Download MBBS Surgery Presentations 30 Intestinal Obstruction Lecture Notes

--- Content provided by‌ FirstRanker.com ---

OBSTRUCTION

Classify Intestinal Obstruction. Discuss the D\D and

management of AIO in a 70 yr old male.

--- Content provided by​ FirstRanker.com ---

Describe the c\f ,diagnosis and management of AIO.
Enumerate causes of dynamic IO. Discuss the

diagnosis and management of acute small bowel

--- Content provided by⁠ FirstRanker.com ---

obstruction.


The common Scenario

--- Content provided by‌ FirstRanker.com ---

A 50 year old gentleman presents

with abdominal pain, distension and

--- Content provided by‌ FirstRanker.com ---

absolute constipation. With

repeated episodes of vomiting.

His vital sign were stable, abdomen

--- Content provided by‍ FirstRanker.com ---

distended with diffuse tenderness

but minimal peritonism. Bowel

--- Content provided by‌ FirstRanker.com ---

Sounds are hyperactive.

The plain abdominal xray was taken

on admission.

--- Content provided by⁠ FirstRanker.com ---

What are your objectives?

You should be able to address the following questions

--- Content provided by FirstRanker.com ---

1. Is this bowel obstruction or ileus?

2. Is this a small or large bowel obstruction?

3. Is this proximal or distal obstruction?

--- Content provided by‍ FirstRanker.com ---

4. What is the cause of this obstruction?

5. Is this a complex or simple obstruction?

--- Content provided by‌ FirstRanker.com ---

6. How should I start investigating my patient?

7. What is the role of other supportive investigations?

8. What is my immediate/ intermediate treatment plan?

--- Content provided by​ FirstRanker.com ---

9. What are the indications for surgery?

10. What are the medico-legal and ethical issues that I

--- Content provided by‍ FirstRanker.com ---

should address?
Definition

Any condition that interferes with normal propulsion

--- Content provided by FirstRanker.com ---

and passage of intestinal contents.

Can involve the small bowel, colon or both.

TYPES

--- Content provided by‌ FirstRanker.com ---

Dynamic: where peristalsis is working against a

mechanical obstruction.

--- Content provided by‍ FirstRanker.com ---

Adynamic: mechanical element is absent
- Peristalsis may be absent(paralytic ileus)
-May be present in non propulsive form. (mesenteric

vascular occlusion or pseudo-obstruction)

--- Content provided by‍ FirstRanker.com ---

Mechanical Obstruction

Acute vs Chronic
Partial vs Complete
Simple vs Closed loop

--- Content provided by‌ FirstRanker.com ---

Gangrenous vs Nongangrenous

PATHOPHYSIOLOGY

Small Intestine Function

--- Content provided by FirstRanker.com ---

Transport - Distension stimulates contractions
Mixing and peristalsis
Absorption
Colon Function
Water Absorption

--- Content provided by‍ FirstRanker.com ---

Transport
Storage
PATHOPHYSIOLOGY

Dependent Upon:

--- Content provided by‍ FirstRanker.com ---

Degree of Obstruction
Duration of Obstruction
Presence and Severity of Ischemia
Results in:
Accumulation of fluid and air

--- Content provided by FirstRanker.com ---

Bacterial overgrowth
Maximal by 24 hrs after obstruction
Gut translocation to nodes and portal system
Once Distended :
Impaired fluid and nutrient absorption

--- Content provided by‍ FirstRanker.com ---

Secretion of isotonic fluid (intravascular to intraluminal)

PATHOPHYSIOLOGY

Systemic symptoms are secondary to:

--- Content provided by‌ FirstRanker.com ---

Hypovolemia
Bacterial translocation (typically E. coli)
Ischemia worsens general inflammatory state,

