Intestinal Obstruction New

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INTESTINAL OBSTRUCTION

Transcript of Intestinal Obstruction New

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INTESTINAL OBSTRUCTION

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INTESTINAL OBSTRUCTION

when there is pathological interference with the normal progration of the intestinal luminal contents distally, the condition is called intestinal obstruction.

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CLASSIFICATION• 1, Mechanical obstruction • obturation obstructoin• lesions in the intestinal wall• lesions extrinsic to the bowel.• 2, Nonmechanical obstruction• dynamic ileus----->including paralytic ileus/blood ileus• 3, simple mechanical obstruction

- strangulated obstruction• - closed loop obstruction• 4, Acute

-chronic

-Acute on chronic obstruction

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Obturation obstructoin

• Meconium

• Hair,fruit and vegetable fibers

• Gall stone

• Polypoid tumour of bowel.

• Interssusception

• Impaction of barium

• worms

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lesions in the intestinal wall

• Congenital-Atresia,stenosis,megacolon,Meckle diverticulum,imperferforete anus etc

• Traumatic-• Inflammatory-

Chohn’s disease,ulcerative colitis• Noeplastic-tumoures• Miscellaneous-

Radiation, post op stenosis

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lesions extrinsic to the bowel.

• Adhesive band constriction or angulation by adhesion.

• External hernia

• Volvulus

• Extrinsic mass-haematoma,abscess,neoplasms outside/inside the bowel

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Nonmechanical obstruction

• Paralytic ileus-

(failure of transmission of peristalsis wave due to neuromuscular failure)

Types-Post operative

-peritonitis

-metabolic

reflex–retroperitoneal abscess, # vertebra

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simple mechanical obstruction

• Obstruction

• Blood supply remain intact

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strangulated obstruction

• Obstruction

• Mesenteric vessels involved.

• Emergency ,required surgery.

• Causes-

1.Adhesive band obstruction

2.Hernia

3.Volvulus

4. intussuception

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closed loop obstruction

• When the afferent and efferent loop are obstructed

• Both limb of loop obstructed.

• Neither progression.

• Nor regratation.

• emergency

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Acute

• Central abdominal pain

• Early vomiting

• Central abdominal distention

• Constipation later on disention

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Chronic

• Obstruction is confined to the large bowel

• Lower abdominal pain

• Absolute constipation later on dist

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Acute on chronic obstruction

• Start in large intestine-gradually small intestine involved.

• Early pain

• Constipation

• Vomiting

• Abdominal distantion.

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PATHOPHYSIOLOGY

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• Adhesion -40%

• Due to obstructed hernia-12 %

• Inflammatory- 15 %

• Ca-15 %

• Faecal impaction-8%

• Pseudo-obstruction-5%

• Miscellaneous-5%

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Bowel motility

• When the intestine is obstructed the part of the intestine above the obstruction shows vigorous peristalsis to overcome the obstruction

• Duration-2 to 4 days.• More distal obstruction-more vigorous peristalsis with longer

duration• If obstruction not relived-

-Intestine ensues

-Peristalsis ceases

-Obstructed intestine flaccid

-paralysis

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• For a few hours the intestine below the obstruction shows normal peristalsis and absorption

• This empty contain

-Immobile

-Contracted

-Pale.

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Distention

• Accumulation of fluid and gas proximal to the obstruction

• distention.

• (ingested fluid, digestive secretion and intestinal gas)

• Bacterial proliferation

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Fluid and electrolyte imbalance• Large volume of saliva, gastric secretion, bile and pancreatic juice

enter gut daily.• These are menially absorbed in small intestine • Distention increases intestinal secretion and decreases absorption.• Fluid accumulation-proximal to onstruction

various digestive juice-8000 ml /day

saliva--------------------1500ml /day

gastric juice-----------2500 ml /day

pancreatic juice--------1000 ml /day• Repeated Vomiting

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• (vomiting and fluid collection leads to-loss of water,Na,Cl,H,K ions producing metabolic alkolosis,hypocalamia and dehydration)

• Dehydration-

-------------Oliguria

------------Reduced cardiac output

-Low CVP

-Hypotension

-Hypovolaemic shock

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Intestinal gases

Most of distention caused by accumulation of

1. Swallowed gas

2. Organic gas

(hydrogen sulphied,ammonia,hydrogen and amines)

3. Diffusion from blood (CO2)

4. Bacterial fermentation

(70 % nitrogen,12% O2,CO2-8%,Remaining 10%)

