Download MBBS Intestinal Obstruction Lecture PPT

INTESTINAL
OBSTRUCTION
S4 UNIT

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? It is the partial or complete blockage of the

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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.

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? Morbidity and mortality are particularly high
in patients who are managed incorrectly or in
whom the diagnosis is delayed.

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? Aswin. R- Classification and pathophysiology
? Athira CP-Special types of intestinal obstruction

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? Athira S Thampi-Clinical features of intestinal
obstruction
? Bhagyalakshmi U-Volvulus and Adynamic
obstruction
? Aysha Tamanna-Imaging

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? Ahal ya B.S-Treatment of acute intestinal
obstruction
? Balasree V.S-Treatment of acute large bowel
obstruction
? Beyona Susan Benny-Chronic large bowel

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obstruction

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CLASSIFICATION
ASWIN R
Roll No:34

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I:Aetiopathological Classification
1)Dynamic- mechanical obstruction.
v Acute
v Chronic
2) Adynamic- paralytic ileus or pseudo-obstruction

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Causes of intestinal obstruction
Dynamic Adynamic
1 Intraluminal Paralytic ileus
? Faecal impaction Pseudo-obstruction

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? Foreign bodies / Bezoars
? Gallstones
2 Intramural
? Stricture
? Malignancy

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? Intussusception
? Volvulus
3 Extramural
? Bands/adhesions
? Hernia

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I : Depending on Site of
Obstruction
Proximal smal
Distal smal
Large bowel

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bowel
bowel
Site of
Duodenum and
Ileum

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Anywhere in large
obstruction
jejunum
intestine
Causes:

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? Congenital
? Tuberculosis
? Malignancy
? Lipomas
strictures

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? Tuberculosis
? Leiomyomas
? Malignancy
stricture
? Bands

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? Gal stones
? Anorectal
? Adhesions
? Hernias--
malformation

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common
? Volvulus
cause
? Congenital
? Roundworm

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megacolon
? Diverticulitis

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Classification I I

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Congenital Acquired
Anorectal
Hernia (commonest)
malformations
Roundworm

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Congenital megacolon Gallstones
Duodenal atresia
Tuberculosis
Malignancy

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PATHOPHYSIOLOGY
Dynamic obstruction

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Changes proximal to the bowel
obstruction

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Intestinal obstruction
Increased peristalsis
Becomes vigorous &
retrograde peristalsis
Obstruction not relieved

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Peristalsis ceases
Flaccid, paralysed, dilated bowel

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Distension is caused by two factors:
1) Gas:

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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

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litre ? all per 24 hours).
vaccumulates in the gut lumen

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Changes at the site of obstruction in
closed loop obstruction:

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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,

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loss of peristalsis.
Gangrene.
Perforation occurs.
Peritonitis.

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Bowel distal to the obstruction
? is inactive and collapsed

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Dehydration and electrolyte loss are due to:
? reduced oral intake

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? defective intestinal absorption
? losses as a result of vomiting
? sequestration in the bowel lumen
? transudation of fluid into the peritoneal cavity

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STRANGULATION

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STRANGULATION
vWhen strangulation occurs, the
blood supply is compromised

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and the bowel becomes
ischaemic.
vIntestinal obstruction not
immediately life-threatening
unless there is superimposed

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strangulation.

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Causes of strangulation
Direct pressure on the bowel wal
? Hernial orifices

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? Adhesions/bands
Interrupted mesenteric blood flow
? Volvulus
? Intussusception

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Increased intraluminal pressure
? Closed-loop obstruction

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? Distention results in high pressure within the bowel
wall.
? Venous return is compromised. The resultant

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increase in capillary pressure leads to impaired local
perfusion
? Once the arterial supply is impaired, haemorrhagic
infarction occurs.
? Systemic exposure to anaerobic organisms and

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endotoxin occurs.

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? Morbidity and mortality dependent on the duration
of the ischaemia and its extent.
? Elderly patients and those with comorbidities are

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more vulnerable.

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vIschaemic bowel can cause systemic effects
secondary to sepsis and significant
dehydration.

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vWhen bowel involvement is extensive
circulatory failure is common.

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Closed-loop obstruction
? Bowel is obstructed at both the

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proximal and distal points.
? Distention is principally marked in the
closed loop.

