Large bowel obstruction -dr.p.saravanakumar ms pg tanjore medical college
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Transcript of Large bowel obstruction -dr.p.saravanakumar ms pg tanjore medical college
LARGE BOWEL OBSTRUCTION
&
ACPO
LARGE BOWEL OBSTRUCTION
INTERRUPTION IN THE PASSAGE OF LARGE
INTESTINAL CONTENTS
CLASSIFICATION OF LBO
Depending on nature of obstruction
Depending on the blood supply
Depending Upon Presentation
Depending Upon In Relation To Lumen
DEPENDING ON THE NATURE OF OBSTRUCTION
DYNAMIC OBSTRUCTION• Carcinoma colon
• Volvulus
• Diverticulosis
• Intussusceptions
• Adhesions
ADYNAMIC OBSTRUCTION• Ogilvie’s syndrome
• Toxic mega colon
• Metabolic (hypokalemia)
• Post-op ileus
• Inflammatory disorder
• Hirschsprung’s disease
DEPENDING ON THE BLOOD SUPPLY
• Simple obstruction
• Strangulated obstruction
• Closed loop obstruction
DEPENDING UPON PRESENTATION• Acute Obstruction : volvulus /obstructed
hernia
• Chronic obstruction : carcinoma colon / diverticulosis
• Acute on chronic obstruction : ca colon
DEPENDING IN RELATION TO LUMEN
• Outside the wall
• Inside the wall
• Inside the lumen-Foreign body,Fecal impaction
DEPENDING IN RELATION TO LUMEN
OUTSIDE THE WALL
• Volvulus
• Hernias
• Tumour in adjacent organs
• Intra abdominal abscess
• Colonic obstructions
INSIDE THE WALL
• Carcinoma• Inflammation
(diverticulosis,crohn’s disease,LGV,schistosomiasis,TB)
• Hirschsprung’s disease• Ischemia• Radiation• Intussusceptions• Anatomical stricture
MOST COMMON CAUSES OF LBO
• Colorectal cancer-65%
• Colonic volvulus-15%
• Diverticulitis-10%
• Others-10% Hernia Intussusceptions
MOST COMMON CAUSES OF LBO
PATHOGENESIS OF INTESTINAL OBSTRUCTION
Changes proximal to bowel obstrucion
Changes at the site of obstruction
Closed loop obstruction
Changes in the bowel distal to obstruction-Inactive and collapsed
CHANGES PROXIMAL TO BOWEL OBSTRUCTION
Intestinal obstruction
Increased peristalsis
Vigorous peristalsis
If obstruction not relieved Cessation of peristalsis
Cessation Of Peristalsis
Flaccid, Paralysed Bowel
Dilated Bowel
CHANGES AT THE SITE OF OBSTRUCTION
Intestinal obstruction Distension
Venous compression
Congestion and edema
Progressive arterial compromise
Loss of shineness, Blackish discolouration Loss of peristalsis
Gangrene & Perforation
Bacteria and toxins migrate into peritoneum
Peritonitis
CLOSED LOOP OBSTRUCTION
Growth in the right colon with competent ileocaecal valve
Pressure increases in the caecum Stercoral ulcer in the caecum
Gangrene&Perforation
Fecal peritonitis
CLINICAL FEATURES OF LARGE BOWEL OBSTRUCTION
• Symptoms : Abdominal Distension Abdominal Pain Obstipation Vomiting Nausea / Anorexia
SIGNS OF LARGE BOWEL OBSTRUCTION
• General signs of dehydration • Abdominal findings :
Distension Tympanitic Note
Rt To Lt Colonic PeristalsisBorborygmi
SIGNS OF STRANGULATION
Features of septic shock : fever/hypotension/ renal failure/respiratory signs
Rebound tendernessGuarding / rigidityAbsent bowel soundsConstant pain / severe painFever / tachycardia / leucocytosis
INVESTIGATIONS • Blood : CBC / RBS / RFT / LFT / Electrolytes/ grouping
typing / ABG• Imaging
1.upright chest x ray2.supine / upright abdominal x ray3.barium enema (single/ double contrast)
(gastrografin)4.USG abdomen5.CT with oral water soluble contrast / IV
contrast / rectal contrast6.colonoscopy / sigmoidoscopy
MANAGEMENT OF LARGE BOWEL OBSTRUCTION
Sun should not be both rise and set
PRINCIPLES
• Aspiration (ryles tube)• Bowel care / blood transfusion• Charts (temp,PR,RR,I/O,)/ critical care• Drugs : antibiotics• Exploratory laparotomy• Fluids : IVF
PRINCIPLES OF EXPLORATORY LAPAROTOMY
• Ideally done 6 – 8 hrs• Long midline incision• Check viability of bowel – if not viable resection
& anastomosis• Adhesion – release • Bands – divide • Volvulus – untwist / resection• Obstructed hernia – reduce • Stricture – resection / stricturoplasty
FEATURES OF VIABLE BOWEL
• Normal peristalsis
• Normal peritoneal sheen is present
