Download MBBS (Bachelor of Medicine and Bachelor of Surgery) Intestinal Obstruction PowerPoint PPT presentation
INTESTINAL
OBSTRUCTION
S4 UNIT
? It is the partial or complete blockage of the
bowel that prevents contents of the intestine
from passing through.
? It is an important cause of acute abdomen
accounting upto 5% of emergency admission
to surgical services.
? Morbidity and mortality are particularly high
in patients who are managed incorrectly or in
whom the diagnosis is delayed.
? Aswin. R- Classification and pathophysiology
? Athira CP-Special types of intestinal obstruction
? Athira S Thampi-Clinical features of intestinal
obstruction
? Bhagyalakshmi U-Volvulus and Adynamic
obstruction
? Aysha Tamanna-Imaging
? Ahal ya B.S-Treatment of acute intestinal
obstruction
? Balasree V.S-Treatment of acute large bowel
obstruction
? Beyona Susan Benny-Chronic large bowel
obstruction
CLASSIFICATION
ASWIN R
Roll No:34
I:Aetiopathological Classification
1)Dynamic- mechanical obstruction.
v Acute
v Chronic
2) Adynamic- paralytic ileus or pseudo-obstruction
Causes of intestinal obstruction
Dynamic Adynamic
1 Intraluminal Paralytic ileus
? Faecal impaction Pseudo-obstruction
? Foreign bodies / Bezoars
? Gallstones
2 Intramural
? Stricture
? Malignancy
? Intussusception
? Volvulus
3 Extramural
? Bands/adhesions
? Hernia
I : Depending on Site of
Obstruction
Proximal smal
Distal smal
Large bowel
bowel
bowel
Site of
Duodenum and
Ileum
Anywhere in large
obstruction
jejunum
intestine
Causes:
? Congenital
? Tuberculosis
? Malignancy
? Lipomas
strictures
? Tuberculosis
? Leiomyomas
? Malignancy
stricture
? Bands
? Gal stones
? Anorectal
? Adhesions
? Hernias--
malformation
common
? Volvulus
cause
? Congenital
? Roundworm
megacolon
? Diverticulitis
Classification I I
Congenital Acquired
Anorectal
Hernia (commonest)
malformations
Roundworm
Congenital megacolon Gallstones
Duodenal atresia
Tuberculosis
Malignancy
PATHOPHYSIOLOGY
Dynamic obstruction
Changes proximal to the bowel
obstruction
Intestinal obstruction
Increased peristalsis
Becomes vigorous &
retrograde peristalsis
Obstruction not relieved
Peristalsis ceases
Flaccid, paralysed, dilated bowel
Distension is caused by two factors:
1) Gas:
vaerobic and anaerobic organisms
vnitrogen and hydrogen sulphide.
2) Fluid:
vdigestive juices (saliva 500 mL, bile 500 mL,
pancreatic secretions 500 mL, gastric secretions 1
litre ? all per 24 hours).
vaccumulates in the gut lumen
Changes at the site of obstruction in
closed loop obstruction:
Initial y venous return is impaired
Congestion, oedema of bowel wal occurs
which turns purple.
Later this jeopardizes the arterial supply.
Loss of shineness, blackish discolouration,
loss of peristalsis.
Gangrene.
Perforation occurs.
Peritonitis.
Bowel distal to the obstruction
? is inactive and collapsed
\
Dehydration and electrolyte loss are due to:
? reduced oral intake
? defective intestinal absorption
? losses as a result of vomiting
? sequestration in the bowel lumen
? transudation of fluid into the peritoneal cavity
STRANGULATION
STRANGULATION
vWhen strangulation occurs, the
blood supply is compromised
and the bowel becomes
ischaemic.
vIntestinal obstruction not
immediately life-threatening
unless there is superimposed
strangulation.
Causes of strangulation
Direct pressure on the bowel wal
? Hernial orifices
? Adhesions/bands
Interrupted mesenteric blood flow
? Volvulus
? Intussusception
Increased intraluminal pressure
? Closed-loop obstruction
? Distention results in high pressure within the bowel
wall.
? Venous return is compromised. The resultant
increase in capillary pressure leads to impaired local
perfusion
? Once the arterial supply is impaired, haemorrhagic
infarction occurs.
? Systemic exposure to anaerobic organisms and
endotoxin occurs.
? Morbidity and mortality dependent on the duration
of the ischaemia and its extent.
? Elderly patients and those with comorbidities are
more vulnerable.
vIschaemic bowel can cause systemic effects
secondary to sepsis and significant
dehydration.
vWhen bowel involvement is extensive
circulatory failure is common.
Closed-loop obstruction
? Bowel is obstructed at both the
proximal and distal points.
? Distention is principally marked in the
closed loop.
