Intestinal Obstruction

Armando G. Santos, MD, FPCS

 Intestinal Obstruction:
Essential Features
 Mechanical disruption of passage of
intestinal contents along the bowel
 Two main types:
 Small bowel obstruction (SBO)
 Large bowel obstruction (LBO)
 Classified as:
 Partial vs. Complete
 Simple vs. Strangulating
 Open loop vs. Closed loop
 Frequent Causes of
Obstruction
Age Group Etiology
Young adults Adhesions and bands
and Incarcerated hernia

Middle-aged Granulomatous disease

(Crohn’s disease, TB)

Colonic cancer

Diverticulitis

Elderly Impacted feces

Adhesions

Incarcerated hernia
 Pathological Derangement in
Intestinal Obstruction
 Fluid and electrolyte disturbance
 Bacterial proliferation
 Vascular disturbance
 Bowel wall changes
Intestinal Obstruction: Clinical
Diagnosis
 Main symptoms:
 Abdominal pain
 Vomiting
 Abdominal distention
 Obstipation
 Character/onset of Sx help determine
level of obstruction
 Intestinal Obstruction: Clinical
Diagnosis
 History of previous operation/cancer/hernia
 Signs of strangulation/perforation
 Signs of dehydration/shock
 Abdominal distention
 Operative scar
 Visible peristalsis
 Borborygmi
 Abdominal/rectal mass
 Incarcerated hernia
Visible Peristalsis
Strangulated Femoral
Hernia
 Clinical Findings Suggestive of
Strangulation
 Continuous pain
 Fever
 Tachycardia
 Peritoneal irritation
 Leukocytosis
 C-reactive protein elevation
 Increase in serum lactate

No clinical parameters or laboratory tests can

accurately detect or exclude presence of
strangulation in all cases
 Intestinal Obstruction: Vital
Steps in Clinical Diagnosis
1. Recognition of presence of
intestinal obstruction
2. Attempt to locate its level (site)
3. Attempt to detect if strangulation
present
4. Discovery of etiology of obstruction
 Small Bowel Obstruction:
Diagnostic Investigation
 CBC
 Serum electrolytes
 BUN/creatinine
 ABG – if complication suspected
 Supine and erect plain x-ray films
 CT scan
 Abdominal ultrasound
 Barium radiography
Proximal SBO: Plain
Radiographs
Distal SBO: Plain
Radiographs

Supine Upright
 Distal SBO: Plain
Radiograph and CT
 Barium Radiograph:
Jejunojejunal Intussusception
 Jejunojenunal
Intussusception
CT: Ileal Intussusception with
Typical Target Sign
UTZ: Dilated Jejunal Loops
 Causes of SBO in Adults as to
Site
Extrinsic to bowel Intrinsic to bowel wall
wall Congenital
Adhesions (post-op Duplication/cysts
esp.) Inflammatory
Hernia TB
Neoplasms Diverticulitis
Carcinomatosis Neoplastic
Extra-intestinal tumor Primary/metastatic tumors
Intraluminal
Intra-abdominal Traumatic
Gallstone
abscess Hematoma
Bezoar
Miscellaneous
Foreign body Intussusception
SBO due to Adhesive Band
SBO due to Dense
Adhesions
SBO: Internal Hernia due to
Adhesive Bands
SBO due to Carcinoid Tumor
 Causes of SBO in Adults
Cause Incidence (%)
Adhesion 50-75
Neoplasm 8-15
Hernia 8-15
Volvulus 3
Inflammatory bowel 1
disease <1
Intussusception
<1
Gallstone ileus
<1
Radiation enteritis
<1
Intra-abdominal abscess
<1

 SBO: Management
 Initial resuscitation and decompression
 Conservative Tx reserved for partial SBO
 Close monitoring mandatory if under
conservative Tx
 Surgery generally indicated for:
 Complete SBO
 No improvement in 48 hours
 Surgery urgent in suspected strangulation
 - Abdominal pain
- Nausea/vomiting
- Abdominal distention
- Obstipation

