INTESTINAL OBSTRUCTION,

COLORECTAL CANCER

Mrs. Meghana D. Goswami

1st year M.Sc. Nursing student
M.B.N.C
INTESTINAL
OBSTRUCTION
Definition
Intestinal Obstruction occurs when
intestinal contents cannot pass through the
GI tract.
OR
Intestinal Obstruction is significant
mechanical impairment which is partial or
complete blockage of the bowel that results
in the failure of the passage of intestinal
contents through the intestine.
Incidence
About 90% of bowel obstructions occur in small
intestine, especially in the ileum. Obstruction of
small intestine is common surgical emergency.
Large bowel obstruction usually occurs in
sigmoid colon.
The mortality rate for acute obstruction in small
bowel is 10% and in the large bowel 30%
Complete obstruction in any part of the bowel
untreated, can cause death within hours due to
shock untreated and vascular collapse
About 85% of partial small bowel obstructions
resolve with non-operative treatment, whereas
about 85% of complete small bowel obstruction
requires operation
Classification/ Types of
Intestinal obstruction
Simple Intestinal Obstruction: In this blockage
prevents intestinal contents from passing.
Blockage occurs without vascular compromise.
Strangulated Intestinal Obstruction: in this
blood supply to part or all of the obstructed
section of intestine is cut off, in addition to
blockage of lumen. Venous obstruction occur first,
followed by arterial occlusion, resulting in rapid
ischemia of the bowel wall.
Closed loop intestinal obstruction: in this both
ends of an intestine section are obstructed,
isolating from remaining of the intestine.
 Mechanical Intestinal Obstruction: It is a
physical block to passage of intestinal contents
with or without disturbing blood supply of
bowel.
Functional Intestinal Obstruction: There is
no mechanical blockage of the intestine.
Obstructions results from ineffective peristalsis
movement. The muscle of intestine cannot
propel the intestine content properly.
Vascular Intestinal Obstruction: when
blood supply to celiac and superior and inferior
mesenteric artery is interrupted the part cease
to function and pain occur.
 Small Intestinal Obstruction

Large Intestinal Obstruction

Partial Intestinal Obstruction

Complete Intestinal Obstruction

Causes
Mechanical obstruction
Adhesion: loop of intestine
become adherent to areas that
heal slowly or scar after
abdominal surgery, occurs most
commonly in small intestine.
Irritants that remain in the
abdomen following abdominal
procedure enhance the
formation of adhesion. Adhesion
produces a kinking of an
intestine.
 Intussusception: One part of
intestine slips into another part
located below it(like a telescope
shortening); occurs most commonly
in infants than adults. The intestinal
lumens become narrow, and blood
supply becomes strangulated.
Peristaltic action telescope the
proximal bowel into the bowel distal
to it.
Volvulus: Bowel twists and turns on
itself and occludes the blood supply.
Intestinal lumen becomes
obstructed. Gas and fluid become
accumulate in the trapped bowel.
Hernia: Protrusion of intestine
through a weakened area in the
abdominal muscle. Intestinal flow
may be completed obstructed. Blood
flow of that area may be obstructed
as well.
 Tumour: A tumour that exists within the wall
of intestine extends into the intestinal lumen,
or a tumour outside the intestine cause
pressure in the wall of the intestine. Most
common type is colorectal adenocarcinoma.
Intestinal lumen become partial obstructed; if
tumour not removed complete obstruction
results.
 Functional Obstruction: Neurogenic factors
are responsible for functional obstruction are :
Amyloidosis: Depositions of amyloid (waxy
glycoprotein) extracellulary affect the
peristalsis movement.
Muscular dystrophy
Endocrine disorder: like Diabetes mellitus.
In DM complication is neuropathy that is
diabetic autonomic neuropathy involving the
GI tract which impaired GI motility.
Neurogenic disorder: like Parkinson disease.
severe constipation from Parkinsons disease,
which leads to impacted bowel
Spinal cord injury, vertebral fracture
Paralytic ileus: Paralysis of distension of
intestine.
 Vascular Obstruction: It occurs in large
intestine when an atherosclerotic
narrowing interrupts the blood supply to
bowel. This narrowing inhibits peristalsis
and can lead to life threatening intestinal
ischemia.
Mesenteric infraction: occlusion of
blood supply to bowel, effectively stop
bowel function.
Abdominal muscle angina
Mesenteric thrombosis
Risk Factors
IBD
Stricture or stenosis
Abscess
Atresia
Diverticulitis: a condition in which small,
bulging pouches (diverticula) in the
digestive tract become inflamed or
infected
Crohns disease:
 Abdominal or pelvic surgery
Infection
Certain medications that affect muscles
and nerves, including tricyclic
antidepressants, such as
amitriptyline and imipramine (Tofranil)
gallstones, which can press against your
intestine and block the flow of its contents
Pathophysiology
Due to causes and Risk factors