? A classic form of closed-loop
obstruction is seen in malignant
stricture of the colon with a
competent ileocaecal valve.
? It is also seen in Obstructed hernia.
? Increase in luminal pressure, which is greatest at the
caecum, with subsequent impairment of blood flow in
the wall.
? Unrelieved, this results in necrosis and perforation
SPECIAL TYPES OF
MECHANICAL INTESTINAL
OBSTRUCTION
ATHIRA C.P
INTERNAL HERNIA
Rare entity
? When a portion of small intestine become trapped in one of the
congenital mesenteric defect or in retroperitoneal fossae
? the foramen of winslow -- duodenal retroperitoneal fossae
? a defect in mesentery -- caecal/appendicular retroperitoneal
? a defect in transeverse colon fossae
? defect in broad ligament -- intersigmoid fossae
? congenital or acquired diaphragmatic hernia
? Usually associated with adhesion.
? Treatement - divide the adhesion or release
constriction
ENTERIC STRICTURES
1. BENIGN - TB or crohn's dIsease
2. MALIGNANT ? lymphoma/carcinoma , sarcoma (GIST) ; (rare)
? Clinical presentation - subacute or chronic.
? Treatement - Resection & anastomosis
Strictureplasty(crohn's d/s)
BOLUS OBSTRUCTION
1. gall stones
2. food
3. bezoar
4. worms
GALLSTONE ILEUS
? Erosion of a large gallstone from gallbladder to duodenum.
? Get impacted at 60 cm proximal to ileocaecal valve.
? Acute or Recurrent
? RIGLER'S TRIAD
? Treatment- either crushing the stone or enterotomy from
outside
FOOD
After total or partial gastrectomy-unchewed articles can pass
directly into small bowel.
BEZOAR
? Firm masses of undigested hair ball & fruit/vegetable fibre.
? Predisposition
high fibre intake
inadequate chewing
previous gastric surgery
hypochlorhydria
loss of gastric pump mechanism.
? Preoperative dx difficult
? open removal
WORMS
ADHESIONS
? Commonest cause
? Causes ?
Foreign material - talc /starch(glove powder), gauze, silk
Infection - peritonitis , TB
Inflammatory - crohn's d/s
Radiation enteritis
? How to prevent
v good surgical technique
meticulous surgery
avoid bleeding
using laproscopy ie,minimally invasive technique
whenever possible
v peritoneal saline wash to remove clots
v Use of powder free gloves
v minimising contact with gauze
v covering anastomoses &raw peritoneal surface.
? LAPROSCOPIC SURGERY
contact of peritoneal cavity & foreign material is
avoided
BANDS
ACUTE INTUSSUSCEPTION
Intussucipiens
Apex
Intussusceptum
? Telescoping of one bowel to neighbouring bowel.
? Types ? Antegrade(most common)
Retrograde(jejunogastric ? post GJ)
? Children ? most common, weaning period
Hyperplasia of payer's patches in the terminal ileum
? Adults- intraluminal mass,lipoma,polyp
carcinoma, meckel's diverticulum
? Commonest sites
Children- ileocolic
Adults ?colocolic
? Classical radiological sign- CLAW SIGN (Barium enema)
? Treatement- saline reduction using ultrasound(children)
or
surgical reduction(adults or failed saline
reduction in children)
VOLVULUS
? Twisting or axial rotation of a portion of bowel about its
mesentery.
? Types ? sigmoid (most common)
caecal(rare)
compound(extremely rare)
volvulus neonatorum
SIGMOID VOLVULUS
CAECAL VOLVULUS
? Second common site
? Commonest cause of large bowel obstruction in pregnancy
? Caecum markedly distended & found in centre of abdomen
(lack of fixation- mobile caecum)
? X ray-round gas shadow in Rt iliac region
? Treatment ? resection & anastomosis
COMPOUND VOLVULUS
? Also known as ileosigmoidal knotting
? Long pelvic mesocolon allows ileum to twist around sigmoid
colon,resulting in gangrene of either or both segments of
bowel
? Presentation- a/c intestinal obstruction ,distension is mild
? Plain radiography- distended ileal loops in distended sigmoid
colon
? Treatment ? resection & anastomosis
CLINICAL FEATURES OF
INTESTINAL OBSTRUCTION
ATHIRA. S. THAMPI
DYNAMIC OBSTRUCTION
4 CARDINAL FEATURES :
? Abdominal pain
? Distension
? Vomiting
? Absolute constipation
CLINICAL CLASSIFICATION
nSmall bowel obstruction
nLarge bowel obstruction
nComplete
nIncomplete
nSimple
nStrangulation
1.Smal bowel obstruction
2.Large bowel obstruction
i) High :
? Distension
pronounced(flanks)
? Vomiting occurs early
? Pain less severe
? Distension is minimal.