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? A classic form of closed-loop

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obstruction is seen in malignant
stricture of the colon with a
competent ileocaecal valve.
? It is also seen in Obstructed hernia.

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? 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

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SPECIAL TYPES OF

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MECHANICAL INTESTINAL
OBSTRUCTION
ATHIRA C.P

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INTERNAL HERNIA

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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

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? a defect in mesentery -- caecal/appendicular retroperitoneal
? a defect in transeverse colon fossae
? defect in broad ligament -- intersigmoid fossae
? congenital or acquired diaphragmatic hernia

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? Usually associated with adhesion.

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? Treatement - divide the adhesion or release
constriction

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ENTERIC STRICTURES

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1. BENIGN - TB or crohn's dIsease

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2. MALIGNANT ? lymphoma/carcinoma , sarcoma (GIST) ; (rare)
? Clinical presentation - subacute or chronic.
? Treatement - Resection & anastomosis
Strictureplasty(crohn's d/s)

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BOLUS OBSTRUCTION

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1. gall stones
2. food
3. bezoar
4. worms

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GALLSTONE ILEUS

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? Erosion of a large gallstone from gallbladder to duodenum.
? Get impacted at 60 cm proximal to ileocaecal valve.
? Acute or Recurrent
? RIGLER'S TRIAD

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? Treatment- either crushing the stone or enterotomy from
outside

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FOOD
After total or partial gastrectomy-unchewed articles can pass

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directly into small bowel.

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BEZOAR

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? Firm masses of undigested hair ball & fruit/vegetable fibre.
? Predisposition

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high fibre intake
inadequate chewing
previous gastric surgery
hypochlorhydria
loss of gastric pump mechanism.

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? Preoperative dx difficult
? open removal

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WORMS

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ADHESIONS

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? Commonest cause
? Causes ?
Foreign material - talc /starch(glove powder), gauze, silk
Infection - peritonitis , TB
Inflammatory - crohn's d/s

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Radiation enteritis

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? How to prevent
v good surgical technique
meticulous surgery
avoid bleeding

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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

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v covering anastomoses &raw peritoneal surface.

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? LAPROSCOPIC SURGERY
contact of peritoneal cavity & foreign material is
avoided

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BANDS

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ACUTE INTUSSUSCEPTION
Intussucipiens
Apex
Intussusceptum

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? Telescoping of one bowel to neighbouring bowel.

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? 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

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carcinoma, meckel's diverticulum

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? Commonest sites
Children- ileocolic
Adults ?colocolic

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? Classical radiological sign- CLAW SIGN (Barium enema)

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? Treatement- saline reduction using ultrasound(children)
or
surgical reduction(adults or failed saline
reduction in children)

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VOLVULUS

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? Twisting or axial rotation of a portion of bowel about its
mesentery.
? Types ? sigmoid (most common)
caecal(rare)

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compound(extremely rare)
volvulus neonatorum

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SIGMOID VOLVULUS

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CAECAL VOLVULUS

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? Second common site
? Commonest cause of large bowel obstruction in pregnancy
? Caecum markedly distended & found in centre of abdomen

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(lack of fixation- mobile caecum)
? X ray-round gas shadow in Rt iliac region
? Treatment ? resection & anastomosis

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COMPOUND VOLVULUS

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? Also known as ileosigmoidal knotting

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? 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

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? Plain radiography- distended ileal loops in distended sigmoid
colon
? Treatment ? resection & anastomosis

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CLINICAL FEATURES OF
INTESTINAL OBSTRUCTION

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ATHIRA. S. THAMPI

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DYNAMIC OBSTRUCTION
4 CARDINAL FEATURES :
? Abdominal pain

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? Distension
? Vomiting
? Absolute constipation

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CLINICAL CLASSIFICATION
nSmall bowel obstruction

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nLarge bowel obstruction
nComplete
nIncomplete
nSimple
nStrangulation

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1.Smal bowel obstruction
2.Large bowel obstruction
i) High :
? Distension
pronounced(flanks)

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? Vomiting occurs early
? Pain less severe
? Distension is minimal.
? Vomiting and dehydration
? Little evidence of dilated small

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later features
bowel loops on radiography.
? Colon proximal to obstruction-
distended on radiography.
ii) Low :

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? Pain predominant with central
distension.
? Vomiting delayed.
? Multiple dilated small bowel
loops seen on radiography.

