Intestinal Obstruction July 2008

Intestinal Obstruction

Armando G. Santos, MD, FPCS

Intestinal Obstruction: Essential Features 



Mechanical disruption of passage of intestinal contents along the bowel Two main types:  



Small bowel obstruction (SBO) Large bowel obstruction (LBO)

Classified as:   

Partial vs. Complete Simple vs. Strangulating Open loop vs. Closed loop

Frequent Causes of Obstruction

Age Group

Young adults and Middle-aged

Elderly

Etiology

Adhesions

and bands Incarcerated hernia Granulomatous disease (Crohn’s disease, TB) Colonic cancer Diverticulitis Impacted feces Adhesions Incarcerated hernia

Pathological Derangement in Intestinal Obstruction    

Fluid and electrolyte disturbance Bacterial proliferation Vascular disturbance Bowel wall changes

Intestinal Obstruction: Clinical Diagnosis 

Main symptoms:    



Abdominal pain Vomiting Abdominal distention Obstipation

Character/onset of Sx help determine level of obstruction

Intestinal Obstruction: Clinical Diagnosis         

History of previous operation/cancer/hernia Signs of strangulation/perforation Signs of dehydration/shock Abdominal distention Operative scar Visible peristalsis Borborygmi Abdominal/rectal mass Incarcerated hernia

Visible Peristalsis

Strangulated Femoral Hernia

Clinical Findings Suggestive of Strangulation       

Continuous pain Fever Tachycardia Peritoneal irritation Leukocytosis C-reactive protein elevation Increase in serum lactate No clinical parameters or laboratory tests can accurately detect or exclude presence of strangulation in all cases

Intestinal Obstruction: Vital Steps in Clinical Diagnosis 1.

2. 3.

4.

Recognition of presence of intestinal obstruction Attempt to locate its level (site) Attempt to detect if strangulation present Discovery of etiology of obstruction

Small Bowel Obstruction: Diagnostic Investigation        

CBC Serum electrolytes BUN/creatinine ABG – if complication suspected Supine and erect plain x-ray films CT scan Abdominal ultrasound Barium radiography

Proximal SBO: Plain Radiographs

Distal SBO: Plain Radiographs

Supine

Upright

Distal SBO: Plain Radiograph and CT

Barium Radiograph: Jejunojejunal Intussusception

Jejunojenunal Intussusception

CT: Ileal Intussusception with Typical Target Sign

UTZ: Dilated Jejunal Loops

Causes of SBO in Adults as to Site Extrinsic to bowel wall Adhesions (post-op esp.) Hernia Neoplasms Carcinomatosis Extra-intestinal tumor Intraluminal

Intra-abdominal Gallstone abscess Bezoar Foreign body

Intrinsic to bowel wall Congenital Duplication/cysts

Inflammatory TB Diverticulitis

Neoplastic Primary/metastatic tumors

Traumatic Hematoma

Miscellaneous Intussusception

SBO due to Adhesive Band

SBO due to Dense Adhesions

SBO: Internal Hernia due to Adhesive Bands

SBO due to Carcinoid Tumor

Causes of SBO in Adults Cause Adhesion Neoplasm Hernia Volvulus Inflammatory bowel disease Intussusception Gallstone ileus Radiation enteritis Intra-abdominal abscess 

Incidence (%) 50-75 8-15 8-15 3 1 <1 <1 <1 <1 <1

SBO: Management   



Initial resuscitation and decompression Conservative Tx reserved for partial SBO Close monitoring mandatory if under conservative Tx Surgery generally indicated for:  



Complete SBO No improvement in 48 hours

Surgery urgent in suspected strangulation

- Abdominal pain - Nausea/vomiting - Abdominal distention - Obstipation

Mx Algorith m for SBO

- Clinical history - Physical examination - Abdominal radiographs

Partial SBO

Complete SBO

Treat appropriately

- Crescendo pain - Unrelenting pain - Clinical deterioration - Radiograph deterioration

No

- NGT decompression - Serial PE - Serial radiographs - Fluid & electrolyte Mx

Large bowel obstruction

Yes Operation

Previous Hx of prohibitive reoperative risks & successful conservative Mx

Causes of LBO in Adults           

Cancer: 60% Volvulus: 10-15% Diverticulitis: 10-15% Hernia Ischemia/radiation induced stricture Carcinomatosis Pelvic recurrence of rectal cancer Intussusception Foreign body Inflammatory bowel disease Fecal impaction

LBO: Diagnostic Investigation       

Supportive blood tests Supine and erect plain radiographs CT scan Water-soluble contrast enema Colonoscopy Abdominal ultrasound Barium radiography

LBO: Management Strategy   





Resuscitation promptly administered Dx should guide appropriate Tx Initial non-surgical Tx, if possible, with elective definitive surgery Non-operative and surgical Tx tailored to cause If indicated, emergency surgery must:  Relieve obstruction  Treat underlying pathology if feasible

Obstructed Colorectal Ca: Mx 



If uncomplicated:  Endoscopic stent placement and elective resection If complicated or with failed endoscopic stenting:  Resection and anastomosis (if feasible)  Resection and colostomy

Obstructed Distal Transverse Colon with Competent Ileocecal Valve

Obstructed Proximal Transverse Colon with Incompete nt Ileocecal Valve

Obstructive Hepatic Flexure CA

Volvulus of the Colon: Predisposing Factors 



Redundant mobile colon segment with narrow base Distention of colon by feces or gas

Sigmoid Volvulus

Volvulus of the Colon: Types   

Sigmoid volvulus (>65% of cases) Cecal volvulus Transverse colon volvulus

Sigmoid Volvulus: Plain Radiograph

Cecal Volvulus: Plain Radiograph

Contrast Enema: “Bird’s Beak” at Level of Cecal Volvulus

Sigmoid Volvulus: Surgical Mx 



If uncomplicated:  Endoscopic decompression and elective resection of redundant sigmoid If complicated or with failed endoscopic decompression:  resection and colostomy

Sigmoid Volvulus: Pre and Post-decompression X-ray

Gangrenous Sigmoid Volvulus

Cecal Volvulus

Intestinal Obstruction: Summary 







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Thorough Hx/P.E. plus plain x-ray usually adequate to make Dx and Tx plan Further tests indicated for uncertain cases Supportive measures provided in all cases Complete SBO generally requires surgery Operation urgent for strangulation

Intestinal Obstruction: Summary 





LBO largely caused by colorectal cancer, sigmoid volvulus and diverticulitis Mx of LBO should be non-operative initially followed by elective definitive surgery, if feasible Emergency operation for LBO should aim to treat underlying pathology

Strangulated SBO with Gangrene due to Adhesion

Barium Enema: Ileocecal TB Cecum and ascending colon fibrotic and retracted craniad, scarred and sacculated (curved arrows); terminal ileum relatively patulous (straight arrows) and probably nodular. v=ileocecal valve.

Ileocecal TB

CT: Complete SBO due to Incisional Hernia

CT: SBO with Fluid-filled, Dilated Small Bowel Loops (white arrows); Collapsed Right Colon (red arrow)  

Mid-sigmoid Obstruction due to Adhesive Band

Have a Nice Day!