? Vomiting and dehydration
? Little evidence of dilated small
later features
bowel loops on radiography.
? Colon proximal to obstruction-
distended on radiography.
ii) Low :
? Pain predominant with central
distension.
? Vomiting delayed.
? Multiple dilated small bowel
loops seen on radiography.
1)Complete:
? Small bowel obstruction - all cardinal
features.
? Large bowel obstruction- delayed
presentation of symptoms.
2)Incomplete [partial or subacute]:
? Symptoms are mild and intermittent.
1)Simple:
Blood supply intact
2)Strangulation:
Interference to blood flow
[Closed loop obstruction]
Clinical features vary according to:
? Location of obstruction:proximal & distal
? Duration of obstruction:acute & chronic
? Underlying pathology
? Presence or absence of intestinal ischemia
PAIN
? Sudden and severe.
? Colicky
? Centered on umbilicus
(mid gut) or lower abdomen(hind gut).
? Severe(continuous)pain- presence of
strangulation
VOMITING
? If proximal: occurs earlier;
If distal: occurs late
proximal duodenal obstruction : stomach contents
? Contents: smal bowel obstruction : bilious
colonic obstruction : faeculent
? As obstruction progresses: digested food to
faeculent material.
DISTENSION
? Small bowel obstruction:central
distension;more pronounced in distal
ileal obstruction.
? Colonic obstruction:distension is an early
feature;occur in flanks.
? Visible peristalsis- demonstrated by flicking
the abdominal wall.
[Step Ladder pattern]
Visible peristalsis-
Step ladder pattern
CONSTIPATION
? Absolute:Neither faeces nor flatus is passed.
Relative:Only flatus is passed.
? Absolute constipation-cardinal feature of
complete intestinal obstruction
? Small bowel:late feature
Large bowel:early feature
? Administration of enemas should be avoided
in cases of suspected obstruction.
Absolute constipation may not be present in:
lRichter's hernia
l mesenteric vascular occlusion
l all cases of partial obstruction (in which
diarrhoea may occur)
Other manifestations
1)Dehydration:
? Common feature
? Results from:
i. Vomiting
ii. Sequestration of fluid within bowel & peritoneal cavity
iii. Decreased intake
2) Hypokalaemia:
? Not a common feature
? Increase in serum potassium may be associated with the
presence of strangulation.
3)Fever:
Indicate:
onset of ischaemia
intestinal perforation
inflammation or abscess associated with the
obstructing disease.
Hypothermia:septic shock
4)Abdominal tenderness
? Localised tenderness: impending or
established ischaemia.
? Diffused tenderness: peritonitis(infarction or
perforation).
5)Bowel sounds
? Mechanical obstruction:High pitched & high
frequency(small bowel).
? Paralytic ileus :Non propulsive tinkling
sounds like bells at evening pealing
? Bowel sounds may be scanty or absent, if
obstruction is longstanding and if small
bowel has become inactive.
CLINICAL FEATURES
nStrangulation
nIntussusception
CLINICAL FEATURES OF
STRANGULATION
Case of surgical emergency.
Diagnosis is almost entirely clinical.
n Constant,severe pain:Indicate strangulation
n Tenderness with rigidity:Indicate need for early
laparotomy
n Shock:Indicate underlying ischaemia
n Things to be noted:
? Patient appears listless.
? Suspect strangulation if pain persist
despite conservative management.
? Suspect strangulation in a hernia if lump
is:
i. Tense
ii. Tender
iii. Irreducible
iv. No expansile cough impulse
v. Skin blebs
CLINICAL FEATURES OF INTUSSUSCEPTION
Episodes of screaming and drawing up of
legs in a previously wel male infant.The
attacks last for few minutes and recur
repeatedly.
During attacks the child appears pale;
between episodes he may be listless.
Vomiting becomes conspicuous and bile-
stained.
Stool is mixed with blood and mucus-
redcurrant jel y stool.
Redcurrant jelly stool
n Examination:
? A lump that hardens on palpation seen in
60%of cases.
? Feeling of emptiness in the right iliac fossa-sign
of Dance.
? On rectal examination, blood-stained mucus
found on the finger.
? In extensive ileocolic or colocolic
intussusception, the apex may be palpable or
may protrude from the anus.
Intussusception protruding from anus
If unrelieved, progressive dehydration and
abdominal distension wil occur, fol owed by
peritonitis secondary to gangrene.
? Differential diagnosis
? Acute gastroenteritis
? Henoch?Sch?nlein purpura
? Rectal prolapse
V
O
L
V
U
L
BHAGYALEKSMI. U
U
S
Volvulus
? Twisting or axial rotation of a portion of bowel about
its mesentery .
