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Bowel Obstruction

a.k.a

Ileus

Bowel Obstruction
Occurs when the normal propulsion
and passage of intestinal contents
does not occur
Can involve:
Only the small intestine
Only the large bowel
Generalized ileus, involving both

Definisi
Gangguan pasase usus

2 Jenis
Paralitik
Adynamic
Fungsional, Pseudo-obstruction, Ileus
Related to ineffective motility without any physical obstruction

Biochemical disturbance
Drugs
Post operation
Peritonitis, Sepsis

Mekanik
Dynamic
Terdapat struktur nyata yg menghambat pasase usus

Tumor intra dan ekstra lumen usus


Adhesive band
Volvulus
Hernia strangulata
Impacted feces
Foreign bodies

Bowel Obstruction

CLASSIFICATION

According to
Etiopathogenesis
Mechanical
Functional

Time of presentation
Acute
Chronic

Extent of obstruction
Partial
Complete

Type of obstruction
Simple
Closed-loop
Strangulation

Bowel Obstruction

MECHANICAL
BOWEL OBSTRUCTION

Mechanical Bowel
Obstruction
Intestinal obstruction caused by a
physical blockage of the intestinal
lumen
Intrinsic
Extrinsic

Mechanical Bowel
Obstruction
Partial
The intestinal lumen is narrowed but still allows the
transit of some intestinal content aborally

Complete
The lumen is totally obstructed, and none of the
intestinal contents can move distally
Carries a markedly increased risk of strangulation
(vascular compromise)
Can be categorized as:
Simple
Closed-loop
Strangulation

Mechanical Bowel
Obstruction
Complete
Simple
An obstruction without any vascular compromise
Closed-loop
Occur when both ends of the involved intestinal segment
are obstructed increased intestinal secretion and
accumulation of fluid in the involved intestinal segment
increased intraluminal pressure
A much higher risk of vascular compromise and
irreversible intestinal ischemia
Strangulation
The blood supply to the affected segment is compromised

Mechanical Bowel
Obstruction
Signs & symptoms predictive for
strangulation obstruction:
Continuous pain
Tachycardia
Leukocytosis
Peritoneal signs
Fever

Adhesions
Is: abnormal connective tissue
attachments between tissue surfaces
Can be:
Congenital
Acquired
Postinflammatory
Postoperative

Invagination
a.k.a. intussusception
Is: the invagination of bowel into the lumen of adjacent
bowel
The enfolded portion always points down the fecal stream
4 types:
1.
2.
3.
4.

Ileum into ileum


Ileum into ileocecal valve
Ileocecal valve into colon
Colon into colon

Pathognomonic sign: oblong mass in the right or upper


mid-abdomen and absence of bowel in the right lower
quadrant (Dance sign)

Strangulated Hernia
When the blood supply of
incarcerated contents is interrupted

Volvulus
The gut twists upon itself closedloop obstruction
The most common:
Cecum
Sigmoid
(Because their longer mesenteries allow
rotation)

A bird beak cutoff is noted in colonic


gas on noncontrast x-rays

Mechanical
Bowel
Obstruction

Bowel Obstruction

FUNCTIONAL
BOWEL OBSTRUCTION

Functional Bowel
Obstruction
No physical site of mechanical
obstruction present ~
pseudoobstruction
Factors that cause either paralysis or
dysmotility of intestinal peristaltis
prevents coordinated aboral transit
of luminal contents

Postoperative Ileus
The small bowel returns to normal motor
activity within a few hours after operation
Indeed, contractile activity in the small
intestine remains present even during a
celiotomy
The stomach recovers normal motor
activity and emptying characteristics in 2448 hours
The large bowel takes 3-5 days to recover
coordinated propulsive function

Early Postoperative Obstruction


Requiring Surgical Management

Acute adhesions
Internal herniation
Intraabdominal abscess
Intramural intestinal hematoma
Anastomotic edema or leak

Radiologic Findings
An upright chest x-ray
Detect extraabdominal conditions
that
may present with a clinical
picture similar
to bowel obstruction
Detect the presence of
subdiaphragmatic
free air indicative of a perforated
viscus

Abdominal Radiographs
Diameter

Dilated Small
Intestine

Dilated Large Intestine

> 3 cm

> 9 cm (proximal colon)


> 5 cm (sigmoid colon)

Gas Patterns Lay in the central


portion of the abdomen
Recognized by the
presence of the
valvulae conniventes
or plica circulares that
traverse the full
diameter of the bowel

Visualized in the periphery of


the abdominal films
Identified by the presence of
haustral markings that only
partially traverse the bowel
wall

Ileus
paralit
ik

Volvulus
yeyunum

Volvulus
sigmoid

Perforasi
rektum

Berpikir

Berpikir
Pasien hernia skrotalis strangulata
dengan gejala dan tanda obstruksi
usus mekanik yang jelas, masih
perlukah dilakukan pemeriksaan
ronsen abdomen 2 posisi?

Berpikir
Pasien datang dengan gejala dan
tanda obstruksi usus mekanik total
serta pada pemeriksaan RT teraba
massa tumor, masih perlukah
dilakukan pemeriksaan ronsen
abdomen 2 posisi?

Berpikir
Pasien geriatri dengan keluhan tidak
dapat BAB disertai gangguan
metabolik, imobilisasi, intake sulit,
haruskan dilakukan pemeriksaan
ronsen abdomen 2 posisi?

Rememb
er
You are a
DOCTOR

Not a ROBOT

Berpikir
Jadi
Pada kasus apa pemeriksaan ronsen
abdomen 2 posisi sebaiknya
dilakukan?

Management
Decompression of the obstructed
bowel
Aggressive fluid resuscitation
Prevention of aspiration

Nonoperative
Management
Only for uncomplicated small bowel
obstruction
Contraindication:
Suspected ischemia
Acute complete large bowel obstruction
with competent ileocecal valve
Closed-loop obstruction
Stangulated hernia
Perforation

Thank
You