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1)Complete:
? Small bowel obstruction - all cardinal
features.
? Large bowel obstruction- delayed
presentation of symptoms.

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2)Incomplete [partial or subacute]:
? Symptoms are mild and intermittent.

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1)Simple:
Blood supply intact
2)Strangulation:

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Interference to blood flow
[Closed loop obstruction]

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Clinical features vary according to:
? Location of obstruction:proximal & distal
? Duration of obstruction:acute & chronic

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? Underlying pathology
? Presence or absence of intestinal ischemia

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PAIN
? Sudden and severe.

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? Colicky
? Centered on umbilicus
(mid gut) or lower abdomen(hind gut).
? Severe(continuous)pain- presence of
strangulation

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VOMITING
? If proximal: occurs earlier;
If distal: occurs late
proximal duodenal obstruction : stomach contents

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? Contents: smal bowel obstruction : bilious
colonic obstruction : faeculent
? As obstruction progresses: digested food to
faeculent material.

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DISTENSION
? Small bowel obstruction:central
distension;more pronounced in distal
ileal obstruction.
? Colonic obstruction:distension is an early

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feature;occur in flanks.
? Visible peristalsis- demonstrated by flicking
the abdominal wall.
[Step Ladder pattern]

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Visible peristalsis-
Step ladder pattern

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CONSTIPATION
? Absolute:Neither faeces nor flatus is passed.

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Relative:Only flatus is passed.
? Absolute constipation-cardinal feature of
complete intestinal obstruction
? Small bowel:late feature
Large bowel:early feature

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? Administration of enemas should be avoided
in cases of suspected obstruction.

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Absolute constipation may not be present in:
lRichter's hernia

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l mesenteric vascular occlusion
l all cases of partial obstruction (in which
diarrhoea may occur)

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Other manifestations
1)Dehydration:

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? Common feature
? Results from:
i. Vomiting
ii. Sequestration of fluid within bowel & peritoneal cavity
iii. Decreased intake

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2) Hypokalaemia:
? Not a common feature
? Increase in serum potassium may be associated with the
presence of strangulation.

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3)Fever:

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Indicate:
onset of ischaemia
intestinal perforation
inflammation or abscess associated with the
obstructing disease.

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Hypothermia:septic shock

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4)Abdominal tenderness
? Localised tenderness: impending or
established ischaemia.
? Diffused tenderness: peritonitis(infarction or

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perforation).

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5)Bowel sounds
? Mechanical obstruction:High pitched & high
frequency(small bowel).
? Paralytic ileus :Non propulsive tinkling

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sounds like bells at evening pealing
? Bowel sounds may be scanty or absent, if
obstruction is longstanding and if small
bowel has become inactive.

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CLINICAL FEATURES

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nStrangulation
nIntussusception

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CLINICAL FEATURES OF
STRANGULATION

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Case of surgical emergency.
Diagnosis is almost entirely clinical.
n Constant,severe pain:Indicate strangulation
n Tenderness with rigidity:Indicate need for early
laparotomy

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n Shock:Indicate underlying ischaemia

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n Things to be noted:
? Patient appears listless.
? Suspect strangulation if pain persist
despite conservative management.

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? Suspect strangulation in a hernia if lump
is:
i. Tense
ii. Tender
iii. Irreducible

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iv. No expansile cough impulse
v. Skin blebs

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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.

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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-

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redcurrant jel y stool.

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Redcurrant jelly stool

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n Examination:
? A lump that hardens on palpation seen in

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60%of cases.
? Feeling of emptiness in the right iliac fossa-sign
of Dance.
? On rectal examination, blood-stained mucus
found on the finger.

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? In extensive ileocolic or colocolic
intussusception, the apex may be palpable or
may protrude from the anus.

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Intussusception protruding from anus

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If unrelieved, progressive dehydration and
abdominal distension wil occur, fol owed by
peritonitis secondary to gangrene.
? Differential diagnosis
? Acute gastroenteritis

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? Henoch?Sch?nlein purpura
? Rectal prolapse

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V
O
L

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V
U
L
BHAGYALEKSMI. U
U

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S

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Volvulus
? Twisting or axial rotation of a portion of bowel about
its mesentery .
? May involve the smal intestine,caecum or sigmoid

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colon.
? >180? torsion- obstruction of lumen.
? >360?torsion-vascular occlusion of mesentery---
>thrombosis--->ischemia.