? May involve the smal intestine,caecum or sigmoid
colon.
? >180? torsion- obstruction of lumen.
? >360?torsion-vascular occlusion of mesentery---
>thrombosis--->ischemia.
? Bacterial fermentation distention
Increased intraluminal
pressureimpaired
capillary perfusion
? Neonatal midgut volvulus secondary to midgut
malrotation is life threatening.
? Primary or secondary
? Primary--due to congenital malrotation of the gut,
abnormal mesenteric attachments or congenital
bands.
? Ex: volvulus neonatorum
Caecal volvulus
Sigmoid volvulus
? secondary-- most common
Due to rotation of segment of bowel
around an acquired adhesion or stoma
VOLVULUS NEONATORUM
? This occurs secondary to intestinal
malrotations.
? Potentially catastrophic.
SIGMOID VOLVULUS
? Rotation-Anticlock wise direction
? Comorbidities - chronic psychotropic drug use
? Prognosis inversely related to duration of
symptoms.
? Predisposing factors.
? and also high residue
diet and constipation.
? Presentation can be ,
1.fulminant: sudden onset
Severe pain
Early vomiting
Rapidly deteriorating
2.Indolent: Insidious onset
Slow progressive
Less pain
Late vomiting
? Sigmoid volvulus. (A) Counterclockwise
torsion at base of mesentery. (B) Adhesions
at base of sigmoid mesocolon leading to
formation of fixed omega loop that is
susceptible to repeat torsion.
COMPOUND VOLVULUS
? Ileosigmoid knitting.
? rare condition.
? ileum twist around the Sigmoid colon-->gangrene of
either or both segment of bowel
? Distension is comparatively mild.
? Plain radiography- distended ileal loops in a distended
Sigmoid colon.
Clinical features
Volvulus of smal intestine
? Primary or secondary
? Usually occurs in the lower ileum
? Predisposing factors- consumption of large
amount of vegetables
- secondary to
adhesions
passing to the parietes or female
pelvic organs
Caecal volvulus
? Occurs as part of volvulus neonatorum or
denovo
? clock wise twist
? more common in females in the 4th and 5th
decades
? presents acutely with classic features of
obstruction , ischemic is common
? commonly felt as palpable tympanic swel ing in
the midline or left side of the abdomen.
? Cecal volvulus. (A) Clockwise torsion of
mesentery of cecum, ascending colon, and
terminal ileum. (B) Absence of dorsal
mesenteric attachments of cecum and
proximal ascending colon, leading to lack of
fixation to retroperitoneum.
? The radiograph shows a markedly distended loop of bowel
15-cm in diameter with its axis running from the right lower
quadrant to the mid abdomen. This loop of bowel
represent a twisted cecum with the caput cecum directed
medially (arrows). The haustra within the cecum (C) are
effaced.
Sigmoid volvulus
? Large bowel obstruction.
? Presentation varies in severity and acuteness.
? abdominal distension is an early progressive
sign.
? associated with hiccough and retching.
? absolute constipation.
? in some patients, the grossly distended left
colon is visible through the abdominal wall.
Treatment
Caecal volvulus
? Decompression- needle
? ischemic- need resection
? viable- should be reduced
? Further management-caecopexy(fixation of
caecum to right iliac fossa)
? Caecostomy
? Right Hemicolectomy
? Extent of resection for cecal volvulus is
similar to that in right hemicolectomy for
benign disease.
? Terminal ileum is anastomosed to
transverse colon in reconstruction after
right hemicolectomy.
SIGMOID VOLVULUS
CONSERVATIVE
Flatus tube or
MANAGEMENT
sigmaoidoscope
Gush of air escapes abd.
distension reducesbowel
No response Laprotomy
derotates
Bowel healthy
Bowel gangrenous
Sigmoidopexy or
Patient stable Patient unstable
resection and end to
end anastomosis
resection and
Hartmann's
anastomosis
procdure
Gangrenous
sigmoid
volvulus
ADYNAMIC OBSTRUCTION
Paralytic ileus
? A state in which there is failure of transmission
of peristaltic waves due to neuromuscular
failure.
? It may be localised or generalised
? The resultant stasis leads to accumulation of
fluid and gas with in the bowel,with associated
distension,vomiting,absence of bowel sounds
and absolute constipation.
VARIETIES
? Post operative: usual y self limiting ,with a
variable duration of 24-72 hours.May be
prolonged in the presence of hypoproteinaemia
or metabolic abnormality.
? Infection: Intra abdominal sepsis may give rise
to localised or generalised ileus .
? Reflex ileus: this may occur following fractures
of the spine or ribs ,retroperitonial
haemorrhage or even the application of
plaster jacket.