• Normal pulsation are visible or felt at mesentery
• Normal pink colour is present
IN DOUBTFUL VIABILITY
• Warm saline soaked mop is placed over the doubtful areas with 100% oxygen for 10 min
if colour become normal with peristalsis
Bowel is viable
PRINCIPLES OF EXPLORATORY LAPAROTOMY
• Ideally done 6 – 8 hrs• Long midline incision• Check viability of bowel – if not viable resection
& anastomosis• Adhesion – release • Bands – divide • Volvulus – untwist / resection• Obstructed hernia – reduce • Stricture – resection / stricturoplasty
COMPLICATIONS OF INTESTINAL OBSTRUCTION
• Peritonitis• Hypovolemia & septic shock• Renal failure• ARDS• Intra abdominal abscess formation
POST SURGICAL COMPLICATIONS
• Pelvic abscess• Subphrenic abscess• Biliary or fecal fistula• Burst abdomen• Bands and adhesion• Incisional hernia
MANAGEMENT OF MALIGNANT LARGE BOWEL OBSTRUCTION
• Primary goal: Decompression of obstructed segment to prevent perforation
• Secondary goal : Removal of the malignant lesion
OBSTRUCTING LESION OF THE RIGHT COLON
Stable patient:
Resection And Ileotransvese Anastomosis In Single Stage
OBSTRUCTING LESION OF THE RIGHT COLON
• Unstable patient & bowel perforation1st stage:
Resection Of Lesion But No Primary Anastomosis
Terminal Ileostomy And Transverse Colon Mucus Fistula
2nd Stage:Ileotransverse Anastomosis
OBSTRUCTING LESION OF THE RIGHT COLON
Non - resectable lesion : (Fixed To Posterior Abdominal Wall ,
Common Iliac Vessels)
Palliative: Ileotransverse Anastomosis Caecosigmoidostomy
OBSTRUCTING LESION OF THE TRANSVERSE COLON
• Treatment :Extended Rt Hemicolectomy + Removal Of Whole Omentum, Transverse Colon+
Ileocolic Anastomosis (Distal Transverse Colon Or Proximal Descending Colon)
OBSTRUCTING LESIONS OF THE LEFT COLON
Treatment options:
Three stage operation- Unstable Patient
Two stage operation- Unstable Patient
Single stage operation- Stable Patient
Sub total colectomy and ileorectal anastomosis - Unhealthy proximal colon
THREE STAGE OPERATION Transverse colostomy
After 3 – 6 weeks Elective resection of tumour with an anastomosis After 8 weeks
Colostomy closure
TWO STAGE OPERATION
Hartmann’s Operation
After Six weeks
Restoration Of Bowel Continuity
SINGLE STAGE OPERATION
Stable Patient: Left Hemicolectomy & Colorectal
Anastomosis
UNRESECTABLE LESION
External diversion: colostomy
Internal diversion: caecosigmoidostomy
COLONIC STENTS
Decompression Of The Obstruction
Emergency Situation Elective Setting
COLONIC STENTS
COLONIC VOLVULUS
SIGMOID VOLVULUS – 53%
CECAL VOLVULUS - <42%
TRANSVERSE COLON-3%
SPLENIC FLEXURE-2%
SIGMOID VOLVULUS
SIGMOID VOLVULUS
• Predisposing factors Long mesentery of the pelvic colon
Narrow attachment at the base
Long, redundant and pendulous sigmoid
Loaded colon due to residue diet
Diverticulitis with band/adhesions
CLINICAL FEATURES OF SIGMOID VOLVULUS
• Acute sigmoid volvulusAbdominal pain
Absolute constipation
Abdominal distension-tympanitic abdomen
Tyre like feel
Features of peritonitis
CHRONIC RECURRENT SIGMOID VOLVULUS
• Clinical features
Recurrent left lower abdominal pain
Abdominal distension
Relieved by passage of large amount of flatus
INVESTIGATIONS Contrast Enema
Bird’s beak sign
Bird of prey sign
Ace of spade sign
CT AbdomenWhirl pattern
X- Ray Abd Erect
Omega sign
Coffee bean sign
Bent inner tube sign
SIGMOID VOLVULUS
INTRA-OPERATIVE INTRA-OPERATIVE
MANAGEMENT
• Non operative managementResuscitation Endoscopic Decompression Using
Flatus Tube/Sigmoidoscopy/ Flexible Colonoscopy
If Obstruction Relieved If Not
Elective Surgery Emergency After One Week Laparotomy
Non operative management
NON OPERATIVE MANAGEMENT-FLATUS TUBE
OPERATIVE MANAGEMENT
If Bowel Is Gangrenous Single Stage- Resection And End To End Anastomosis Hartmann’s Operation Exteriorisation Of Bowel
If Bowel Is Not Gangrenous Single Stage- Resection and End To End AnastomosisSigmoidopexy
COMPOUND VOLVULUS