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CLINICAL FEATURES

• 1, Abdominal pain

• 2, Vomiting

• 3, constipation

• 4, Distention

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Abdominal pain• First symptom

• Sudden onset

• Cramping in nature

• With 4 to 5 min interval

• Upper abdominal-high obstruction

Umbelicus-ileal obstruction

Lower abdominal-colon obstruction

Perineum-rectisigmoid obstruction

• Poorly localized

• Continuous sever pain without any quiescent period --STRANGULATION

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Vomiting• Early vomiting is reflex-followed by quiescent period• Interval of vomiting depends on site of Obstruction• High obstruction-frequent-copious colour-relived by

decompression• Low small bowel obstruction-less frequient/does not

get relief• In acute small bowel obstruction character of vomit

alters -initially partly digested food-yellow/green-finally faeculent

• IN COLON OBSTRUCTION VOMITING IS ABSENT

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constipation

• There may be one or two natural action of bowel

• IN FEW CONDITION LIKE RICHTER’S HERNIA,MESENTRIC VASCULAR OCCLUSION CONSTIPATION MAY NOT BE PRESENT.

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Distention

• In early small bowel obstruction there may not be any abdominal distention.

• Distention is less in –high small B.A.

Centrally located - low small B.A.

• Visible peristalsis

• High sound

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Physical Examination• Tachycardia and hypotension indicate sever dehydration and/or

peritonitis.• Degree of dehydration axamin-skin turgor and moisture of the

mucous membrane • Fever suggest –strangulation• GC-POOR-sever illness .• 1, Inspection : • peristalsis (long standing obstruction), • state of nutrition , • behavior ,skin color , and turgor , • surgical scar,• Abdominal distention,• fluid thrill, • shifting dullness, • fullness in flank• All hernial orifices examination

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• 2, Palpation :

• demonstrating the sites of the distress, then localizing the anatomic areas of possible abnormality.

• Garding/rigidity

• Skin temperature (Local site /general body )

• Rebond tenderness

• Mass/lump

• 3,Purcussion

• Tenderness on slight percussion suggest strangulation.

• 3, Auscultation :

• it is of great value. simple one ----noisy and is heard as rushes. During attacks of colic ,the sounds become loud ,high-pitched and metallic .

• In paralytic ileus no sound will heard.

• 4, Digital examination of the rectum

• 5,sigmoidoscopy examination

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Systemic Effects of Obstruction

• 1, water and electrolyte losses

• 2, toxic materials and toxemia

• 3, cardiopulmonary dysfunction

• 4, shock

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Laboratory Examination

• 1, complete blood count normal/slight raised W.B.C.-Simple mechanical obstruction.

Moderate(15000 to 20000) raised W.B.C.-Strangulation.

Very high raised (30000 to 40000).-primary mesenteric vascular occlusion

• 2, serum electrolytes and amylase determination• 3, arterial blood gas analysis• 4, urine specific gravity test • 5,blood gas analysis

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Radiologic Examination• X-ray is the most important diagnostic procedure. Intestinal

gas often is found. Not so often. Sometimes can display the intestinal loop.

• Straight X-ray abdomen-AP and lateral• Lt lateral or decubitus • Gas-fluid level –highly suggestive of I.O./P.I.• Houstral fold • Straight pipe- CHARACTER LESS • Normally infants under 2 yr of age shows a few fluid level• Fluid level appears later than gas Shadows.• No.of fluid level =degree and site of obstruction. • BARIUM ENEMA

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DIAGNOSIS• 1, Whether obstruction : according to clinical

manifestation ,we can know.

• 2, Mechanical or dynamic one .

• 3, Simple or strangulated one.

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• Differentiation :• 1, continuous rather than intermittent pain .• 2, the presence of shock and rapid pulse,

elevated temperature and white blood count.• 3, the presence of peritoneal irritation• 4, a palpable tender abdominal mass.

• 5, vomitus , gastrointestinal decompression is

bloody.• 6, active non operative treatment is no use.• 7, X-ray examination show isolated. large

intestinal loop.

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TREATMENT

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Nonoperative Treatment

• Basic treatment :• 1, redress water , electrolyte and acid-base balance

2, gastrointestinal decompression .

. 3, antibiotic treatment.

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• Fluid and electrolyte therapy-• 18 no venous catheter• Site –Superior vena cava• Urine catheterization• RL,D-5%,• Potassium• In sever dehydration-3.5 lit/day• And later on 2.5 lit/day + nasogastric

aspirated fluid• Rate-according to CVP

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gastrointestinal decompression

• Short tube (Levin)

• Long tube (Miller-Abott)

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Surgical Treatment• 1, principle of operation (when to operate)

For strangulation and closed-loop obstruction

the operation is required as soon as possible.