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? Bacterial fermentation distention
Increased intraluminal
pressureimpaired
capillary perfusion
? Neonatal midgut volvulus secondary to midgut

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malrotation is life threatening.

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? Primary or secondary
? Primary--due to congenital malrotation of the gut,
abnormal mesenteric attachments or congenital
bands.

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? Ex: volvulus neonatorum
Caecal volvulus
Sigmoid volvulus
? secondary-- most common
Due to rotation of segment of bowel

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around an acquired adhesion or stoma

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VOLVULUS NEONATORUM
? This occurs secondary to intestinal
malrotations.

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? Potentially catastrophic.

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SIGMOID VOLVULUS
? Rotation-Anticlock wise direction
? Comorbidities - chronic psychotropic drug use
? Prognosis inversely related to duration of

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symptoms.

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? Predisposing factors.
? and also high residue
diet and constipation.

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? Presentation can be ,
1.fulminant: sudden onset
Severe pain
Early vomiting
Rapidly deteriorating

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2.Indolent: Insidious onset
Slow progressive
Less pain
Late vomiting

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? 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.

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COMPOUND VOLVULUS
? Ileosigmoid knitting.
? rare condition.

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? 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.

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Clinical features

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Volvulus of smal intestine
? Primary or secondary
? Usually occurs in the lower ileum
? Predisposing factors- consumption of large

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amount of vegetables
- secondary to
adhesions
passing to the parietes or female
pelvic organs

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Caecal volvulus
? Occurs as part of volvulus neonatorum or
denovo
? clock wise twist

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? 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

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the midline or left side of the abdomen.

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? Cecal volvulus. (A) Clockwise torsion of
mesentery of cecum, ascending colon, and

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terminal ileum. (B) Absence of dorsal
mesenteric attachments of cecum and
proximal ascending colon, leading to lack of
fixation to retroperitoneum.

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? 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

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medially (arrows). The haustra within the cecum (C) are
effaced.

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Sigmoid volvulus
? Large bowel obstruction.
? Presentation varies in severity and acuteness.

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? abdominal distension is an early progressive
sign.
? associated with hiccough and retching.
? absolute constipation.
? in some patients, the grossly distended left

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colon is visible through the abdominal wall.

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Treatment

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Caecal volvulus
? Decompression- needle
? ischemic- need resection

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? viable- should be reduced
? Further management-caecopexy(fixation of
caecum to right iliac fossa)
? Caecostomy
? Right Hemicolectomy

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? Extent of resection for cecal volvulus is
similar to that in right hemicolectomy for
benign disease.

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? Terminal ileum is anastomosed to
transverse colon in reconstruction after
right hemicolectomy.

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SIGMOID VOLVULUS
CONSERVATIVE
Flatus tube or

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MANAGEMENT
sigmaoidoscope
Gush of air escapes abd.
distension reducesbowel
No response Laprotomy

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derotates
Bowel healthy
Bowel gangrenous
Sigmoidopexy or
Patient stable Patient unstable

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resection and end to
end anastomosis
resection and
Hartmann's
anastomosis

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procdure

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Gangrenous
sigmoid

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volvulus

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ADYNAMIC OBSTRUCTION

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Paralytic ileus
? A state in which there is failure of transmission
of peristaltic waves due to neuromuscular

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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

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and absolute constipation.

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VARIETIES
? Post operative: usual y self limiting ,with a
variable duration of 24-72 hours.May be

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prolonged in the presence of hypoproteinaemia
or metabolic abnormality.
? Infection: Intra abdominal sepsis may give rise
to localised or generalised ileus .

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? Reflex ileus: this may occur following fractures

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of the spine or ribs ,retroperitonial
haemorrhage or even the application of
plaster jacket.
? Metabolic : uraemia and hypokalaemia are the
most common contributory factors.

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Clinical features
History
? No passing flatus and feces.
? vomiting(copious).
? dull abdominal pain.

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? Respiratory distress due to pressure over the diaphagm.
? On examination
? Dehydration,tachycardia
? tympanic
? High pitched tinkling note `like bells at evening pealing'

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Investigations
? Lab: serum electrolytes,RFT
? X ray abdomen.
? USG abdomen to find out the possible causes
of ileus,eg ;sepsis.