bacterial translocation, and fluid requirements

--- Content provided by⁠ FirstRanker.com ---

Large Bowel Obstruction
Ileocecal valve plays prominent role in

pathophysiology of LBO

--- Content provided by‍ FirstRanker.com ---

If competent valve = closed loop obstruction
Caecal ischemia around 10-13 cm

--- Content provided by​ FirstRanker.com ---

Causes- SBO

Luminal

--- Content provided by​ FirstRanker.com ---

Mural

Extraluminal

--- Content provided by FirstRanker.com ---

F.Body

Neoplasims

Postoperative

--- Content provided by⁠ FirstRanker.com ---

Bezoars

lipoma

--- Content provided by‍ FirstRanker.com ---

adhesions

Gallstone

polyps

--- Content provided by​ FirstRanker.com ---

FoodParticles

leiyomayoma

--- Content provided by‍ FirstRanker.com ---

Congenital
adhesions

A.lumbricoides

--- Content provided by​ FirstRanker.com ---

hematoma
lymphoma

Hernia

--- Content provided by‍ FirstRanker.com ---

carcimoid
carinoma

Volvulus

--- Content provided by FirstRanker.com ---

secondaryTumors

Crohns
TB
Stricture

--- Content provided by‍ FirstRanker.com ---

Intussusception
Congenital

Intussusception

--- Content provided by‌ FirstRanker.com ---

Gall stone Ileus

IBD
Large Bowel Obstruction

--- Content provided by‌ FirstRanker.com ---

?Distinguishing ileus from mechanical obstruction is challenging

?According to Laplace's law: maximum pressure is at the it's

maximum diameter. Cecum is at the greatest risk of perforation

--- Content provided by FirstRanker.com ---

?Perforation results in the release of formed feaces with heavy

bacterial contamination

--- Content provided by⁠ FirstRanker.com ---

Aetiology:

1. Carcinoma: The commonest cause, 18% of colonic ca. present

with obstruction

--- Content provided by FirstRanker.com ---

2. Benign stricture: Due to Diverticular disease, Ischemia,

Inflammatory bowel disease.

--- Content provided by​ FirstRanker.com ---

3. Volvulus: 1. Sigmoid Volvulus: Results from long redundant,

faecaly loaded colon with a narrow pedicle

2. Caecal Volvulus

--- Content provided by​ FirstRanker.com ---

4. Hernia.

5. Congenital : Hirschusbrung, anal stenosis and agenesis

--- Content provided by⁠ FirstRanker.com ---

Colonic Obstruction

Sigmoid Volvulus
COMMON CAUSES:
Adhesions- 40%

--- Content provided by‍ FirstRanker.com ---

Tumors -15%
Inflamatory- 15%
Obstructed hernia-12%
Intraluminal-10%
Miscellaneous -8%

--- Content provided by FirstRanker.com ---

SYMPTOMS

The four cardinal features of intestinal obstruction:

--- Content provided by⁠ FirstRanker.com ---

-abdominal pain

-vomiting

-distension

--- Content provided by‍ FirstRanker.com ---

-constipation

Vary according to:-

--- Content provided by FirstRanker.com ---

location of obstruction

Duration of obstruction

underlying pathology

--- Content provided by⁠ FirstRanker.com ---

intestinal ischemia
HISTORY

Did this ever happen before?

--- Content provided by‍ FirstRanker.com ---

Change in bowel habits (acute vs chronic)
Progressive vs acute abd. distention
Weight loss
Flatus?
Prior Surgeries

--- Content provided by‌ FirstRanker.com ---

Hx of abdominal CA?
Hx of Inflammatory Bowel Dz
Prior abdominal XRT?
Meds: Anticoagulants, Anticholinergics, Opioids,

--- Content provided by​ FirstRanker.com ---

Antihistamines, Alpha-agonists, Catecholamines

SYMPTOMS

Abdominal pain:

--- Content provided by‍ FirstRanker.com ---

- colicky in nature, around the umbilicus in SBO while in

the lower abdomen in LBO

--- Content provided by‍ FirstRanker.com ---

- if it becomes continuous, think about perforation or

strangulation.

- does not usually occurs in paralytic ileus.

--- Content provided by⁠ FirstRanker.com ---

Vomiting

-starts early in SBO and late in LBO

-As obstruction progresses vomitus alters from digested food

--- Content provided by FirstRanker.com ---

to faeculent due to enteric bacterial overgrowth
Distension

-more with lower obstruction

--- Content provided by‍ FirstRanker.com ---

SYMPTOMS

Constipation
-more with lower or complete obstruction

--- Content provided by‍ FirstRanker.com ---

- constipation is either absolute (no feces or flatus)

or relative (flatus passed).
-diarrhea may be present with partial obstruction

--- Content provided by​ FirstRanker.com ---

SYMPTOMS

Dehydration
More common in small bowel obstruction, due to repeated

--- Content provided by​ FirstRanker.com ---

vomiting.

Secondary polycythemia due to raised B.urea & hematocrit.

--- Content provided by​ FirstRanker.com ---

Pyrexia
Onset of ischemia.
Intestinal perforation.
Inflammation associated with int. obst.