2, For simple one ,if the non operative method is no use ,the operation is needed.

• Within 24 hr.

• A period of preparation is required except in strangulation, closed loop obstruction

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• Type of anaesthesia- G.A.• Incision-midline vertical• After opening –presence or absence of fluid noted

with colour• Straw colour-simple obstruction• Bloodly-strangulation• Caecum has to be searched• If Caecum grossly distended-obstruction is in

colon.• And if collapsed-small bowel

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Whether the affected segment is viable or not

• Colour

• Motility

• Arterial pulsation

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The Procedure of Operation• Procedures not requiting opening of bowel

• Enterotomy for removal of obturation obstruction

• Resection of the obstructing lesion or strangulated bowel with primary anastomosis.

• Bypass anastomosis around an obstruction.

• The selection depend on the etiological causes.

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colostomy• If obstruction in Right colon-

Right colectomy with ileotransverse

colostomy.

If obstruction in Left colon-

3 stage –

proximal defunctioning colostomy

anastomosis

closer of colostomy

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Postoperative Care

• The principles are :

fluid and electrolyte management ,

antibiotics and

gastrointestinal decompression.

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Common Types of Intestinal Obstruction

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Peritoneal Adhesions and Bands

• Congenital : less

• Acquired : more usual. Most are due to injure ,operation and infection.

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Diagnosis

• 1, History of operation, injure ,infection.

• 2, Clinical manifestation .

• 3, maybe no manifestation in long time , suddenly the symptoms appears ,and the pain is severe.

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PROPHYLAXIS • 1, Avoiding any unnecessary trauma ,strangulation

of tissue and contamination during operative procedures.

• 2, All debris should be removed and any unnecessary foreign material, excessive suture material and mass ligation in the wound should be avoided.

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TREATMENT

• 1, Intestinal decompression by nasogastric incubation.

• 2, operation : sewing the intestine to itself so that the loops of intestine are arranged in an orderly ,ladder like fashion.

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VOLVULUS• Volvulus is a twisting or rotation of bowel upon its

mesentery , often resulting in intestinal obstruction. Circulatory impairment may follow , particularly when the twist is more than 180 degree .

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• Common site-

• 90 % sigmoid colon-Sigmoid –anticlockwise

rotates.

• Occasionally 10% in caecum-clockwise rotates.

• In transverse colon extremely rare

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DIAGNOSIS

• 1, Sigmoid volvulus :

• 1,common in the elderly with chronic constipation,neurologic disease indivuduals

• 2, cramping abdominal pain is a constant complaint.

• 3, nausea and vomiting are inconstant symptoms. And tend to occur late

• 4, there is an enormous gas -filled loop of the large intestine.

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• 2, Small bowel volvulus :

• 1, common in the young person.

• 2, presents following labor activity after eating.

• 3, sudden onset of severe abdominal pain ,nausea, vomiting and distention.

• 4, shock in the early stage with the necrosis of a large segment or entire small intestine.

• 5, not easy differentiated from other types of mechanical intestinal obstruction until laparotomy.

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TREATMENT

• 1, Sigmoidoscopic reduction with a large rectal tube or fiber optic colonoscopic reduction.

• 2, The most volvulus should be approached by transabdominal operation , and the surgeon should choose the necessary procedure.

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INTUSSUSCEPTION • 1, An intussusception is an invagination of part of

the intestinal tract into the lumen of the adjacent intestine.

• 2, 80% of intussusception occur in children under 2 years. In adults ,in contrast to children, the cause is usually related to intestinal tumors.

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• Proximal to distal is commonly seen• When it is distal it proximal it is called

retrograde intussception• Compound type• AETIOLOGY• Primary –no definite cause• Secondary –polyp,ca,submucous

lipama,stump of appendix

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TREATMENT• 1,Hydrostatic pressure

• 2, use barium enema

• 3, resection of the involved bowel including the leading point with end-to-end anastomosis.

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Pseudo-Obstruction of The Colon• 1, Cause : surgical or blunt trauma but may be related

to other extracolonic or extraabdominal disease.

• 2, Signs: massive dilatation of the cecum and ascending and transverse colon with no vomiting and no peritoneal signs. No air in distal portion of colon.

• 3, Treatment: conservative methods. If conservative methods fail ,and cecum is greater than 12cm, laparotomy is indicated. And if signs of acute abdomen. Usually cecostomy is the choice.