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? CT (diagnostic in prolonged cases)

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Treatment
? Primary cause must to be treated.
? bowel rest and nasogastric decompression.
? IV fluids

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? Electrolyte management
? Catheterisation and urine output mesurement

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? Do not stimulate the peristalsis(`don't flog a tired
horse)
? Measurement of abdominal girth is necessary to see

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whether patient is recovering or not.
? Most often patient recovers in 3 days
? In prolonged, life threatening paralytic
ileus,laparotomy is done.

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PSEUDO OBSTRUCTION

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? Colon is usually affected.
? No mechanical cause.
? Associated with a variety of syndromes .
? With underlying neuropahy and or/myopathy
.

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Smal intestinal pseudo obstruction
? primary or secondary
? recurrent subacute obstruction.
? Diagnosis: exclusion of a mechanical cause.

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? Treatment :initial correction of any underlying
disorder.
? Metoclopramide and erythromycin may be of
use.

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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

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mechanical obstruction.
? Complication: caecal perforation
? Abdominal radiographs show evidence of colonic
obstruction ,with marked caecal distention .
? Confirmation by colonoscopy or a single contrast water

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soluble barium enema or CT.

---

---

Treatment
? Treatment of any identifiable cause.
? IV neostigmine (1mg),with a further 1mg given

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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

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DECOMPRESSION should be performed.

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IMAGING
AYSHA TAMANNA
2015 BATCH

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Imaging indicates

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? location
? degree
? cause of an obstruction
? and assess for the presence of ischemia.

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TYPES OF IMAGING

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? CONVENTIONAL RADIOGRAPHY
? BARIUM STUDIES
? SONOGRAPHY
? CT
? MRI

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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

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2.Multiple air fluid level ?on erect view
3.Paucity of air in colon

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CHARACTERISTIC FEATURES ON X-RAY
? Jejunum-valvulae conniventes giving a concertina
effect.

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? 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.

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JEJUNUM-valvulae conniventes

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ILEUM-Featureless

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LARGE BOWEL-Haustral folds

---

CAECUM-Gas shadow in the right ileac
fossa

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PNEUMOBILIA-gas in the biliary tree

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BARIUM STUDIES
? Limited use in acute setting
? Useful in recurrent and chronic obstruction

---

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SONOGRAPHY

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? 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

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3.absence of peristalsis

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ROLE OF CT
? Use triple contrast(IV ,oral,rectal)
? Can detect pathology in the

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i. Bowel wall
ii. Mesentery
iii. Peritoneum
? It can
i. Localise the obstruction

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ii. Detect ischemia
a. Reduced vascularity to bowel wall
b. Free fluid
i. Some times the etiology(volvulus,hernia,bowel mass

---

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ROLE OF MRI

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? MRI is a useful adjunct in obstetric setting

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Imaging in INTUSSUSCEPTION
? Plain abdominal X-ray- absent caecal gas
shadow in ileocaecal cases.
? Barium enema-claw sign(ileocaecal;does not

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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

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within the bowel lumen)

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Claw sign

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Target sign

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Sonography

---

Imaging in VOLVULUS

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? SIGMOID VOLVULUS
? CAECAL VOLVULUS
? VOLVULUS NEONATORUM

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Sigmoid Volvulus
? Bird beak sign

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? Pneumatic
tyre
? Omega sign

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Caecal Volvulus
? Plain X-ray-

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1. caecal dilatation
2. Proximal small bowel dilatation
3. Collapsed distal colon
? Barium enema-absence of barium in the
caecum

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? CT-when diagnosis is in doubt

---

---

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Volvulus Neonatorum
? X-ray-initially shows duodenal obstruction,
when strangulation has occurred abdomen
becomes gasless

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? Occasionally shows double bubble sign

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Double bubble sign

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TREATMENT OF ACUTE
INTESTINAL OBSTRUCTION B.S AHALLYA

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Rol no: 38

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GENERAL TREATMENT
PRINCIPLES
? EVALUATE FOR STANGULATION

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? Hippocritic facies-in advanced strangulation
? Tachycardia/hypotension
? Localised/generalised abdominal tenderness
? Check for organ failure
? Respiratory failure-tachypnoea

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? Renal failure-oliguria

---

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INITIAL MANAGEMENT
? BOWEL REST- NIL PER ORAL
? DECOMPRESSION- continuous ryles tube aspiration

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? CORRECT DEHYDRATION- IV fluids
? CORRECT ELECTROLYTE IMBALANCE
? IV ANTIBIOTICS, if strangulation is suspected

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DEFENITIVE MANAGEMENT
? CONSERVATIVE MANAGEMENT- if

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post-operative adhesions are
suspected.
? DEFENITIVE MANAGEMENT? if cause
is unlikely to be adhesions.

