CLASSIFICATION
DYNAMIC
(MECHANI
CAL)
Peristalsis is
working
against a
mechanical
obstruction
ADYNAM
IC
(FUNCTI
ONAL)
Result
from atony of the
intestine with loss of
normal peristalsis, in the
absence of a mechanical
cause.
or it may be present in a
non-propulsive form (e.g.
mesenteric vascular
occlusion or pseudoobstruction)
Intraluminal
Impaction
Foreign bodies
Bezoars
Gallstone
Intramural
Extramural
Pathophysiology:
Proximal
bowel
dilated &
develops
altered
motility
dilate
reduce
peristaltic
strength
flaccidity
&
paralysis
(prev.
vascular
damage
due to
increasing
intralumin
al
pressure
Distal to
obs. Bowel
exhibits
normal
peristalsis
&
absorbtion
become
empty
contract &
become
immobile
Distention
is by gas &
fluid
-Gas:
aerobic &
anaerobic
growth
-Fluid:
Digestive
juices &
retarded
absorption
Dehydratio
n&
electrolyte
s loss:
Reduced
oral intake,
defective
intestinal
absorption,
loses from
vomiting &
sequestrati
on in bowel
of lumen.
CLINICAL FEATURES
High small bowel obstruction
vomiting occurs early and is
profuse with rapid dehydration.
Distension is minimal with little
evidence of fluid levels on
abdominal radiography
CARDINAL FEATURES:
Colicky pain
Vomiting
Abd distention
Constipation
OTHER FEATURES:
Dehydration
Hypokalaemia
Pyrexia
Abd tenderness
PHYSICAL EXAMINATION
INSPECTION
Abdominal distention, scars, visible peristalsis,
darm contour
PALPATION
Mass, tenderness
PERCUSSION
Tymphanic, dullness
AUSCULTATION
Bowel sound are high pitch and increase in
frequency
INVESTIGATIONS:
Lab:
Leukocytosis/ leucopeni
Arterial blood gasses
Ur & Cr
Na, K, LFT and glucose
Radiological:
Plain abdominal x-ray
Abdominal CT Scan , MRI, Contrast
studies)
Figure 3. Lateral
decubitus view of the
abdomen, showing
air-fluid levels
consistent with
intestinal obstruction
(arrows).
Large bowel
Peripheral ( diameter 6
cm max)
Presence of haustration
TREATMENT OF INTESTINAL
OBSTRUCTION
SUPPORTIVE
1. Resuscitation
2. Decompression of proximal to the obstruction,
reduce subsequent aspiration during induction
of anesthesia and post extubation.
3. DC to decompression and observe urine
product
3. Electrolite corection
4. Broad spectrum antibiotic (not mandatory but
need in all patient undergoing surgery.
SURGICAL
IND: obstructed / strangulated
external hernia, Internal
intestinal strangulation and
acute obstruction
1.Midline incision usually look on
CAECUM
2.Operative decompression
3.Look at viability of intestine
4.Large bowel obstruction:
INDICATIONS FOR
SURGERY
Absolute
Generalised peritonitis
Localised peritonitis
Visceral perforation
Irreducible hernia
Relative
Palpable mass lesion
'Virgin' abdomen
Failure to improve
Trial of conservatism
Incomplete obstruction
Previous surgery
Advanced malignancy
Diagnostic doubt - possible ileus
MANAGEMENT FOR
LARGE BOWEL
OBSTRUCTION
All patients require
Adequate resuscitation
Prophylactic antibiotics
Consenting and marking for potential stoma formation
Appropriate operations include:
Right sided lesions right hemicolectomy
Transverse colonic lesion extended right hemicolectomy
Left sided lesions various options
Three-staged procedure
Defunctioning colostomy
Resection and anastomosis
Closure of colostomy
Two-staged procedure
Hartmanns procedure
Closure of colostomy
One-stage procedure
Resection, on-table lavage and primary anastomosis
Three stage procedure will involve 3 operations!
Associated with prolonged total hospital stay
Transverse loop colostomy can be difficult to manage
With two-staged procedure only 60% of stomas are ever reversed
With one-stage procedure stoma is avoided
Anastomotic leak rate of less than 4% have been reported
Irrespective of option total perioperative mortality is about 10%
Complications
associated with
intestinal obstruction
repair
include
excessive bleeding
infection
formation of abscesses (pockets of
pus)
leakage of stool from an anastomosis
adhesion formation
paralytic ileus (temporary paralysis of
the intestines)
http://www.surgeryencyclopedia.com/Fi-La/Intestinal Source:
reoccurrence
of the obstruction.
COLOSTOMY TECHNIQUE
Single Colostomy
The single colostomy
technique can also be called
an 'end' or 'terminal'
colostomy. This tecnique
involves bring one end of the
colon out through an opening
made in the abdominal wall.
In this technique the
diseased part of the bowel is
removed, bt the rectal pouch
still remains.
Divided Colostomy
The Divided colostomy tecnique
involves two edges of the colon
being brought out through an
opening in the abdominal wall.
These two edges are seperate.
The edge which comes from the
digestive/proximal end is normally
active, therefore is known as the
colostomy. The other edge
brought through the abdominal
wall is known as the Distal end.
This tecnique is normally used
when spillages of faeces into the
bowel needs to be avoided.
Loop Colostomy
The Loop colostomy Techniqe is when the
surgeon brings a loop of the bowel up
through the opening in the abdominal wall.
This loop is normally supported by a plastic
bridge, rod or plastic tubing. The surgeon
will cut two openings in the abdominal wall.
One opening is the proximal/afferent end,
and the other is the Distal/efferent end.
The afferent end is active and functioning
part of the colon,and will pass stools and
gas through the stoma. The efferent end is
the non active, non functioning part of the
colon. This tecnique is normally performed
in emergencies and will tend to be located
on transverse colon. A loop colostomy can
be temporary or permanent.
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