--- Content provided by‌ FirstRanker.com ---

SYMPTOMS

In strangulation:
severe constant abdominal pain
fever

--- Content provided by⁠ FirstRanker.com ---

tachycardia
tenderness with rigidity/rebound
tenderness.
shock

--- Content provided by‌ FirstRanker.com ---

CLINICAL EXAMINATION

General examination-

Vital signs

--- Content provided by FirstRanker.com ---

Signs of dehydration ?tachycardia, hypotension

dry mucus membrane, decreased skin turgor, decreased urine output
Inspection

--- Content provided by​ FirstRanker.com ---

distension, scars, peristalsis, masses, hernial orifices

Palpation

--- Content provided by​ FirstRanker.com ---

tenderness, masses, rigidity

Percussion

tympanitic abdomen

--- Content provided by FirstRanker.com ---

Auscultation

high pitched bowel sound or silent abdomen
*Examine rectum for mass, blood, feces or it may be empty in case of

--- Content provided by‍ FirstRanker.com ---

complete obstruction
INVESTIGATIONS

Hemogram - WBC (neutrophilia-strangulation)
Hyper kalemia, hyperamylasemia & raised LDH may

--- Content provided by‍ FirstRanker.com ---

be associated with strangulation.

Plain AXR
Sigmoidoscopy (carcinoma, volvulus)

--- Content provided by​ FirstRanker.com ---

Contrast x-ray
CT abdomen.

The most helpful diagnostic radiographic procedure

--- Content provided by‍ FirstRanker.com ---

in suspected SBO is:

A. CT of Abdomen and Pelvis
B. UGI gastrograffin contrast study
C. Supine and Erect plain films of abdomen

--- Content provided by‌ FirstRanker.com ---

D. U/S of the abdomen
Imaging ? Plain Films

Dilated loops, SB dilation? AFLs?
Are AFL's and bowel loops in same place on supine and upright

--- Content provided by‍ FirstRanker.com ---

films?

Is there gas throughout the entire colon? Ileus or pSBO
Paucity of distal colonic gas or abrupt cutoff of colonic gas

--- Content provided by‍ FirstRanker.com ---

w/proximal distention and/or AFLs? Suggesting complete or

near-complete LBO

--- Content provided by FirstRanker.com ---

Massive dilation of colon, especially of the cecum or sigmoid?

Suggestive of volvulus or pseudoobstruction

Evidence of strangulation? Thickened SB loops, mucosal

--- Content provided by​ FirstRanker.com ---

thumb printing, pneumatosis cystoides intestinalis, or free air

Are there biliary calculi? Pneumobilia? GS ileus?

--- Content provided by‍ FirstRanker.com ---

AXR

When distended by gas:
Jejunum is characterized by valvulae conniventes.
Ileum is featureless.

--- Content provided by‌ FirstRanker.com ---

Caecum is shown by rounded gas shadow in RIF.
Colon shows haustral folds.
Fluid level appears later than gas shadow
Two fluid level in smal bowel considered normal.
No. of fluid level is proportional to degree of obstruction

--- Content provided by‌ FirstRanker.com ---

and distal site in smal bowel.
The Difference between small and

large bowel obstruction

--- Content provided by​ FirstRanker.com ---

Large bowel

Small Bowel

--- Content provided by‌ FirstRanker.com ---

?Peripheral ( diameter 8 cm max)

?Central ( diameter 5 cm max)

?Presence of haustration

--- Content provided by⁠ FirstRanker.com ---

?Vulvulae coniventae

?Ileum: may appear tubeless

--- Content provided by⁠ FirstRanker.com ---

Adjunctive Tests

Sigmoidoscopy
When large amounts of air extend down to the rectum

--- Content provided by⁠ FirstRanker.com ---

Flex or Rigid wil exclude rectal or distal sigmoid

obstruction ?

CT Scan or U/S

--- Content provided by FirstRanker.com ---

When normal plain films but history and exam are

consistent with obstruction

Plain films in SBO wil be nondiagnostic approximately

--- Content provided by‍ FirstRanker.com ---

30% of the time


Role of CT

--- Content provided by‍ FirstRanker.com ---

Used with iv contrast, oral and

rectal contrast (triple contrast).

--- Content provided by⁠ FirstRanker.com ---

Able to demonstrate

abnormality in the bowel wall,

mesentery, mesenteric vessels

--- Content provided by‍ FirstRanker.com ---

and peritoneum.