---

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ADHESIONS

---

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TREATMENT OF ADHESIONS
? Conservative management- for upto maximum
48hrs
Strangulation sets in early

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? Laprotomy if
Obstruction not relieved by 48hrs
? Laprotomy preferred over laproscopy
1. Grossly distended bowel
Inadvertant

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2. Possible adhesions to anterior abdominal wal
bowel injury
? However experienced laroscopic ssurgeons
might attempt laproscopy

---

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LAPROSCOPIC
ADHESIOLYSIS

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INTUSSUSCEPTION

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---

NPO,IV fluids,
antibiotics,
No signs of
nasogastric
perfo.,

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drainage
peritonitis
Saline
C/I: perforation,
enema-

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Failure or
peritonitis
USG
contraindic
guidance

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ated
Surgery

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SURGERY COPE'S
? Transverse rt.sided abdominal incision METHOD
? Reduction- gentle compression over the most

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distal part of intussusception towards its
origin..do not pul
? After reduction-->appendix and terminal ileum
would appear oedematous and bruised.-->check
viability-->

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? Appendicectomy
? Irreducible/infarcted segment-->resection and
anastomoses

---

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INTESTINAL
ATRESIA

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DUODENAL ATRESIA
Treatment-->Duodeno

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duodonostomy+correction of
associated malformations, if any.

---

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---

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---

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ILEAL
ATRESIA

---

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TREATMENT
Resection and primary end-to-end
anastomosis.

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M
E

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C
O
N I
I L
U E

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M US

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Meconium ileus
? Conservative measures- trying to dissolve the inspissated
meconium using Breaks the disulphide

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N-Acetyl Cysteine. bonds in meconium
and helps in retrieval
? If it doesn't work, or
SURGERY
? Evidence of peritonitis, or

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MAYBE
REQUIRED
? Child is too sick

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EXTREMELY SICK
LESS RISK OF LEAKAGE

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TREATMENT OF ACUTE LARGE
BOWEL OBSTRUCTION
BALASREE V S
ROLL NO: 39

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---

? Large bowel obstruction is
commonly caused by carcinoma.
? Other causes include:

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Caecal / sigmoid volvulus
Diverticular disease
Bands / adhesions
? Pseudo-obstruction to be
excluded by a contrast CT when

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in doubt.

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Diagnosis
History
? Constipation for 10 - 14 days.
? Dull ache in the abdomen.

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? Peripheral distension (distension of flanks).
? Past history of bleeding or passing mucus PR /
altered bowel habits.
? Vomiting >>>>>>> late feature
faeculent

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? Strangulation / perforation >>severe abdominal pain
patient may col apse

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General Appearance
? Strangulation / perforation :
patient presents in an unstable condition

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? Hippocratic facies
? Tachycardia >>>> Hypotension
? Hyper/ Hypothermia
?
SIRS

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Tachypnoea
? Leucocytosis / Leucocytopenia

---

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Abdomen

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? Distension
(especially of flanks)
? Rigidity and tenderness
(strangulation /
perforation)

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Per Rectal Examination
? Empty ballooned up rectum
? Finger may be stained with blood or malenic
stool
? Rectal carcinoma may be palpable

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Investigations
? Plain X-Ray Abdomen
? dilated large bowel
loops

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? giant caecum ( >9 cm ),
if Ileocaecal valve
is competent
? CT with contrast:
? If patient is stable

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? Can detect etiology

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Investigations....
? CBC , LFT
? Ultrasound Scan
? CEA (carcinoembryonic antigen).