? Metabolic : uraemia and hypokalaemia are the
most common contributory factors.
Clinical features
History
? No passing flatus and feces.
? vomiting(copious).
? dull abdominal pain.
? Respiratory distress due to pressure over the diaphagm.
? On examination
? Dehydration,tachycardia
? tympanic
? High pitched tinkling note `like bells at evening pealing'
Investigations
? Lab: serum electrolytes,RFT
? X ray abdomen.
? USG abdomen to find out the possible causes
of ileus,eg ;sepsis.
? CT (diagnostic in prolonged cases)
Treatment
? Primary cause must to be treated.
? bowel rest and nasogastric decompression.
? IV fluids
? Electrolyte management
? Catheterisation and urine output mesurement
? Do not stimulate the peristalsis(`don't flog a tired
horse)
? Measurement of abdominal girth is necessary to see
whether patient is recovering or not.
? Most often patient recovers in 3 days
? In prolonged, life threatening paralytic
ileus,laparotomy is done.
PSEUDO OBSTRUCTION
? Colon is usually affected.
? No mechanical cause.
? Associated with a variety of syndromes .
? With underlying neuropahy and or/myopathy
.
Smal intestinal pseudo obstruction
? primary or secondary
? recurrent subacute obstruction.
? Diagnosis: exclusion of a mechanical cause.
? Treatment :initial correction of any underlying
disorder.
? Metoclopramide and erythromycin may be of
use.
Colonic pseudo obstruction
? Acute or a chronic form
? Ogilvie's syndrome :presents as acute large bowel
obstruction and dilation of colon in the absence of any
mechanical obstruction.
? Complication: caecal perforation
? Abdominal radiographs show evidence of colonic
obstruction ,with marked caecal distention .
? Confirmation by colonoscopy or a single contrast water
soluble barium enema or CT.
Treatment
? Treatment of any identifiable cause.
? IV neostigmine (1mg),with a further 1mg given
IV within a few minutes if the first dose is
ineffective.
? ECG monitoring while giving neostigmine ,and
atropine should be available.
? If not effective COLONOSCOPIC
DECOMPRESSION should be performed.
IMAGING
AYSHA TAMANNA
2015 BATCH
Imaging indicates
? location
? degree
? cause of an obstruction
? and assess for the presence of ischemia.
TYPES OF IMAGING
? CONVENTIONAL RADIOGRAPHY
? BARIUM STUDIES
? SONOGRAPHY
? CT
? MRI
CONVENTIONAL RADIOGRAPHY
? Diagnosis is best made on supine films.
? In erect film the air fluid level occurs only late.
? Triad of small bowel obstruction
1.Dilated small bowel loops >3 cm-on a supine view
2.Multiple air fluid level ?on erect view
3.Paucity of air in colon
CHARACTERISTIC FEATURES ON X-RAY
? Jejunum-valvulae conniventes giving a concertina
effect.
? Ileum-featureless
? Large bowel-haustral folds, folds are widely spaced,
folds on the opposite wal do not meet.
? Caecum-rounded gas shadow in the right iliac fossa.
? Pneumobilia(gas in biliary tree)due to gal -stone ileus.
JEJUNUM-valvulae conniventes
ILEUM-Featureless
LARGE BOWEL-Haustral folds
CAECUM-Gas shadow in the right ileac
fossa
PNEUMOBILIA-gas in the biliary tree
BARIUM STUDIES
? Limited use in acute setting
? Useful in recurrent and chronic obstruction
SONOGRAPHY
? Limited use in intestinal obstruction( due to
excessive gas that reflects ultra sound waves
? The warning signs of ischaemia
1.ascites
2.bowel wall thickness of more than 4mm
3.absence of peristalsis
ROLE OF CT
? Use triple contrast(IV ,oral,rectal)
? Can detect pathology in the
i. Bowel wall
ii. Mesentery
iii. Peritoneum
? It can
i. Localise the obstruction
ii. Detect ischemia
a. Reduced vascularity to bowel wall
b. Free fluid
i. Some times the etiology(volvulus,hernia,bowel mass
ROLE OF MRI
? MRI is a useful adjunct in obstetric setting
Imaging in INTUSSUSCEPTION
? Plain abdominal X-ray- absent caecal gas
shadow in ileocaecal cases.
? Barium enema-claw sign(ileocaecal;does not
demonstrate small bowel intussusception)
? Ultrasound-typical doughnut appearance of
concentric rings in transverse section.