It can define

--- Content provided by⁠ FirstRanker.com ---

the level of obstruction

The degree of obstruction

The cause: volvulus,

--- Content provided by‌ FirstRanker.com ---

hernia, luminal and mural

causes

--- Content provided by⁠ FirstRanker.com ---

The degree of ischaemia

Free fluid and gas

Ensure: patient vitally stable

--- Content provided by⁠ FirstRanker.com ---

with no renal failure and no

previous allergy to iodine

--- Content provided by‌ FirstRanker.com ---

Role of barium gastrografin

studies

Barium should not be used in

--- Content provided by FirstRanker.com ---

a patient with peritonitis

As: fol ow through, enema

--- Content provided by‌ FirstRanker.com ---

Limited use in the acute

setting

Gastrografin is used in

--- Content provided by FirstRanker.com ---

acute abdomen but is

diluted

--- Content provided by‌ FirstRanker.com ---

Useful in recurrent and

chronic obstruction

May able to define the level

--- Content provided by FirstRanker.com ---

and mural causes.

Can be used to distinguish

--- Content provided by‍ FirstRanker.com ---

adynamic and mechanical

obstruction
TREATMENT

--- Content provided by‌ FirstRanker.com ---

Three main measures-

- GI drainage
- Fluid &Electrolyte replacement
- Relief of obstruction, usually surgical

--- Content provided by FirstRanker.com ---

Treatment

Conservative:
-Nasogastric aspiration by Ryles tube

--- Content provided by‍ FirstRanker.com ---

-IV fluids- volume varies depending on dehydration

-NPO

--- Content provided by​ FirstRanker.com ---

-urinary catheter

-check temp. and pulse 2 hourly
-abdominal examination 8 hourly

--- Content provided by‌ FirstRanker.com ---

-Broad spectrum antibiotics initiated early- reduce

bacterial overgrowth.
? Some cases wil settle by using this conservative regimen, other

--- Content provided by⁠ FirstRanker.com ---

need surgical intervention.

? Surgery should be delayed til resuscitation is complete unless signs

of strangulation and evidence of closed-loop obstruction.

--- Content provided by‌ FirstRanker.com ---

? Cases that show reasons for delay should be monitored

continuously for 72 hours in hope of spontaneous resolution e.g.

--- Content provided by‌ FirstRanker.com ---

adhesions with radiological findings but no pain or tenderness

? "The sun should not both rise and set" in cases of unrelieved

obstruction.

--- Content provided by‍ FirstRanker.com ---

Indication for surgery:


- failure of conservative management

--- Content provided by‍ FirstRanker.com ---

- tender, irreducible hernia
- strangulation

If the site of obstruction is unknown; laparotomy

--- Content provided by‌ FirstRanker.com ---

assessment is directed to-

-The site of obstruction.
-The nature of obstruction.

--- Content provided by⁠ FirstRanker.com ---

-The viability of gut.


Surgical treatment

--- Content provided by⁠ FirstRanker.com ---

Operative decompression required-if

dilatation of bowel loops prevent exposure,
bowel wall viability is compromised,
or if subsequent closure will be compromised.

--- Content provided by⁠ FirstRanker.com ---

Savage's decompressor used within

seromuscular purse-string suture.
Or large-bore NG tube maybe used for milking

--- Content provided by⁠ FirstRanker.com ---

intestinal contents into stomach.

SURGERY

--- Content provided by​ FirstRanker.com ---

The type of surgical procedure depend upon the cause of

obstruction viz division of bands,adhesiolysis, excision ,or

bypass

--- Content provided by FirstRanker.com ---

*Once obstruction relieved, the bowel is inspected for

viability, and if non-viable, resection is required.

--- Content provided by‌ FirstRanker.com ---

Indicators of non-viability
1.absent peristalsis
2.loss of normal shine

3.loss of pulsation in mesentry

--- Content provided by FirstRanker.com ---

4.green or black color of bowel
SURGERY

If in doubt of viability, bowel is wrapped in hot packs

--- Content provided by​ FirstRanker.com ---

for 10 minutes with increased oxygen and reassessed

for viability.

--- Content provided by⁠ FirstRanker.com ---

Resection of non viable gut should be done followed

by stoma.

Sometimes a second look laprotomy is required in 24-

--- Content provided by‍ FirstRanker.com ---

48 hours e.g. multiple ischemic areas.

