Intestinal obstruction neo

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Intestinal obstruction

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  • 1. Level High small bowel Low small bowel Large bowel

2. 1. Dynamic - mechanical obstruction 1. Adynamic- Peristalsis absent Peristalsis -non- propulsive form 3. Dynamic Acute Chronic Acute on Chronic Subacute 4. Type of presentation Simple Intact blood supply Strangulated Compromised blood supply 5. Pathology Proximal to obstruction : Altered mobility Distension 6. Distension Gaseous : Swallowed air Diffusion from blood Products of digestion and bacterial activity O2 & CO2 reabsorbed Nitrogen 90% and H2S 7. Strangulation External compression Hernia/Adhesions/Bands Interruption of mesenteric flow Volvulus/ Intussuception Rising intraluminal pressure Closed loop obstruction 8. Veins compressed first - Edema and hemorrhages Arterial compression Haemorrhagic infarction Translocation of bacteria, toxins and systemic absorption 9. Strangulation External Internal Smaller absorptive surface Short segment Less blood and fluid loss Larger absorptive surface Large segment More blood and fluid loss - shock 10. Closed loop obstruction Obstruction both at proximal and distal point Strangulated loops Colonic obstruction with a competent ileocecal valve 11. Clinical features Pain Vomiting Distension Constipation 12. Other features Dehydration Hypokalemia Pyrexia Ischemia/perforation/Inflammatory obs. Abdominal tenderness 13. Signs of strangulation Continous pain Localised tenderness, rigidity, rebound tenderness Shock Does not respond to conservative management 14. Radiology X ray abdomen Erect Air fluid levels X ray abdomen Supine Distended bowel 15. Small bowel Central and transverse lie Jejunum Valvulae conniventes (concertina / Stack of coins) Ileum Characterless Colon Haustral folds 16. Sigmoid volvulus Impacted foreign bodies Gallstone ileus 17. Treatment Gastrointestinal drainage Fluid and electrolyte replacement Relief of obstruction 18. Timing of surgery Emergent Obstructed/strangulated Ext hernia Internal intestinal strangulation Acute obstruction Other cases Atleast within 24 hrs Adhesions upto 72hrs 19. Principles of Surgical intervention Mt. of the segment at the site of obstruction The distended proximal bowel Underlying cause of obstruction 20. Approach Caecum Dilated Not dilated Large bowel Small bowel Trace distally Trace proximally 21. Surgical procedure Adhesiolysis Excision / Resection Bypass / Proximal decompression 22. Viability of bowel Viable 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 23. Doubtful Resected ends as stomas No resection / Multiple ischaemic areas (Mesenteric Vasc Occlusion) 2nd look laparotomy after 24-48hrs 24. Operative decompression Compromise of Exposure / Viability / Closure Septic complications of spillage Savages decompressor / NG tube Replace fluid 25. Large bowel obstruction Caecum to Prox trans colon Rt. Hemicolectomy, if resectable Ileotransverse bypass if not resectable Splenic flexure Extended Rt.Hemicolectomy 26. Left colon / Rectosigmoid Decompression proximal colostomy Resection with Anastamosis with covering colostomy Paul Mikulicz procedure Hartmanns procedure 27. Adhesions Most common cause Difficult to differentiate from paralytic ileus 28. Causes Ischaemic areas Foreign material Infection & Inflammatory conditions Radiation enteritis Drugs Practolol 29. Peritoneal irritation Local fibrin production Adhesion between apposed surfaces Early fibrinous adhesions Late fibrous adhesions 30. Prevention Good Surgical technique Peritoneal wash Minimizing contact with gauze Covering anastamosis & raw peritoneal surfaces 31. Classification Early / Flimsy Late/ Dense 32. Bands Congenital Acquired Peritonitis Greater omentum adherent to parietes 33. Treatment Conservative NPO RT aspiration IV fluids Vital signs & Abd. girth monitoring Signs of strangulation Maximum 72hrs 34. Surgery Adhesiolysis Only those causing obstruction Covering with omental grafts Constriction sites 35. Recurrent adhesive obstruction Repeat Adhesiolysis Nobles plication procedure Charles phillip Transmesenteric plication Intestinal intubation