? CT-'target sign-sausage shaped soft-tissue
mass with a layering effect(mesenteric vessels
within the bowel lumen)
Claw sign
Target sign
Sonography
Imaging in VOLVULUS
? SIGMOID VOLVULUS
? CAECAL VOLVULUS
? VOLVULUS NEONATORUM
Sigmoid Volvulus
? Bird beak sign
? Pneumatic
tyre
? Omega sign
Caecal Volvulus
? Plain X-ray-
1. caecal dilatation
2. Proximal small bowel dilatation
3. Collapsed distal colon
? Barium enema-absence of barium in the
caecum
? CT-when diagnosis is in doubt
Volvulus Neonatorum
? X-ray-initially shows duodenal obstruction,
when strangulation has occurred abdomen
becomes gasless
? Occasionally shows double bubble sign
Double bubble sign
TREATMENT OF ACUTE
INTESTINAL OBSTRUCTION B.S AHALLYA
Rol no: 38
GENERAL TREATMENT
PRINCIPLES
? EVALUATE FOR STANGULATION
? Hippocritic facies-in advanced strangulation
? Tachycardia/hypotension
? Localised/generalised abdominal tenderness
? Check for organ failure
? Respiratory failure-tachypnoea
? Renal failure-oliguria
INITIAL MANAGEMENT
? BOWEL REST- NIL PER ORAL
? DECOMPRESSION- continuous ryles tube aspiration
? CORRECT DEHYDRATION- IV fluids
? CORRECT ELECTROLYTE IMBALANCE
? IV ANTIBIOTICS, if strangulation is suspected
DEFENITIVE MANAGEMENT
? CONSERVATIVE MANAGEMENT- if
post-operative adhesions are
suspected.
? DEFENITIVE MANAGEMENT? if cause
is unlikely to be adhesions.
ADHESIONS
TREATMENT OF ADHESIONS
? Conservative management- for upto maximum
48hrs
Strangulation sets in early
? Laprotomy if
Obstruction not relieved by 48hrs
? Laprotomy preferred over laproscopy
1. Grossly distended bowel
Inadvertant
2. Possible adhesions to anterior abdominal wal
bowel injury
? However experienced laroscopic ssurgeons
might attempt laproscopy
LAPROSCOPIC
ADHESIOLYSIS
INTUSSUSCEPTION
NPO,IV fluids,
antibiotics,
No signs of
nasogastric
perfo.,
drainage
peritonitis
Saline
C/I: perforation,
enema-
Failure or
peritonitis
USG
contraindic
guidance
ated
Surgery
SURGERY COPE'S
? Transverse rt.sided abdominal incision METHOD
? Reduction- gentle compression over the most
distal part of intussusception towards its
origin..do not pul
? After reduction-->appendix and terminal ileum
would appear oedematous and bruised.-->check
viability-->
? Appendicectomy
? Irreducible/infarcted segment-->resection and
anastomoses
INTESTINAL
ATRESIA
DUODENAL ATRESIA
Treatment-->Duodeno
duodonostomy+correction of
associated malformations, if any.
ILEAL
ATRESIA
TREATMENT
Resection and primary end-to-end
anastomosis.
M
E
C
O
N I
I L
U E
M US
Meconium ileus
? Conservative measures- trying to dissolve the inspissated
meconium using Breaks the disulphide
N-Acetyl Cysteine. bonds in meconium
and helps in retrieval
? If it doesn't work, or
SURGERY
? Evidence of peritonitis, or
MAYBE
REQUIRED
? Child is too sick
EXTREMELY SICK
LESS RISK OF LEAKAGE
TREATMENT OF ACUTE LARGE
BOWEL OBSTRUCTION
BALASREE V S
ROLL NO: 39
? Large bowel obstruction is
commonly caused by carcinoma.
? Other causes include:
Caecal / sigmoid volvulus
Diverticular disease
Bands / adhesions
? Pseudo-obstruction to be
excluded by a contrast CT when
in doubt.
Diagnosis
History
? Constipation for 10 - 14 days.
? Dull ache in the abdomen.
? Peripheral distension (distension of flanks).
? Past history of bleeding or passing mucus PR /
altered bowel habits.
? Vomiting >>>>>>> late feature
faeculent
? Strangulation / perforation >>severe abdominal pain
patient may col apse
General Appearance
? Strangulation / perforation :
patient presents in an unstable condition
? Hippocratic facies
? Tachycardia >>>> Hypotension
? Hyper/ Hypothermia
?
SIRS
Tachypnoea
? Leucocytosis / Leucocytopenia
Abdomen
? Distension
(especially of flanks)
? Rigidity and tenderness
(strangulation /
perforation)
Per Rectal Examination
? Empty ballooned up rectum
? Finger may be stained with blood or malenic
stool
? Rectal carcinoma may be palpable
Investigations
? Plain X-Ray Abdomen
? dilated large bowel
loops
? giant caecum ( >9 cm ),
if Ileocaecal valve
is competent
? CT with contrast:
? If patient is stable
? Can detect etiology
Investigations....