Adhesions

--- Content provided by FirstRanker.com ---

Most common cause of intestinal obstruction.
Peritoneal irritation results in local fibrin production,

which produce adhesions.

--- Content provided by FirstRanker.com ---

BANDS
Congenital : obliterated vitellointestinal duct.
A string band following previous bacterial peritonitis.
A portion of greater omentum adherent to parietes.

--- Content provided by​ FirstRanker.com ---

Causes of adhesions :

Abdominal operation : anastomosis, raw peritoneal surfaces

Foreign material: talc, starch, gauze, silk

--- Content provided by FirstRanker.com ---

Infection: peritonitis, T.B.

Inflammatory conditions: crohn's disease.

--- Content provided by‍ FirstRanker.com ---

Radiation entritis.


Prevention

--- Content provided by‌ FirstRanker.com ---

Good surgical technique.

Washing the peritoneal cavity with saline to remove the clots.

Minimizing contact with gauze.

--- Content provided by​ FirstRanker.com ---

Covering the anastomosis & raw peritoneal surfaces.

TREATMENT

--- Content provided by⁠ FirstRanker.com ---

Usually conservative treatment is curative.
(i.v. rehydration & nasogastric decompression)
It should not be prolonged beyond 72 hrs.

Surgery

--- Content provided by‌ FirstRanker.com ---

Division of band.
Minimal adhesiolysis.
Tt. Of recurrent obstruction due to

adhesions

--- Content provided by‌ FirstRanker.com ---

Repeat adhesiolysis alone.
Noble's plication : adjacent intestinal coils (15-20

cms) are sutured with serosal sutures.

--- Content provided by‍ FirstRanker.com ---

Charles-Phillips trans-mesenetric plication.
Intestinal intubation : initraluminal tube insertion via

a WITZEL jejunostomy or gastrostomy.

--- Content provided by​ FirstRanker.com ---

INTERNAL HERNIA

When a portion of small intestine is entrapped in one

--- Content provided by FirstRanker.com ---

of retropritoneal fossae or in a congenital mesentric

defect.

Sites of internal herniation:

--- Content provided by‍ FirstRanker.com ---

Foramen of winslow.
A hole in mesentry / transverse mesocolon.
Defects in broad ligaments.
Congenital/ acquired diaphragmatic hernia.
Duodenal retroperitoneal fossae- Lt. paraduodenal &

--- Content provided by​ FirstRanker.com ---

rt. Duodenoojejunal.

intersigmoid fossae.
It is uncommon in the absence of adhesions.

--- Content provided by​ FirstRanker.com ---

Treatment : to release the constricting agent by

division.

Gal stone ileus

--- Content provided by‌ FirstRanker.com ---

It tends to occur in elderly.
Erosion of large gallstone into duodenum.
Present with recurrent obstruction.
X-ray: small bowel obstruction with air in billiary tree.

--- Content provided by‌ FirstRanker.com ---

-may show a radio opaque gall stone.
Treatment : laparotomy & removal /crushing of stone.
FOOD

After partial /total gastrectomy.

--- Content provided by​ FirstRanker.com ---

Unchewed food can cause obstruction.
Treatment similar to gall stone.
BEZOARS

Trichobezoars

--- Content provided by FirstRanker.com ---

Phytobezoars

WORMS
Ascaris lumbricoides
Frequently follows initiation of antihelminthic

--- Content provided by⁠ FirstRanker.com ---

therapy.

Eosinophilia/worm with in gas filled bowel loops.
Laparotomy.

--- Content provided by⁠ FirstRanker.com ---

INTUSSUSCEPTION

One portion of gut becomes invaginated with in

--- Content provided by FirstRanker.com ---

adjacent segment.

Most common in children(3-9 months.)
Idiopathic-70%
Associated gastroenteritis/UTI- 30%

--- Content provided by⁠ FirstRanker.com ---

Hyperlpasia of Peyer's patches in terminal ileum can

be initiating factor.
In older children intussusception is usually associated with

--- Content provided by‌ FirstRanker.com ---

a lead point ? meckel's diverticulum, polyp, & appendix.

Adults: always with a lead point.- polyp, submucosal

lipoma/ tumor.

--- Content provided by⁠ FirstRanker.com ---

It is composed of three parts:

-Entering/ inner tube(Intussusceptum)

--- Content provided by‌ FirstRanker.com ---

- Returning/ middle tube

-Sheath/ outer tube(intussuscipiens)
It is an example of strangulating obstruction with

--- Content provided by‌ FirstRanker.com ---

impaired blood supply of inner layer.

