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Intestinal obstruction

By:- Lemessa Jira

December ,2016

Gondar ,Ethiopia

Presentation out line Session objective Introduction to intestinal obstruction Classification of intestinal obstruction Causes of intestinal obstruction Small bowel obstruction Large bowel obstruction Management of intestinal obstruction Nursing interventionReferenceAcknowledgment

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Session objective Define intestinal obstruction Identify the type of intestinal

obstruction List possible cause of intestinal

obstruction Describe the clinical features of

intestinal obstruction . Describe the nursing intervention

of IO. Understand the management of

intestinal obstruction 05/01/2023 by:- Lemessa J. 3

IntroductionIntestinal obstruction is blockage prevents the normal flow of intestinal contents through the intestinal tract. It is potentially risky surgical emergency associated with high morbidity and mortality(Ullah S, et al 2010)05/01/2023 by:- Lemessa J. 4

Cont..

The prevalence of intestinal obstruction was 21.8 % among patients admitted with the acute abdomen conditions and 4.8 % among total surgical admission patients(Soressa Uet al ,2016)About 85 % of intestinal obstruction occurs in the small bowel, while 15 % of occurs in the large intestine (Kakoza R ,2010)05/01/2023 by:- Lemessa J. 5

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Mechanical( Dynamic )Functional( A dynamic)

Classification of intestinal obstruction

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Mechanical obstructions is when something physically blocks the intestine. It can be caused by :-

1. Intraluminal:- Fecal impaction, foreign bodies, gallstones, Bezoars and parasites .

2. Intramural:- tumors, inflammatory strictures, lymphomas and colonic carcinoma .

3. Extramural:- adhesion, hernias, volvulus, intussusception, tumors.

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Intussusceptions: one part of the intestine slips in to the another part located below it like a telescope shortening.Adhesions: loops of the intestine become adherent to areas that heal slowly or scar after abdominal surgery.(Thampi D et al ,2014)

Cont.…

Volvulus: bowel twist and turns upon it. Hernias: protrusion of intestine through a weakened area in the abdominal muscle or wall.Tumors, and neoplasm.

(Thampi D et al ,2014)

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Functional( A dynamic)

It occurs due to muscles or nerves within either the small or large intestine function poorly. This process is called paralytic ileus if it’s an acute or self-limiting condition.

(Brunner 11th edition )05/01/2023 by:- Lemessa J. 10

Cont..The intestines normally work in a coordinated system of movement. If something interrupts these coordinated contractions, it can cause a functional intestinal obstruction.

Causes for paralytic ileus include:- Muscular dystrophy, endocrine disorders such as DM, neurological disorders such as Parkinson’s disease. (Brunner 11th edition. )

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Cont.… The obstruction can be partial

or complete. Its severity depends:

On the region of bowel affected

The degree to which lumen is occluded and especially the degree to w/c vascular supply is disturbed. 05/01/2023 by:- Lemessa J. 12

Small bowel obstruction

Most bowel obstructions (85%) occur in the small intestine. Adhesion is the most common cause of SBO, followed by hernias and neoplasms.

(Gn BB, et al ,2015)

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Intestinal contents, fluid, and gas accumulate above the intestinal obstruction.The abdominal distension and retention of fluid reduce the absorption of fluids and Stimulate more gastric secretion. This caused edema, congestion, necrosis and eventually rupture or perforation of the intestinal wall, with resultant peritonitis (Brunner 11th edition. ).

Cont.…

Reflux vomiting may be caused by abdominal distension Dehydration and acidosis develop from loss of water and sodium. With acute fluid losses

hypovolemic shock may occur. (Brunner 11th edition. )05/01/2023 by:- Lemessa J. 15

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Initially crampy pain that is wavelike and colicky.Blood and mucus may pass, but no fecal matter and no flatus.Abdomen becomes distended.If obstruction is complete- the peristaltic wave become reverse direction so intestinal content come to the mouth. If obstructions is in the ileum- fecal vomiting takes place. (Thampi D et al ,2014)

Cont..

First the patient vomits the stomach contents then the bile stained contents of the duodenum and the jejunum and finally with each paroxysm of pain, the darker, fecal like contents of the ileum.

(Thampi D et al ,2014)05/01/2023 by:- Lemessa J. 17

Cont.. Sign of DHN become evident Intense thirst Drowsiness Generalized malaise Abdominal distention Hypovolemic shock from DHN Constipation

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Diagnostic Evaluation Patient Hx and P/E plain abdominal X-ray Barium EnemaUltra sound Laboratory studies (electrolyte studies and CBC)

(Thampi D et al ,2014)05/01/2023 by:- Lemessa J. 19

ManagementNon operative management:- fluid resuscitation, bowel decompression, administration of analgesia and antiemetic as indicated clinically and administration of antibiotics. Complete obstruction needs surgical intervention (Brunner 11th edition).

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Cont..

Activity as tolerated:- With paralytic ileus, the patient is encouraged to ambulate to enhance return of peristalsis.IV therapy to replace the depleted water, and electrolyte before surgery .Antiemetic agents:- For relief of nausea and vomiting.Prophylactic antibiotics .Monitor intake and out put Supportive care

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Large bowel obstruction

As in small bowel obstruction, large bowel obstruction results in an accumulation of intestinal contents, fluid and gas proximal to the obstruction.It is About 15% of intestinal obstruction. The most common cause are carcinoma, diverticulitis, inflammatory bowel diseases and benign tumors ,mostly it occurs at sigmoid colon.

(Love M. Practice , 2013)05/01/2023 by:- Lemessa J. 22

Clinical manifestation LBO differs clinically from

small bowel obstruction in that Symptoms develop slowly relative to SBO.