Ileo Sigmoid KnottingDue To Presence Of Long Pelvic Mesocolon Allows The Ileum To Twist Around The Sigmoid ColonPresents As Acute Intestinal ObstructionX-ray : Dilated Both Ileal And Sigmoid LoopsTreatment: Resuscitation Decompression f/b Resection And Anastomosis or Exteriorisation Of Bowel
COMPOUND VOLVULUS
ILEO SIGMOID KNOTTING
CECAL VOLVULUS
• Due to failure of fixation of the ileal and caecal mesentery to the posterior abdominal wall
• Predisposing factors: Previous surgeryPregnancyObstructing lesion of left colonMalrotation
INVESTIGATIONS • Plain Xray Abdomen Erect
Comma Shaped Dilated Ceacum In Left Upper Abdomen
Single Long Fluid Level
Dilated Small Bowel Right Of The Distended Caecum
Contrast Enema: Tapering Of
Ascending ColonCT Abdomen:
Dilated Caecum With Fluid Level
CAECAL VOLVULUS
CAECAL VOLVULUS
MANAGEMENT
Right hemicolectomy with primary anastomosis
Caecostomy/Caecopexy
Endoscopic decompression/derotation not advisable
INTUSSUSCEPTION
• Defined as the Invagination of one segment of intestine into the adjacent segment
• Types: Antigrade:
Simple: Ileocolic, ileoileal, colocolicCompound: IleoileocolicRetrograde: Jejunogastric intususception
Ileocolic-iss
PARTS OF INTUSSUSCEPTION
Intussuscipiens:Distal bowel which receives the intestine
Intussusceptum:Proximal bowel which enter into distal segment
Apex:Is the part which advances
Lead point
CAUSES OF INTUSSUSCEPTION
In Infants
Change in diet during weaning period
Upper respiratory tract viral infection
In Adults
Intestinal polypsSubmucous lipomasMeckel's diverticulumCarcinomaLeomyoma of intestinePurpuric submucosal haemorrhages-HSP
CLINICAL FEATURES OF INTUSSUSCEPTION
Symptoms
Severe cramping abdominal pain
Vomiting
Red current jelly stool
SignsSausage shaped mass in umbilical region
Right iliac fossa empty
Step ladder peristalsis
Features of peritonitis
PR shows blood stained mucus-Red current jelly
INVESTIGATIONS PlainX-ray:Multiple air fluid levels
Barium enema:Claw Sign Or Coiled Spring Sign Or Meniscus Sign
Ultrasound abdomen :– Target sign– Psuedokidney sign– Bull’s eye sign
Doppler Study :
To Check Blood Supply Of Bowel It Shows Mass With Doughnut Sign
CT Abdomen Target sign
MANAGEMENT
• Non operative management: Hydrostatic reduction – Contrast enema – Air enema– Warm salineContraindications:
Perforation Profound shock and known pathological lesion
SURGICAL MANAGEMENT OF ISS
• Laparotomy and reduction of intussusception milking method
If Reduction possible If not possible
check the viability & Resection and suture terminal ileum anastomosisto ascending colon
SURGICAL MANAGEMENT OF ISS
• Laparotomy and reduction of intussusception milking method
If Reduction possible If not possible
check the viability & Resection and suture terminal ileum anastomosisto ascending colon
ACUTE COLONIC PSEUDO OBSTRUCTION-ACPO
• Defined as Massive Colonic Distension In The Absence Of Mechanically Obstructing Lesion
• Etiology: Primary pseudo-obstruction
• Familial visceral myopathy• Sporadic visceral myopathy
SECONDARY PSEUDO OBSTRUCTION
Smooth muscle disorders: Collagen vascular disorders
Scleroderma, DermatomyositisMuscular dystrophy- Myotonic dystrophyAmyloidosis
Neurological disorders– Chaga's disease– Parkinsonism– Spinal cord injury
SECONDARY PSEUDO OBSTRUCTION
Drugs- Phenothiazines, Tricyclic antidepressants and opioids
Metabolic-Uremia, Hypokalemia, Diabetes, Myxoedema, Hypoparathyroidism
Viral infections
CLINICAL FEATURES OF ACPO
Medically ill patient suddenly develops abdominal distension
Tympanitic abdomen
Not tender
Bowel sounds present
INVESTIGATIONS
• Plain Xray Abdomen Erect : Shows Distension Of Colon• Water Soluble Contrast Enema:IOC Differentiates ACPO From Mechanically
Obstructing Lesions• Colonoscopy Not Advisable
Plain Xray Abdomen Erect-acpo
MANAGEMENT
Non operative:– Injection Neostigmine 2.5mg iv over 3 minutes – Epidural anaesthesia – Colonoscopic decompressionOperative:Emergency Laparotomy– If there is no ischemia or perforation-loop colostomy– If there is ischemia or perforation-Resection and
ileostomy with mucus fistula
THANK YOU
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