It may be ileoileal(5%); ileocolic(77%); ileo-ileo-colic(12%);

colocolic (2%) & multiple.

--- Content provided by​ FirstRanker.com ---

CLINICAL FEATURES

Severe colic pain.
vomitting as time progress

--- Content provided by‍ FirstRanker.com ---

blood & mucus (the `redcurrent' jelly stool).
Abdominal lump(sausage shaped)
Emptiness in RIF(the sign of Dance).
Death may occur from bowel obstruction or

--- Content provided by‌ FirstRanker.com ---

peritonitis secondary to gangrene.
RADIOGRAPHY

Plain X-ray Abd.: Bowel obstruction with absent caecal

--- Content provided by‌ FirstRanker.com ---

shadow gas in ileo-ileal & ileo-colic cases.

Ba-enema: the claw sign in ileocolic & colocolic cases.
CT scan in equivocal cases of ileo-ileal intussusception.

--- Content provided by⁠ FirstRanker.com ---

(small bowel mass may be revealed)


Differential Diagnosis
Acute enterocolitis: faecal matter/ bile is always present.

--- Content provided by FirstRanker.com ---

Henoch-schoenlein purpura.
Rectal prolapse: projecting mucosa can be felt in

continuity with perianal skin

--- Content provided by⁠ FirstRanker.com ---

TREATMENT

Theraputic Ba-enema : -in infants.
- unlikely to succeed in lead points.
- contrindications: peritonism, prolonged

--- Content provided by FirstRanker.com ---

history (> 48 hrs.).

Operative
After resuscitation ;Laparotmy with reduction.
Cope's method.

--- Content provided by​ FirstRanker.com ---

Irreducible/ gangrenous intussusception: excision of

mass & anastomosis.

Volvulus of the Colon

--- Content provided by‌ FirstRanker.com ---

Sigmoid most commonly involved
180? or > counterclockwise twist
Cecal volvulus next most common
Transverse colon volvulus is rare 4% of colonic

--- Content provided by⁠ FirstRanker.com ---

volvulus

Splenic flexure volvulus VERY rare
Sigmoid Volvulus

--- Content provided by FirstRanker.com ---

Predisposing Factors
Long and highly-mobile sigmoid
Lengthy mesosigmoid, Narrow at its base
Adhesions between proximal sigmoid and

--- Content provided by⁠ FirstRanker.com ---

rectosigmoid with long loop of colon in between

Chronic constipation and high-fiber diet

--- Content provided by‌ FirstRanker.com ---

Sigmoid Volvulus - Pathogenesis

Closed-loop type obstruction
Proximal colon dilates- Extent depends on ileocecal

--- Content provided by‍ FirstRanker.com ---

valve competence

Simple or Strangulated
Venous then arterial obstruction
With simple form takes a few days for vascular

--- Content provided by‍ FirstRanker.com ---

compromise to develop

In acute fulminating variant much more rapid

--- Content provided by‌ FirstRanker.com ---

course seen
Sigmoid Volvulus - Varieties

Acute Fulminating Type- Mortality 37-80% ,

--- Content provided by FirstRanker.com ---

Younger patient, sudden onset, rapid course Early

vomiting, severe pain, peritonitis, and gangrene

Minimal distension often, hard to diagnose

--- Content provided by FirstRanker.com ---

Subacute Progressive Type- Generally older pt.,

more gradual onset, Hx prior attacks, chronic

--- Content provided by​ FirstRanker.com ---

constipation, Abdominal distension often extreme

Late vomiting, pain is minimal, no peritonitis

Sigmoid Volvulus - Diagnosis

--- Content provided by​ FirstRanker.com ---

Plain films of Abdomen-- Massively dilated and

distended bowel loop

--- Content provided by​ FirstRanker.com ---

Both ends in pelvis,
Bow of loop cephalad
"Bent inner tube" sign
Air/fluid level within loop
Proximal colon & SB may be dilated

--- Content provided by⁠ FirstRanker.com ---

Barium enema-- "Birds beak"
Sigmoid Volvulus - Treatment

Rigid sigmoidoscopic detorsion--decompression,

--- Content provided by FirstRanker.com ---

& placement of rectal tube

RT inserted past obstruction point
Successful 77 - 90% of time
Mortality rate 1.2 - 5.5%

