BOWEL OBSTRUCTION

S. Hasjim
SMF Bedah
RSI Aisyiyah Malang
GENERAL CONSIDERATION
An acute abdomen case
primary illness
develop as part of another disease process

Type:
Mechanical obstruction (obstruction ileus)
Functional obstruction (paralytic ileus)

GENERAL CONSIDERATION
Mechanical obstruction (obstructive ileus)
occurs physical impediment to the aboral
progress of intestinal contents is present

Functional obstruction (paralytic ileus)
occurs when an underlying disease process
interferes with normal peristalsis
etiology
MECHANICAL OBSTRUCTION
Divided in two type:

Simple obstructions
involving only the bowel lumen and
takes place just one location

Strangulated obstructions
impair blood supply and lead to necrosis of the intestinal wall
the bowel is occluded in two or more locations, close loop
obstruction is created
etiology
MECHANICAL OBSTRUCTION
Divided into two level due to the site of obstruction:

Proximal (high level) obstruction
upper Treitz ligament
involve stomach and duodenum

Distal (low level) obstruction
most common
involve jejunum, ileum and large intestine
etiology
FUNCTIONAL OBSTRUCTION

Metabolic derangements
Neurogenic causes
Drug effects
Peritonitis

SMALL-BOWEL
MECHANICAL OBSTRUCTION
etiology
Adhesion
Develops from previous abdominal surgery
The most common cause of small bowel
obstruction

etiology
Incarceration hernias
External hernias (protruded of the bowel
through the abdominal wall
e.g.: inguinal hernia, femoral hernia)
Internal hernias (protruded of the bowel though
the intra-abdominal foramen, e.g.: obturator
hernia, diaphragm hernia, epiploicum hernia)
Cicatrices hernia (protruded of the bowel through
the defects caused by surgery.
etiology
Neoplasm
Tumors within or extrinsic to the small bowel
may produce obstruction directly or by mass
effect
As the lead point for intussusceptions or
invagination
etiology
Intussusceptions (invagination)
Occurs in which one loop of bowel folds into
another
Most in children but rare in adult
With or without a lesion serving as a lead point

etiology
Volvulus (torsion)
Produced when mobile bowel rotates around
the fixed point
Frequently the consequence of congenital
abnormalities, acquired adhesion or
manipulation to the bowel
Leads to intestinal strangulation
etiology
Volvulus (torsion)
Produced when mobile bowel rotates around the
fixed point
Frequently the consequence of congenital
abnormalities, acquired adhesion or
manipulation to the bowel
Leads to intestinal strangulation

etiology
Congenital anomaly
Hypertrophy pyloro-stenosis (HPS)
Atresia duodeni, pancreas annulare
Atresia jejunum or ileum
Malrotation
etiology
Rare case
gallstone ileus
post traumatic hematoma
inflammatory bowel disease
stricture due to radiation therapy
cystic fibrosis
ingested foreign bodies
PATHOPHYSIOLOGY
Abdominal distention
Distention with gas and fluid occurs proximally of
the obstruction.
Bowel distention may be visible beneath the
abdominal wall in thin patient (darm contour)
Pronounced in distal obstruction but rarely in
proximal obstruction

PATHOPHYSIOLOGY
Abdominal distention
Gas
Swallowed air is the major cause of
distention, due to the high nitrogen content
in room air witch is not well absorbed by the
bowel mucosa
Bacterial fermentation produces other gas,
such as methane
PATHOPHYSIOLOGY
Abdominal distention
Fluids
Inflammatory leads to transudation of
fluid from the extracellular space into the
bowel lumen and peritoneal cavity
As the proximal lumen distends and fluids
accumulates, the bidirectional flow of salt and
water is disrupted and secretion is enhanced
PATHOPHYSIOLOGY
Abdominal distention
Fluids
Prostaglandins and endotoxins released
by bacterial proliferation in the static
lumen further the process

Fluids loses may be so severe that the hypotension
results and may ultimately lead to cardiovascular
collapse (dehydration hypovolume shock)
PATHOPHYSIOLOGY
Vomiting
Usually accompanies small bowel obstruction as
anti-peristaltic produce or as the consequence
of over-distention of the stomach and bowel
Pronounce in proximal obstruction
Bile in early stage and becomes progressively
more feculent as the illness progresses
PATHOPHYSIOLOGY
Respiration impairs
affected by abdominal distension and
impaired diaphragmatic excursion
aspiration of vomitus may lead to severe
pneumonia and respiratory distress
PATHOPHYSIOLOGY
Peristaltic rushes
Characteristically accompanies bowel obstruction,
ultimately in early stages of obstruction
Mechanism to release the obstruction
Gurgles and high pitched tinkles (metallic sounds) is
the auscultatory hallmark of obstructive ileus
Bowel peristaltic may be visible beneath the
abdominal wall in the thin patient (darm steifung)
Cramping pain synchrony with high pitch peristaltic
PATHOPHYSIOLOGY
Perforation
Strangulated obstruction leads to gangrene of the
intestinal wall, free perforation occurs as the
consequences of the gangrene
In complete mechanical obstruction (close loops
obstruction), no outlet for the accumulated
intraluminal contents exist, and perforation of the
bowel may occurs
DIAGNOSIS
SYMPTOMS

Patient admission usually with abdominal pain - distention,
vomiting and couldnt defecation - flatus
Proximal obstruction usually present with vomiting
Pain described as intermittent or colicky with a crescendo -
decrescendo pattern
When obstruction is located in the high or mid small bowel
(jejunum prox ileum), pain may be more constant
If obstruction is located distally, poorly localized crampy
pain and abdominal distention become more common
DIAGNOSIS
SIGNS