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? FNAC of left supraclavicular lymph node (if palpable).
? Barium enema / Colonoscopy:
? Not preferred in an emergency setting
? Risk of barium peritonitis
? Cumbersome to perform

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Carcinoembryonic antigen
? Associated with colorectal cancers
? Non specificincrease significantly in :
? Pancreatic carcinoma

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? Gastric carcinoma
? Lung carcinoma
? Breast carcinomas
? Nonmalignant conditions:
Pancreatitis

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Hepatitis
Obstructive jaundice
BPH

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Treatment

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? Emergency resuscitation
? I.V fluids
? Correction of electrolytes
? Optimization of co- morbid states
? Midline laparotomy

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? Confirm diagnosis
? Caecal distension
? Identification of a collapsed distal segment
? Palpate the obstructing tumor

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Procedure

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? 3 surgical options:
? Resection and anastomosis >>>> if the patient is stable
? Resection and diversion >>>>>>> in presence of adverse factors
? Simple diversion >>>>>>>> unstable patient

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Resection and anastomosis

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Removable lesion in the
caecum, ascending colon,
emergency right
hepatic flexure or
hemicolectomy

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proximal transverse colon

---

Transverse colon growth
? An extended right hemicolectomy
Line of

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resection
Terminal 6 cm
ileum

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? Alternatively, in mid-transverse colon growth,

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transverse colon with both flexures can be
removed
? Anastomosing cut ends of ascending and
descending colon-- colocolic
anastomosis

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Extended right
Obstructing lesions at
hemicolectomy with

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the splenic flexure
ileodescending colonic
anastomosis.

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Resection and diversion

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Colostomy
? It is an artificial opening made in the colon to the exterior
(skin) to divert faeces and flatus.
? Types

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? Loop colostomy
? End colostomy
? Double barrel ed colostomy

---

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HARTMANN'S

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Hartmann's procedure
OPERATION
APR
APR

---

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Hartmann's procedure :
resection
exteriorization of proximal
segment
closure of distal segment

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---

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Simple diversion

---

? Unstable patient
(hypotension >>>>>> faecal peritonitis)
? Inexperienced surgeon

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? Advanced disease
Loop colostomy without resection
Ileotransverse anastomosis

---

---

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Non surgical procedures
Stenting:
? Optimal conditions
? Accessible location
? Short segment narrowing

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? Availability of expertise
? Bridge to subsequent resection and
anastomosis

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Complications of colostomy
? Prolapse of mucosa (prolapse of distal loop

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mucosa is common)-- commonest complication
? Retraction
? Necrosis
? Stenosis
? Herniation

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? Bleeding
? Diarrhoea
? Enteritis
? Skin excoriation

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Chronic Large Bowel Obstruction

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CAUSES:
ORGANIC
q Intraluminal(rare)-faecal impaction
q Intrinsic intramural-1.Carcinoma
2.Ulcerative colitis(toxic megacolon)

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3.Crohn's disease(stricture)
4.Anastamotic strictures
5.Diverticulitis
6.Ischaemic colitis
q Extrinsic intramural(rare) ?metastatic deposits(ovarian),

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endometriosis,
stomal stenosis.
FUNCTIONAL
Hirschsprung's ds,
idiopathic megacolon,

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pseudo-obstruction.

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SYMPTOMS(chronological order)
? CONSTIPATION
? ABDOMINAL DISTENTION(flanks)
? PAIN(dull acheing)

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? VOMITING(late,faeculant)
? DEHYDRATION

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CARCINOMA COLON/RECTUM
? Usually affects the elderly

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? Rarely in younger individuals(familial syndromes like
FAP,HNPCC,or IBD)
? CLINICAL FEATURES:
v Constipation
v Constipation alternating with diarrhoea,

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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,

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v Finally faeculant vomiting.

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DIAGNOSIS
? Per rectal examination(Ca rectum)

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? Plain X-ray abdomen showing haustral folds
? CT scan-
thickened large bowel,
proximal dilatation,
with/without ascites or liver mets.

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? Barium enema-Apple core Carcinoma colon

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TREATMENT
v If patient is stable
LAPOROTOMY
RESSECTION OF TUMOUR

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END TO END ANASTAMOSIS
v If patient is unstable
RESUSCITATE THE PATIENT,
EMERGENCY COLOSTOMY
HARTMAN'

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S
PROCEDURE(resect
SIMPLE LOOP
ion of tumour and
COLOSTOMY

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end ileostomy)

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STRICTURES-
CROHN'S DISEASE
? Chronic ,transmural,noncaseating often

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granulomatous disease involving
any area of GIT .
? CAUSES: 1. infection
2.immunologic
3.genetic

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4.Jews
5.smoking,diet,OCP
.

