Complete Intestinal Obstruction

 Intestinal Obstruction exists when blockage prevents the normal flow of intestinal contents through the intestinal tract. Adhesions

Loops of intestines become

After surgery, adhesions produce

adherent to areas that heal

a kinking of an intestinal loop.

slowly or scar after abdominal Intussusception

Volvulus

surgery. One part of the intestine slips

The intestinal lumen becomes

into another part located below it

narrowed.

(like a telescope shortening) Bowel Twists and turns on itself.

Intestinal lumen becomes obstructed. Gas and fluid

Hernia

Tumor

Protrusion of intestine through a

accumulate in the trapped bowel. Intestinal flow may be completely

weakened area in the abdominal

obstructed. Blood flow to the area

muscle or wall. A tumor that exists within the

may be obstructed as well. Intestinal lumen becomes partially

wall of the intestine extends into

obstructed, if the tumor is not

the intestinal lumen, or a tumor

removed, complete obstruction

outside the intestine causes

results.

pressure on the wall of the Paralytic

intestine. Loss of peristaltic motor activity

(adynamic) ileus

in the intestine; associated with abdominal surgery, peritonitis, hypokalemia, ischemic bowel, spinal trauma, or pneumonia.

 Adhesion  Hernia  Vovulus  Cancer  Abdominal Pain  Surgery  Intussusception  Paralytic Ileus  Abdominal Angina  Nausea and Vomiting  Abdominal Pain  Severe Distention  Increase Hgb and Hct  Metabolic Acidosis  Dehydration  Intense Thirst “Medical history and a Physical Exam. During the physical exam, your doctor will feel your abdomen for tenderness or bloating, the abdomen is examined for evidence of scars, hernias, distension, or pain. and will listen with a stethoscope for bowel sounds. He or she will then confirm the diagnosis through other tests” the physician first gives a physical examination to determine the severity of the patient's condition. For your medical history, your doctor will ask questions about your pain, your symptoms, and other digestive conditions or abdominal surgeries that you have had, and also certain factors increase a person's risk of developing a bowel obstruction (including age and a history of constipation) the bowel normally makes some sounds such as gurgling and clicking which can be heard at irregular intervals by using a stethoscope. If an obstruction is present, a healthcare provider may hear high-pitched sounds while listening to the abdomen. If the obstruction has been present for some time, there may be no bowel sounds at all.

- this is normally the first test that is used to determine if there is an obstruction. A radiologist or other specialist can determine if the x-ray shows the signs of a bowel obstruction. This type of X-ray can detect blockages in the small and large intestines. - this test may be used to determine the location of the obstruction. It can also help in showing if the obstruction is actually inside the bowel, or if it is caused by something else in the abdominal cavity that is pushing on the bowel. •

The health care provider will gently insert a well-lubricated tube (enema) into your rectum. The tube is connected to a bag that contains the barium. The barium flows into your colon. A small balloon at the tip of the enema tube may be inflated to help keep the barium inside your colon. The flow of the barium is monitored by the health care provider on an x-ray fluoroscope screen, which is like a TV monitor.

- much like the barium enema, this test can help pinpoint the obstruction, especially if it is in the upper gastrointestinal tract. It is a set of X-rays taken to examine the esophagus, stomach, and small intestine. - this test is often used in cases of abdominal pain or when obstructions appears to be a chronic condition. A CT scan can help your doctor distinguish between a partial and a complete obstruction and can help in diagnosing most cancers. It also can show signs that help determine whether the blood supply has been cut off (strangulated) to the affected part of the bowel. •

The health care provider may inject a dye into one of your veins. This helps certain diseases and organs show up better on the images. Once inside the scanner, the machine's x-ray beam rotates around you. Small detectors inside the scanner measure the amount of x-rays that make it through the abdomen . A computer takes this information and creates several individual images, called slices.

- is an internal examination of the lower large bowel (colon), using an instrument called a sigmoidoscope. The sigmoidoscope is a small camera attached to a flexible tube. It is inserted into the colon to examine the rectum, and the sigmoid and descending portions of the colon. •

During the test, you wear a hospital gown so that the lower half of your body is exposed. You are positioned on your left side with your knees drawn up toward your chest . A gastroenterologist (a specialist in diseases of the digestive system) will gently insert a gloved and lubricated finger (or fingers) into the rectum to check for blockage and to dilate the anus. This is called a digital rectal examination. Following the digital rectal exam, the sigmoidoscope will be inserted. This flexible fiberoptic tube is about 20 inches long.The scope is gently advanced into the colon. Air is introduced into the scope to aid in viewing. The air may cause the urge to defecate. As the sigmoidoscope is slowly removed, the lining of the bowel is carefully examined. A channel in the scope allows for the passage of forceps for biopsies or other instruments for therapy.