Abdominal distention is minimal or absent initially, but
more pronounced with distal obstruction and when
proximal lesions has been allowed to progress without
decompression
In thin patient may visible darm contour and darm steifung
Characteristic peristaltic rushes, gurgles, and high pitched
tinkles may be audible and occur in synchrony with crampy
pain
Rectal examination is usually normal
DIAGNOSIS
SIGNS

Loss of fluid and electrolytes leads to dehydration,
manifested as tachycardia hypovolume shock
Pronounced abdominal distention leads to respiratory
impaired, manifested as tachypneu
Body temperature is usually normal, but may be mildly
elevated
Determine to find etiology of obstruction
DIAGNOSIS
LABORATORY FINDINGS

Early stage usually normal
Progression
hemoconcetration,
leukocytosis,
electrolytes abnormalities
DIAGNOSIS
IMAGING STUDIES

Plain abdominal film (AP and LLD with/without erect)
step-ladder pattern
air-fluid level
dilated small bowel loops
herring bone appearance
colon may not contain gas

Peforation
free air
DIAGNOSIS
IMAGING STUDIES

Contrast studies
not required and should not be performed because of
the risk of barium peritonitis if a perforation is present
essential DIAGNOSIS
Colicky abdominal pain
Emesis
Dehydration
Peristaltic tinkles and rushes
Air fluid level on abdominal x-rays

Differential DIAGNOSIS
OBSTIPATION
Abdominal distention characterize obstruction of the
large intestine
Vomiting seldom occurs, pain is less colicky

Strangulating obstruction may be mimicked by acute
pancreatitis, ischemic enteritis, or mesenteric vascular
obstruction due to venous thrombosis

Paralytic ileus must be differentiated from mechanical
eleus
Treatment
SUPPORTIVE MEASURES
Intravenous hydration to treat hemoconcentration and
corrected electrolyte losses
best guided by urine output
careful in elderly patients and cardio-pulmonary
disease
Nasogastric tube to reduce abdominal distention
(decompression) and risk of vomiting aspiration
If strangulation is suspected, broad-spectrum antibiotic
should be administered promptly
Treatment
SURGERY
The patient must be fully resuscitated before
operation commerce
Surgery depend on etiology of the obstruction
Adhesion or band release
Strangulated or close loops intestinal
resection may be necessary
Large intestine
MECHANICAL OBSTRUCTION
GENERAL CONSIDERATION
An acute abdominal case
15% of bowel obstruction involve large intestine
The sigmoid is most commonly involve
Carcinoma is usually the cause of complete
obstruction
Colonic distension is a progressive process in witch
intraluminal pressures can reach very high levels
that can impair the circulation and lead to
gangrene and perforation
GENERAL CONSIDERATION
If obstruction at the level of caecum signs and
symptom similar due to small bowel obstruction
More distal colonic obstruction physical
findings depend on the competence of the
ileocaecal valve (valvula bauhini)
A form of close loops obstruction will occur if the
colon cannot decompress itself in retrograde
fashion through the ileocaecal valve into the small
bowel
etiology
Carcinoma most common
Diverticular disease
Volvulus
Inflammatory disorders
Benign tumors
Fecal impaction
Bends and intussusceptions rare
DIAGNOSIS
SIGN AND SYMPTOMS

Pain
Deep-seated cramping pain referred to the
hypogastrium is typically patient complain
Pain from obstruction of the sigmoid usually
referred to the left lower quadrant
Severe continuous pain is referred to intestinal
ischemia
DIAGNOSIS
SIGN AND SYMPTOMS

Vomiting
Late finding and may not occur if the ileocaecal
valve does not allow contents to reflux back into
the small intestine
Feculent vomiting is a late manifestation
DIAGNOSIS
SIGN AND SYMPTOMS

Abdominal distention
Combine with peristaltic waves radiating across
the abdominal wall may be observed if the patient
is thin
High pitch metallic tinkling and associated rushes
and gurgles can be heard
Localized tenderness or another non tender
palpable mass may indicate a strangulated close
loops
DIAGNOSIS
ENDOSCOPY

Sigmoidoscopy or colonoscopy are often beneficial
in establishing the diagnosis and may be therapeutic
if sigmoid volvulus id present
Care must be exercised when advancing the
endoscope to prevent accidental perforation of an
attenuated colonic wall
DIAGNOSIS
IMAGING STUDIES

Plain abdominal film reveal a distended colonic
segment
Low sigmoid or rectal obstruction the entire
colon may be dilated
If the ileocaecal valve is incompetent retrograde
decompression will cause distention of the terminal
ileum
Barium is contra-indicated in the presence of
suspected colonic perforation
Differential DIAGNOSIS
Small bowel obstruction
Letter in colonic obstruction
onset is typically slower
less pain
vomiting is very unusual
considerable abdominal distention
plain x-rays are essential to the different diagnosis
TREATMENT
The primary goal of the therapy is decompression of
the obstructed segment and prevention of
perforation
Operation is almost required in cases of mechanical
obstruction
The surgical procedure performed depends upon
the lesion present, the status of the patient, the
extent of colonic dilatation and whether there is
evidence of perforation
A proximal diversion (colostomy) is required to
decompress the dilated colon
Adynamic /
paralitic / functional
OBSTRUCTION
An Internal Medicine
Case
Tor sakalangkong