Constipation (if obstruction in sigmoid colon or the rectum).

Abdomen becomes markedly distended.

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Summery of the LBO and SBO Acute obstruction:- usually in

small bowel and obstruction with severe colicky central abdominal pain, distension, early vomiting and constipation.

Chronic obstruction: -usually in large bowel which is lower abdominal colic & constipation followed by distension.

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The four cardinal features of IO

1. abdominal pain2.

vomiting3. distension4. constipation

Vary according to• location of obstruction• Duration of obstruction• underlying pathology• intestinal ischemia

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Cont..Abdominal pain colicky in nature, around the umbilicus in

SBO while in the lower abdomen in LBO. if it becomes continuous, think about

perforation or strangulation. does not usually occurs in paralytic ileus.Vomiting starts early in SBO and late in LBO As obstruction progresses vomitus alters from

digested food to feculent due to enteric bacterial overgrowth .05/01/2023 by:- Lemessa J. 26

Cont..

Distension more with lower obstruction Loops of large bowel becomes

visibly outlined through the abdominal wall.

Eventually, Crampy lower abdominal pain .

Dehydration occurs more slowly than in the small intestine.

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Dehydrationo More common in small bowel

obstruction due to repeated vomiting .

PyrexiaOnset of ischemia.Intestinal perforation.Inflammation associated with intestinal obstruction .

Differential diagnosis

Acute cholecytitisPerforated peptic ulcer diseaseEctopic pregnancyOvarian cystPIDAppendicitis Acute pancreatitis Peritonitis 05/01/2023 by:- Lemessa J. 29

Diagnosis

Based on symptoms P/EX-ray studies (show distended colon)Imaging abdominal CT MRI findings reveal

(Thampi D et al ,2014)05/01/2023 by:- Lemessa J. 30

General ExaminationVital signs Signs of dehydration :- tachycardia,

hypotension ,dry mucus membrane, decreased skin turgor, decreased urine output.

Inspection : distension, scars, masses, hernia.

Palpation : Rebound tenderness, rigidity, psoas sign and Rovsing sign ???????????05/01/2023 by:- Lemessa J. 31

Cont..Percussion : tympanic

abdomen.Auscultation : Increased

frequency of bowel sounds occur in diarrhea and mechanical intestinal obstruction

Reduced or absent bowel sounds occur in paralytic ileus and generalized peritonitis

(Thampi D et al ,2014).

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Management

Colonoscopy may be performed to untwist and decompress the bowel.Rectal tube to decompress.A nasogastric tube should be considered for patients with severe colonic distention and vomiting.

(Brunner 11th edition).

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Cont.…

The usual Rx, however, is surgical resection to remove the obstructing lesionColostomy /surgical opening of the cecum / may be performed.

(Brunner 11th edition )

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Nursing Diagnoses & InterventionsNausea, distension, and pain related to gastrointestinal obstructive process.Desired outcome: Patient relates a reduction in discomfort and does not exhibit signs of uncontrolled pain.Intervention : Implement comfort measures to provide pain relief like distraction, backrubs, conversation and relaxation therapy.05/01/2023 by:- Lemessa J. 35

Nursing Management

Implement comfort measures to provide pain relief: distraction, backrubs, conversation, relaxation therapy.Administer prescribed analgesics and antiemetic agents as indicated.

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Cont..

Maintain patency and proper functioning of the gastric tube.Monitor in put & out put . Take special note of the amount of GI aspirate.Appropriate IV fluids at the prescribed rate.

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EvidencesProvide adequate fluid resuscitation and NG suctioning non-operative management suggest it to be successful in 65-81% of partial small-bowel obstruction cases without peritonitis (Goyal SK,et al 2016). CT scan of abdomen and pelvis should be considered in all patients with IO because it can provide incremental information over plain films in differentiating grade, severity, and etiology of IO that may lead to changes in management (Adippah, et al 2010 )

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Evidences

Patients with IO should generally be admitted to a surgical service because this has been shown to be associated with a shorter length of stay, less hospital charges, and lower mortality compared with admission to a medical service(Mbbs MD, 2015).

Rectal tube should stay at least for 48 hrs. and Enema is contradicated for all patients who have intestinal obstruction(Dickman R., 2013).05/01/2023 by:- Lemessa J. 39

Reference1. Soressa U, Mamo A, Hiko D, Fentahun N. Prevalence , Causes And

Management Outcome Of Intestinal Obstruction In Adama Hospital , Ethiopia. BMC Surg [Internet]. BMC Surgery; 2016;1–8. Available From: Http://Dx.Doi.Org/10.1186/S12893-016-0150-5

2. Gn BB, Naresh Y, Shivakrishna G. A Prospective Study On Adhesive Intestinal Obstruction In A Tertiary Care Centre , South India. 2015;2(10):178–81.

3. Thampi D, Tukka Vn, Bhalki N, Ss A. ISSN ( O ): 2321 – 7251 A Clinical Study Of Surgical Management Of Acute Intestinal Obstruction. 2014;(1).

4. Ullah S, Khan M, Mumtaz N, Naseer A. Original Article Intestinal Obstruction : A Spectrum Of Causes. :188–92.

5. Thampi D, Tukka VN, Bhalki N, Ss A. ISSN ( O ): 2321 – 7251 A Clinical Study Of Surgical Management Of Acute Intestinal Obstruction. 2014;(1).

6. 5 Kakoza R, Iii HMS, Lieberman G. Mechanical Small Bowel. 2010;(may).05/01/2023 by:- Lemessa J. 40

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Any question???Thank you!