--- Content provided by FirstRanker.com ---

Preferred initial treatment
Colonoscopic decompression
Surgery if:
Decompression not successful
Ischemic or necrotic bowel encountered

--- Content provided by FirstRanker.com ---

Sigmoid Volvulus ? Surgical

Treatment

--- Content provided by​ FirstRanker.com ---

Recurrence rate is high (33 - 60%)
Some advise elective op after 1st episode
Elective: Resection of redundant colon Small

transverse LLQ incision

--- Content provided by‌ FirstRanker.com ---

Sigmoid fixation another option
Emergent: Resection +/- stoma
Ogilvie's Syndrome

--- Content provided by⁠ FirstRanker.com ---

Acute Colonic Pseudo obstruction
Massive dilation of cecum, right, and transverse colon

(non-mechanical), to splenic flexure

--- Content provided by​ FirstRanker.com ---

Dilated SB loops in > 50%
Symptoms: Distension,Nausea and vomiting,

Abdominal pain in 80% ,Bowel sounds may be normal

--- Content provided by⁠ FirstRanker.com ---

or increased

Conditions associated with

Ogilvie's syndrome

--- Content provided by FirstRanker.com ---

Non-operative Trauma
Non-GI surgery (Gyn, Ortho, Cardiac)
Pancreatitis, Cholecystitis
Diabetes, Malignancy

--- Content provided by⁠ FirstRanker.com ---

Narcotics, antidepressants, anticholinergics
Neurologic or Respiratory disease
Electrolyte (hypo K+, Ca+2), Acid / Base disorder
Radiation in past
Ogilvie's Syndrome: DDx and Dx

--- Content provided by FirstRanker.com ---

Plain abdominal films to diagnose and follow cecal

diameter (Q12-24 hrs)

--- Content provided by FirstRanker.com ---

Normal is < 9 cm
If 14 cm - perforation in 23% ?
Differential Includes: Fecal impaction, Cecal or

Sigmoid Volvulus, IschemicBowel,Mechanical

--- Content provided by FirstRanker.com ---

Obstruction

Ogilvie's Treatment :

--- Content provided by‌ FirstRanker.com ---

Correct electrolyte problems and underlying

condition

D/C narcotics and anticholinergics

--- Content provided by FirstRanker.com ---

NPO with NGT, +/- Rectal Tube
Colonoscopic decompression difficult but often

successful, May need 2nd decompression

--- Content provided by​ FirstRanker.com ---

Long colonic drains can be placed via colonoscope

(old)

Neostygmine is the treatment of choice now

--- Content provided by​ FirstRanker.com ---

If signs of perforation then OR
STRANGULATION

The viability of the bowel is threatened.
Causes of strangulation

--- Content provided by⁠ FirstRanker.com ---

External
Hernial orifices
Adhesions/bands
Interrupted blood flow
Volvulus

--- Content provided by FirstRanker.com ---

Intussusception
Increased intraluminal pressure
Closed-loop obstruction
Primary
Mesenteric infarction

--- Content provided by​ FirstRanker.com ---

The venous return is compromised before the arterial

supply.

--- Content provided by FirstRanker.com ---

The resultant increase in capillary pressure leads to local

mural distension with loss of intravascular fluid and red

blood cells intramurally and extraluminally.

--- Content provided by FirstRanker.com ---

Once the arterial supply is impaired, haemorrhagic

infarction occurs.

--- Content provided by‍ FirstRanker.com ---

As the viability of the bowel is compromised there is

marked translocation and systemic exposure to anaerobic

organisms with their associated toxins.

--- Content provided by FirstRanker.com ---

The morbidity of intraperitoneal strangulation is far

greater than with an external hernia?
Closed-loop obstruction

--- Content provided by‌ FirstRanker.com ---

This occurs when the bowel is obstructed at both the

proximal and distal points.

--- Content provided by‌ FirstRanker.com ---

There is no early distension of the proximal intestine.
A classic form of closed-loop obstruction is seen in the

presence of a malignant stricture of the right colon with a

--- Content provided by‍ FirstRanker.com ---

competent ileocaecal valve

The inability of the distended colon to decompress itself

into the small bowel results in an increase in luminal

--- Content provided by⁠ FirstRanker.com ---

pressure, which is greatest at the caecum, with subsequent

impairment of blood supply.

--- Content provided by‌ FirstRanker.com ---

Unrelieved, this results in necrosis and perforation.