? CBC , LFT
? Ultrasound Scan
? CEA (carcinoembryonic antigen).
? FNAC of left supraclavicular lymph node (if palpable).
? Barium enema / Colonoscopy:
? Not preferred in an emergency setting
? Risk of barium peritonitis
? Cumbersome to perform
Carcinoembryonic antigen
? Associated with colorectal cancers
? Non specificincrease significantly in :
? Pancreatic carcinoma
? Gastric carcinoma
? Lung carcinoma
? Breast carcinomas
? Nonmalignant conditions:
Pancreatitis
Hepatitis
Obstructive jaundice
BPH
Treatment
? Emergency resuscitation
? I.V fluids
? Correction of electrolytes
? Optimization of co- morbid states
? Midline laparotomy
? Confirm diagnosis
? Caecal distension
? Identification of a collapsed distal segment
? Palpate the obstructing tumor
Procedure
? 3 surgical options:
? Resection and anastomosis >>>> if the patient is stable
? Resection and diversion >>>>>>> in presence of adverse factors
? Simple diversion >>>>>>>> unstable patient
Resection and anastomosis
Removable lesion in the
caecum, ascending colon,
emergency right
hepatic flexure or
hemicolectomy
proximal transverse colon
Transverse colon growth
? An extended right hemicolectomy
Line of
resection
Terminal 6 cm
ileum
? Alternatively, in mid-transverse colon growth,
transverse colon with both flexures can be
removed
? Anastomosing cut ends of ascending and
descending colon-- colocolic
anastomosis
Extended right
Obstructing lesions at
hemicolectomy with
the splenic flexure
ileodescending colonic
anastomosis.
Resection and diversion
Colostomy
? It is an artificial opening made in the colon to the exterior
(skin) to divert faeces and flatus.
? Types
? Loop colostomy
? End colostomy
? Double barrel ed colostomy
HARTMANN'S
Hartmann's procedure
OPERATION
APR
APR
Hartmann's procedure :
resection
exteriorization of proximal
segment
closure of distal segment
Simple diversion
? Unstable patient
(hypotension >>>>>> faecal peritonitis)
? Inexperienced surgeon
? Advanced disease
Loop colostomy without resection
Ileotransverse anastomosis
Non surgical procedures
Stenting:
? Optimal conditions
? Accessible location
? Short segment narrowing
? Availability of expertise
? Bridge to subsequent resection and
anastomosis
Complications of colostomy
? Prolapse of mucosa (prolapse of distal loop
mucosa is common)-- commonest complication
? Retraction
? Necrosis
? Stenosis
? Herniation
? Bleeding
? Diarrhoea
? Enteritis
? Skin excoriation
Chronic Large Bowel Obstruction
CAUSES:
ORGANIC
q Intraluminal(rare)-faecal impaction
q Intrinsic intramural-1.Carcinoma
2.Ulcerative colitis(toxic megacolon)
3.Crohn's disease(stricture)
4.Anastamotic strictures
5.Diverticulitis
6.Ischaemic colitis
q Extrinsic intramural(rare) ?metastatic deposits(ovarian),
endometriosis,
stomal stenosis.
FUNCTIONAL
Hirschsprung's ds,
idiopathic megacolon,
pseudo-obstruction.
SYMPTOMS(chronological order)
? CONSTIPATION
? ABDOMINAL DISTENTION(flanks)
? PAIN(dull acheing)
? VOMITING(late,faeculant)
? DEHYDRATION
CARCINOMA COLON/RECTUM
? Usually affects the elderly
? Rarely in younger individuals(familial syndromes like
FAP,HNPCC,or IBD)
? CLINICAL FEATURES:
v Constipation
v Constipation alternating with diarrhoea,
v With/without passage of blood/mucus
v Loss of weight ,loss of apetite
v Progressive constipation over 1-2 weeks ,
v Massive distention of flanks,
v Dull ache in abdomen,
v Finally faeculant vomiting.
DIAGNOSIS
? Per rectal examination(Ca rectum)
? Plain X-ray abdomen showing haustral folds
? CT scan-
thickened large bowel,
proximal dilatation,
with/without ascites or liver mets.
? Barium enema-Apple core Carcinoma colon
TREATMENT
v If patient is stable
LAPOROTOMY
RESSECTION OF TUMOUR
END TO END ANASTAMOSIS
v If patient is unstable
RESUSCITATE THE PATIENT,
EMERGENCY COLOSTOMY
HARTMAN'
S
PROCEDURE(resect
SIMPLE LOOP
ion of tumour and
COLOSTOMY
end ileostomy)
STRICTURES-
CROHN'S DISEASE
? Chronic ,transmural,noncaseating often
granulomatous disease involving
any area of GIT .