is an internal examination of the colon (large intestine), using an instrument called a colonoscope. The colonoscope is a small camera attached to a flexible tube. Unlike sigmoidoscopy, which examines only the lower third of the colon, colonoscopy examines the entire length of the colon. •

You will lie on your left side with your knees drawn up toward the chest. After administration of a sedative and pain reliever, the colonoscope is inserted through the anus and gently advanced to the lowest part of the small bowel. Air will be inserted through the scope to provide a better view. Suction may be used to remove secretions. Since better views are obtained during withdrawal than during insertion, a more careful examination is done during withdrawal of the scope. Tissue samples may be taken with tiny biopsy forceps inserted through the scope. Polyps may be removed with electrocautery snares, and photographs may be taken. Specialized procedures, such as laser therapy , may also be performed.

is a medical imaging procedure used to examine the upper GI (gastrointestinal) tract, which includes the esophagus and, to a lesser extent, the stomach. •

The patient is asked to drink a suspension of barium sulfate. Fluoroscopy images are taken as the barium is swallowed. This is typically at a rate of 2 or 3 frames pers second. The patient is asked to swallow the Barium a number of times, whilst standing in different positions, i.e. AP, oblique and lateral, to assess the 3D structure as best possible.

- is a special x-ray of the small intestine that looks at how a liquid called contrast moves through the area. The x-ray images taken during enteroclysis appear on a fluoroscopic monitor (similar to a television screen) in "real time," which means they are seen as the contrast is actually moving through bowel structures. •

This test is done in a hospital radiology department. A tube is passed from the nose or mouth through the stomach and into part of the small bowel. Contrast (usually barium) and air are sent through the tube, and x-rays pictures are taken. X-rays are a form of electromagnetic radiation, as is light. They have higher energy than light, however, so they can penetrate the body to form an image on film. Areas that are dense look white, areas that are less dense look black, and other areas will be shades of gray. The contrast used for this test is dense and can be seen clearly on x-ray.The goal of the study is to image all of the loops of small bowel. Both "real time" pictures and still images are taken. You may be asked to change positions during the exam. The test usually lasts several hours, since it may take a while for the contrast to move through the entire small bowel.

• The first blood test of a patient with an intestinal obstruction usually gives normal results, but later tests indicate electrolyte imbalances. There is no way to determine if an obstruction is simple or strangulated except surgery.

• Results are usually normal or mildly elevated. • If the BUN level is increased, this may indicate decreased volume state (eg, dehydration) • Creatinine level elevations may indicate dehydration. • WBC count may be elevated with a left shift in simple or strangulated obstructions. Increased hematocrit is an indicator of volume state (ie, dehydration). • • • The patient may require surgical intervention.

The Pathophysiology alterations are presented in the figure below. Postoperative paralytic ileus results from inhibitory neural reflexes, inflammatory mediators, and the influence of exogenous and endogenous opioids. If the obstruction is at the pylorus of high in the small intestine, metabolic alkalosis develops initially as a result of excessive loss of hydrogen ions that normally would be reabsorbed from the gastric juice. With prolonged obstruction or obstruction lower in the intestine, metabolic acidosis is more likely to occur because bicarbonate from pancreatic secretions and bile cannot be reabsorbed. Hypokalemia can be extreme, promoting acidosis and atony of the intestinal wall. Metabolic acidosis also may be accentuated by ketosis, the result of declining carbohydrates stores caused by starvation. If pressure from the distention is severe

enough, it occludes the arterial circulation and cause strangulation leading to perforation. Lack of circulation permits the buildup of significant amounts of lactic acid, which worsen the metabolic acidosis. Bacteria also proliferate and may cross the mucosal barrier and cause peritonitis or sepsis.

z

Adhesions / Intussusception / Volvulus / Hernia / Paralytic ileus

Intestinal Obstruction Fluid and gas accumulate above the intestinal obstruction.

Loss of Water and Electrolytes

Distention

Pressure on diaphragm

Colic abdominal Pain Dehydration Nausea and Vomiting  Food intake &Nutrients absorption

 Respiratory Volume

Pressure in Intestinal Lumen Hypovolemia

 Venous Return

Intestinal bowel wall edema

 Capillary Permeability (Fluid loss to peritoneum)

Release of Toxins Bacterial Translocation

Fever Peritonitis

Hypovolemic Shock (shock in which the heart is unable to supply enough blood to the body)