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CLINICAL FEATURES
FIRST STAGE

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SECOND
THIRD STAGE
Mild dairrhoea
STAGE
Colicky pain

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Fistula formation
Anaemia
A/c or C/c
-enterocolic,
Mass in R iliac

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intestinal
enteroenteric,
fossa
obstruction
enterovesical,

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Recurrent
due to
enterocutaneous
perianal abscess
cicatrisation

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with narrowing

---

INVESTIGATIONS....
1.Plain x-ray abdomen,Ultrasound abdomen
2.Single contrast water soluble enema
3.CT scan and CT fistulogram

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4.Colonoscopy >>>normal rectum,
colon showing aphthoid like ulcers ,
reddened mucosal margin.
6.Serum markers-90% patients with ASCA ?positive
and pANCA-negative.

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TREATMENT
? MEDICAL
Lifestyle modifications:Cessation of smoking
Bed rest,
Protein and vitamin

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supplementation.
Drug therapy
Anti-inflamatory:Steroids,Amino salicylates
Immuonsuppresors:Azathioprine,Infliximab,Methotrexate
Antibiotics: Ciplox,Metrogel(abscess,fistula)

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SURGERY
Stricturoplasty
Segmental resection (conservative resection is better)
Ileocaecal resection(common procedure done bcaz
commonly involved site)

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Total colectomy and ileorectal anastomosis
Laparoscopic resection

---

ISCHAEMIC COLITIS
? Occurs in splenic flexure(Griffith's point)where

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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

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peritonitis
2.Stricture type-ischaemia of muscularis layer causing
scarring.
3.Transient type-most vulnerable layer,mucosal involvement
usually recovers completely.

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---

CLINICAL FEATURES
o pain in the left iliac fossa and left
hypochondrium
o vomiting
o diarrhoea

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o passing blood in the stool

---

INVESTIGATIONS
vPlain X-ray ---- `thumb printing sign' ---
mucosal edema and submucosal

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haemorrhage
vCT scan --- colonic wall thickening with
posterior fat shadowing
vIn chronic stage,colonoscopy and contrast
study is a must

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---

TREATMENT
Conservative treatment-bowel rest
fluids
antibiotics
adequate perfusion

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Surgery is indicated in :
gangrene
peritonitis
stricture
segmental ischaemia

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---

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

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affected.
? Etiology-
diet:low fibre diet
aged female
non vegetarians.

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NSAID intake
long standing constipation

---

CLINICAL FEATURES
DIVERTICULITIS
FISTULA

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DIVERTICULOSIS
Pain in L iliac
Ful ness of
fossa,
abdomen,

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Bloody stool,
Bloating,
Massive
Commonly
Flatulence,

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haemorrhage,
colovesical
Vague discomfort
Fever,
Mass in L iliac

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leading to
fossa
pneumaturia.

---

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INVESTIGATIONS
q Barium enema--Saw teeth appearance.
Champagne glass sign(sigmoid diverticula)
q Sigmoidoscopy - not be done in acute

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stage.
q CT scan-thickening of muscle layer
abscess
perforation
fistula

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q Cytoscopy and colonoscopy -- fistula.

---

TREATMENT
Lifestyle--high fibre diet,
bulk purgatives
Drugs-Antibiotics

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CT guided aspiration or percutaneous drainage
tube>>>abscess

---

SURGERY
vEMERGENCY PROCEDURES
resection and anastomosis

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resection and diversion
simple diversion
vELECTIVE PROCEDURES
Resection of the diseased bowel and closure
of fistula--fistula

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---

HIRSCHSPRUNG'S DISEASE(congenital
megacolon)
Congenital familial condition ,occurring in
newborn due to presence of aganglionic

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segment in anorectum.
SYMPTOMS:
o Failure of passing meconium
INVESTIGATIONS
o Plain X-ray

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o Ful thickness rectal biopsy(showing aganglionic
segment)
o Barium enema(to identify spastic segment)

---

TREATMENT

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3 stage approach::
1.COLOSTOMY
2.DEFINITIVE PROCEDURES-various procedures are
available
Principle-excision of aganglionic segment and

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colo-colic anastomosis between ganglionic segment
to distal rectum
3.REVERSAL OF COLOSTOMY

---

Thank you

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