? CAUSES: 1. infection
2.immunologic
3.genetic
4.Jews
5.smoking,diet,OCP
.
CLINICAL FEATURES
FIRST STAGE
SECOND
THIRD STAGE
Mild dairrhoea
STAGE
Colicky pain
Fistula formation
Anaemia
A/c or C/c
-enterocolic,
Mass in R iliac
intestinal
enteroenteric,
fossa
obstruction
enterovesical,
Recurrent
due to
enterocutaneous
perianal abscess
cicatrisation
with narrowing
INVESTIGATIONS....
1.Plain x-ray abdomen,Ultrasound abdomen
2.Single contrast water soluble enema
3.CT scan and CT fistulogram
4.Colonoscopy >>>normal rectum,
colon showing aphthoid like ulcers ,
reddened mucosal margin.
6.Serum markers-90% patients with ASCA ?positive
and pANCA-negative.
TREATMENT
? MEDICAL
Lifestyle modifications:Cessation of smoking
Bed rest,
Protein and vitamin
supplementation.
Drug therapy
Anti-inflamatory:Steroids,Amino salicylates
Immuonsuppresors:Azathioprine,Infliximab,Methotrexate
Antibiotics: Ciplox,Metrogel(abscess,fistula)
SURGERY
Stricturoplasty
Segmental resection (conservative resection is better)
Ileocaecal resection(common procedure done bcaz
commonly involved site)
Total colectomy and ileorectal anastomosis
Laparoscopic resection
ISCHAEMIC COLITIS
? Occurs in splenic flexure(Griffith's point)where
blood supply is precarious.
? Common in elderly with a female preponderance.
? Related to atherosclerosis,emboli,vasculitis,diabetes etc
TYPES:
1.Gangrenous type-ischaemia of full thickness colon causing
peritonitis
2.Stricture type-ischaemia of muscularis layer causing
scarring.
3.Transient type-most vulnerable layer,mucosal involvement
usually recovers completely.
CLINICAL FEATURES
o pain in the left iliac fossa and left
hypochondrium
o vomiting
o diarrhoea
o passing blood in the stool
INVESTIGATIONS
vPlain X-ray ---- `thumb printing sign' ---
mucosal edema and submucosal
haemorrhage
vCT scan --- colonic wall thickening with
posterior fat shadowing
vIn chronic stage,colonoscopy and contrast
study is a must
TREATMENT
Conservative treatment-bowel rest
fluids
antibiotics
adequate perfusion
Surgery is indicated in :
gangrene
peritonitis
stricture
segmental ischaemia
DIVERTICULAR DISEASE OF COLON
? Aquired herniation of colonic mucosa through circular
muscles at the point where blood vessels penetrate.
? Commonly localized to sigmoid colon .Rectum not
affected.
? Etiology-
diet:low fibre diet
aged female
non vegetarians.
NSAID intake
long standing constipation
CLINICAL FEATURES
DIVERTICULITIS
FISTULA
DIVERTICULOSIS
Pain in L iliac
Ful ness of
fossa,
abdomen,
Bloody stool,
Bloating,
Massive
Commonly
Flatulence,
haemorrhage,
colovesical
Vague discomfort
Fever,
Mass in L iliac
leading to
fossa
pneumaturia.
INVESTIGATIONS
q Barium enema--Saw teeth appearance.
Champagne glass sign(sigmoid diverticula)
q Sigmoidoscopy - not be done in acute
stage.
q CT scan-thickening of muscle layer
abscess
perforation
fistula
q Cytoscopy and colonoscopy -- fistula.
TREATMENT
Lifestyle--high fibre diet,
bulk purgatives
Drugs-Antibiotics
CT guided aspiration or percutaneous drainage
tube>>>abscess
SURGERY
vEMERGENCY PROCEDURES
resection and anastomosis
resection and diversion
simple diversion
vELECTIVE PROCEDURES
Resection of the diseased bowel and closure
of fistula--fistula
HIRSCHSPRUNG'S DISEASE(congenital
megacolon)
Congenital familial condition ,occurring in
newborn due to presence of aganglionic
segment in anorectum.
SYMPTOMS:
o Failure of passing meconium
INVESTIGATIONS
o Plain X-ray
o Ful thickness rectal biopsy(showing aganglionic
segment)
o Barium enema(to identify spastic segment)
TREATMENT
3 stage approach::
1.COLOSTOMY
2.DEFINITIVE PROCEDURES-various procedures are
available
Principle-excision of aganglionic segment and
colo-colic anastomosis between ganglionic segment
to distal rectum
3.REVERSAL OF COLOSTOMY
Thank you
This post was last modified on 12 August 2021