- Clinical history
- Physical examination

Mx
- Abdominal radiographs

Algorith Partial
SBO
Complete
SBO
Large bowel
obstruction

m for - Crescendo pain

Treat

SBO
appropriately
- Unrelenting pain
- Clinical deterioration
- Radiograph
deterioration
Previous Hx of
prohibitive reoperative
risks & successful
No Yes conservative Mx

- NGT decompression Operation

- Serial PE
- Serial radiographs
- Fluid & electrolyte Mx
 Causes of LBO in Adults
 Cancer: 60%
 Volvulus: 10-15%
 Diverticulitis: 10-15%
 Hernia
 Ischemia/radiation induced stricture
 Carcinomatosis
 Pelvic recurrence of rectal cancer
 Intussusception
 Foreign body
 Inflammatory bowel disease
 Fecal impaction
 LBO: Diagnostic
Investigation
 Supportive blood tests
 Supine and erect plain radiographs
 CT scan
 Water-soluble contrast enema
 Colonoscopy
 Abdominal ultrasound
 Barium radiography
LBO: Management Strategy
 Resuscitation promptly administered
 Dx should guide appropriate Tx
 Initial non-surgical Tx, if possible,
with elective definitive surgery
 Non-operative and surgical Tx
tailored to cause
 If indicated, emergency surgery
must:
 Relieve obstruction

 Treat underlying pathology if

feasible
 Obstructed Colorectal Ca:
Mx
 If uncomplicated:
 Endoscopic stent placement and

elective resection
 If complicated or with failed
endoscopic stenting:
 Resection and anastomosis (if

feasible)
 Resection and colostomy
Obstructed Distal Transverse
Colon with Competent
Ileocecal Valve
Obstructed
Proximal
Transverse
Colon with
Incompete
nt
Ileocecal
Valve
Obstructive Hepatic Flexure
CA
 Volvulus of the Colon:
Predisposing Factors

 Redundant mobile colon segment

with narrow base
 Distention of colon by feces or gas
Sigmoid Volvulus
Volvulus of the Colon: Types
 Sigmoid volvulus (>65% of cases)
 Cecal volvulus
 Transverse colon volvulus
Sigmoid Volvulus: Plain
Radiograph
Cecal Volvulus: Plain
Radiograph
Contrast Enema: “Bird’s Beak”
at Level of Cecal Volvulus
 Sigmoid Volvulus: Surgical
Mx
 If uncomplicated:
 Endoscopic decompression and

elective resection of redundant

sigmoid
 If complicated or with failed
endoscopic decompression:
 resection and colostomy
Sigmoid Volvulus: Pre and
Post-decompression X-ray
Gangrenous Sigmoid
Volvulus
Cecal Volvulus
 Intestinal Obstruction:
Summary
 Thorough Hx/P.E. plus plain x-ray
usually adequate to make Dx and Tx
plan
 Further tests indicated for uncertain
cases
 Supportive measures provided in all
cases
 Complete SBO generally requires
surgery
 Operation urgent for strangulation
 Intestinal Obstruction:
Summary
 LBO largely caused by colorectal
cancer, sigmoid volvulus and
diverticulitis
 Mx of LBO should be non-operative
initially followed by elective definitive
surgery, if feasible
 Emergency operation for LBO should
aim to treat underlying pathology
 Strangulated SBO with
Gangrene due to Adhesion
Barium Enema: Ileocecal TB

Cecum and ascending

colon fibrotic and retracted
craniad, scarred and
sacculated (curved
arrows); terminal ileum
relatively patulous (straight
arrows) and probably
nodular. v=ileocecal valve.
Ileocecal TB
CT: Complete SBO due to
Incisional Hernia
 CT: SBO with Fluid-filled,
Dilated Small Bowel Loops (white
arrows); Collapsed Right Colon (red
arrow)  
Mid-sigmoid Obstruction due to
Adhesive Band
Have a Nice Day!