneal signs.

X-ray examination1. Kloiber's cups (air-fluid level)2. Intestinal pneumatisation

Differential diagnostics of acute intestinal obstruction with perforative peptic ulcer

• Periodic acute diffuse pain• Constant vomiting and

nausea without any relief• Retention of stool and gases• Abdominal distension• On X-ray of the abdomen

Kloiber's cups (air-fluid levels)

• Splashing sound, increased peristalsis

• Sharp acute diffuse pain• Ulcerative anamnesis• Absence of hepatic

dullness• On X-ray of the abdomen

air above the liver (air sickle)

• Rigidity of anterior abdominal wall

Differential diagnostics of acute intestinal obstruction with acute pancreatitis

• Periodic acute diffuse pain• Constant vomiting and

nausea without any relief• Retention of stool and gases• Abdominal distension• On X-ray of the abdomen

Kloiber's cups (air-fluid levels)

• Splashing sound, increased peristalsis

• Sharp acute constant girdle pain with irradiation into left scapule

• Vomiting and nausea without any relief

• Mayo-Robson symptom• Increased serum amylase• Increased urinary diastase• No retention of stool and gases• Abdominal distension only in

advanced cases.• No increased peristalsis

Differential diagnostics of acute intestinal obstruction with mesenteric thrombosis

• Periodic acute diffuse pain• Constant vomiting and

nausea without any relief• Retention of stool and gases• Abdominal distension• On X-ray of the abdomen

Kloiber's cups (air-fluid levels)

• Splashing sound, increased peristalsis

• Sharp acute constant pain which results in shock

• Abdominal distension.• Decreased peristalsis • Blood stool• Concomitant cardiac pathology• Peritoneal signs

Differential diagnostics of acute intestinal obstruction with acute cholecystitis

• Periodic acute diffuse pain• Constant vomiting and

nausea without any relief• Retention of stool and gases• Abdominal distension• On X-ray of the abdomen

Kloiber's cups (air-fluid levels)

• Splashing sound, increased peristalsis

• Acute pain in a right hypohondrium with irradiation to the scapula

• Muscular tenderness in a right hypohondrium

• Vomiting by bile and nausea without any relief

• Ortner's symptom, phrenic symptom, Murphy’s sign

• Increased serum bilirubin

Conservative treatment

Conservative treatment is indicated only in:1. Adhesive obstruction without signs of strangulation.2. Initial stages of invagination.3. Initial stages of low obturation

•Gastric decompression•Siphon enema•Paranephral procaine block•Ganglio- and sympatholytics•Correction of water-electrolyte balance

Surgical treatmentis indicated only if no improvement during 3-4 hours of conservative treatment

•Wide laparotomy•Procaine block of mesenteric root•Revision of intestine and detecting of the level and cause of obstruction•Decompression of intestine proximal to the obstruction•Assessing of viability of the bowel (peristalsis, colour, vascular pulsation)• Removal of the obstruction (division of adhesions, intestinal resection, collateral anastomosis)•External drainage of intestine (nasogastrointestinal intubation, rectal tube)

Strangulation intestinal obstruction1. Volvulus, (torsion).2. Nodulus (knots).3. Hernial strangulation (incarceration).4.Invagination (refers to mixed forms of intestinal obstruction)

Causes•Elongation of intestinal loop.•Increasing of abdominal pressure.•Long mesentery of the bowel.•Cicatrical shortening of mesenteric root.•Adhesions•Extensive functional overload of the bowel.

Volvulus (torsion)

Small intestine volvulusClinically manifests by high strangulation intestinal obstruction

Cecal volvulus, sigmoid volvulusClinically: low strangulation intestinal obstruction

asymmetric abdomen by palpation enlarged and displaced colon (like balloon) retracted right or left iliac region

Treatment: detorsion, division of adhesions, cecopexia, colon resection

Nodulus

It is the most severe type of strangulation with manifestation of a high strangulated obstruction which rapidly results in shock, bowel necrosis and peritonitis

Treatment: •very short preoperative period (less 1 hour)•untie of the bowel node (till 4-5 hours from the onset)•resection of the bowel

Invagination

It is the insertion of one part of the bowel into the lumen of another

Treatment: desinvagination or resection

Clinically: •signs of obturation and in advanced cases the strangulation ileus•elastic, painful, tumourlike formation in the abdomen•blood in stool (or during rectal examination)

Paralytic ileus

Abdominal• peritonitis• mesenteric thromboses• hemoperitoneum• pancreatitis• postoperative ileus

Retroperitoneal• phlegmone• hematoma• renal colic• spinal trauma

Other• cranial trauma• acidosis• diminished potassium• hypoproteinemia• uremia

Spastic ileus

Abdominal• hepatic colic • ascaridosis

Retroperitoneal• renal colic

Other• lead poisonong

Treatment of dynamic ileus

1. Cholynomymetics (Proserin, ubretid).2. Intravenous infusion of hypertonic solution (10 % NaCl).3. Hypertonic enema.4. Oil enema.5. Gastric decompression.6. Paranephral novocaine block.7. Ultrasound stimulation.