Level

• High small bowel

• Low small bowel

• Large bowel

1. Dynamic- mechanical

obstruction

2. Adynamic- – Peristalsis –absent – Peristalsis -non-

propulsive form

Dynamic

• Acute

• Chronic

• Acute on Chronic

• Subacute

Type of presentation

• Simple – Intact blood supply

• Strangulated – Compromised blood supply

Pathology

Proximal to obstruction :

Altered mobility

Distension

Distension

Gaseous :

Swallowed air Diffusion from blood Products of digestion and bacterial activity

O2 & CO2 reabsorbed

Nitrogen 90% and H2S

Strangulation

• External compression –

Hernia/Adhesions/Bands

• Interruption of mesenteric flow – Volvulus/

Intussuception

• Rising intraluminal pressure – Closed loop

obstruction

• Veins compressed first - Edema

and hemorrhages

• Arterial compression –

Haemorrhagic infarction

• Translocation of bacteria, toxins

and systemic absorption

Strangulation External Internal

• Smaller absorptive surface

• Short segment – Less blood and fluid loss

• Larger absorptive surface

• Large segment – More blood and fluid loss - shock

Closed loop obstruction

• Obstruction both at proximal and

distal point

– Strangulated loops

– Colonic obstruction with a

competent ileocecal valve

Clinical features

• Pain

• Vomiting

• Distension

• Constipation

Other features

• Dehydration

• Hypokalemia

• Pyrexia –

Ischemia/perforation/Inflammatory obs.

• Abdominal tenderness

Signs of strangulation

• Continous pain

• Localised tenderness, rigidity,

rebound tenderness

• Shock

• Does not respond to conservative

management

Radiology

• X – ray abdomen ErectAir fluid levels

• X – ray abdomen SupineDistended bowel

Small bowel

• Central and transverse lie

• Jejunum – Valvulae conniventes

(concertina / Stack of coins)

• Ileum – Characterless

• Colon – Haustral folds

• Sigmoid volvulus

• Impacted foreign bodies

• Gallstone ileus

Treatment

• Gastrointestinal drainage

• Fluid and electrolyte replacement

• Relief of obstruction

Timing of surgery• Emergent

Obstructed/strangulated Ext hernia

Internal intestinal strangulation

Acute obstruction

• Other cases

Atleast within 24 hrs

• Adhesions

upto 72hrs

Principles of Surgical intervention

• Mt. of the segment at the site of

obstruction

• The distended proximal bowel

• Underlying cause of obstruction

Approach

Caecum

Dilated Not dilated

Large bowel Small bowel

Trace distally Trace proximally

Surgical procedure

• Adhesiolysis

• Excision / Resection

• Bypass / Proximal decompression

Viability of bowelViable

Dark color – Light Dark persists

Mesentery bleeds on pricking

No bleeding

Peritoneum – Shiny Dull & Lustreless

Int Musc – Firm, Peristalsis seen

Flabby, thin, friable

Non viable

Mesenteric pulsation + Absent

Doubtful – Resected ends as stomas

No resection / Multiple ischaemic areas (Mesenteric Vasc Occlusion)

2nd look laparotomy after 24-48hrs

Operative decompression

• Compromise of Exposure / Viability / Closure

• Septic complications of spillage

• Savage’s decompressor / NG tube

• Replace fluid

Large bowel obstruction

Caecum to Prox trans colon

– Rt. Hemicolectomy, if resectable

– Ileotransverse bypass if not

resectable

Splenic flexure

– Extended Rt.Hemicolectomy

Left colon / Rectosigmoid

• Decompression proximal colostomy

• Resection with – Anastamosis with covering colostomy– Paul Mikulicz procedure– Hartmann’s procedure

Adhesions

• Most common cause

• Difficult to differentiate from paralytic ileus

Causes

• Ischaemic areas

• Foreign material

• Infection & Inflammatory conditions

• Radiation enteritis

• Drugs – Practolol

Peritoneal irritation

Local fibrin production

Adhesion between apposed surfaces

Early fibrinous adhesions Late fibrous adhesions

Prevention

• Good Surgical technique

• Peritoneal wash

• Minimizing contact with gauze

• Covering anastamosis & raw

peritoneal surfaces

Classification

• Early / Flimsy

• Late/ Dense

Bands

• Congenital

• Acquired

– Peritonitis

– Greater omentum adherent to

parietes

Treatment

• Conservative

– NPO

– RT aspiration

– IV fluids

– Vital signs & Abd. girth monitoring

– Signs of strangulation

– Maximum 72hrs

Surgery

• Adhesiolysis

– Only those causing obstruction

– Covering with omental grafts

– Constriction sites

Recurrent adhesive obstruction

• Repeat Adhesiolysis

• Noble’s plication procedure

• Charles phillip Transmesenteric plication

• Intestinal intubation