Mechanical Functional Vascular

Gases and fluids accumulate in the intestine

 Continue

Increase contraction Dissention of

of proximal intestine intestine

Cessation of peristalsis

Increase intraluminal pressure

Increase secretions into the intestine

 Compression of veins
continue

Increase venous pressure

Decreased absorption

Oedema of the intestine

Decrease arterial blood Compression of terminal

supply branches of mesenteric artery
 Continue
Necrosis of the intestine

Gangrenous Intestinal Wall

Clinical manifestation
Abdominal pain in rhythmically recurring
waves due to distension and intestinal
peristaltic efforts to push contents past the
obstruction. Small intestinal pain is felt in
upper and midabdomen , whereas colonic pain
is experienced in the lower abdomen.
Peristaltic waves visible, accompanied by high
pitched tinkling sound, due to small intestinal
distension.
Absolute constipation due intestinal
obstruction
Abdominal distension due to muscle become
atonic, loops of small bowel dilate and bowel
obstruction
 Dyspnea
Hypoxia
Nausea and vomiting
Vomiting is more sever if the obstruction
is located high in the small bowel.
At first, vomitus is composed of semi-
digested food and chyme,
Later it becomes watery and contains bile.
Finally, the client vomitus dark fecal
material, the result of bacterial growth in
the fluid that has segnated in the
obstructed bowel.
 Hiccups
Dehydration
Anorexia
Weight loss
Reverse peristalsis movement due to
bowel obstruction and increase iliocecal
valve incompetency and increase pressure
in intestine.
Generalized malaise
Shock
Diagnostic evaluation
Plain X-ray film which shows gas shadows
Abdominal ultra sound
Water soluble contrast enema x-ray
Colonoscopy
Upper GI and small bowel series
CT scan
Blood study: Increased haemoglobin and
haematocrit value may indicate dehydration.
Leucocytosis may point to a strangulated bowel
A decrease in sodium, potassium and chloride
level and rise in non-protein nitrogen and BUN
levels may indicate intestinal obstruction
Management
IV fluid therapy
Insertion of NG tube
Urinary catheterization
Colonoscopy
A rectal tube may be inserted to
decompress an area that is lower in bowel
Opioids and antiemetic
Antibiotic
Antimuscarinic/anticholinergic
Surgical management
Lysis adhesion
Hernia repair
Resection with to end to end
anastomosis
Resection with ileostomy or
colostomy
Nursing management
To assess the vomiting or ask the patient
to describe vomitus, which may content
gastric and bile or fecal contents is rare
Assess abdominal pain characteristics and
abdominal distension and visible
peristaltic movement
Measure patients abdominal girth
Auscultate bowel sound
Assess patient vital sign
 Assess patient for tachycardia, urine
output less than 30ml/hr, and delay
capillary blenching- all indicates
hypovolemia and shock.
Provide semi fowler position
Administers medication as per prescribed
by doctor
Insert the NG tube
Administer IV fluids
Maintain I&O chart.
Provide stoma care
COLORECTAL
CANCER
Definition
Cancer that originates in the colon or
rectum may be called colon cancer or
large bowel cancer, rectal cancer or
colorectal cancer. Colorectal cancer is the
term used most commonly used to refer
this type of cancer.
Incidence
95% of all colorectal cancers are
adenocarcinomas that develop when mutation
occurs in cell that line the wall of the colon
and rectum.
The other 5% colorectal cancers are made up
of less common cell type including
neuroendocrine tumours, GI stromal tumours,
lymphomas etc.
It estimated about 135000 new cases of
colorectal cancer are diagnosed each year and
that about 56000 people die of it.
Causes and Risk factors
Unknown
Genetic mutation
Hereditary
Risk factors
Age
Diet
Genetic disorder: Like familial polyposis
and hereditary non polyposis colon cancer
syndrome
Family history
 Personal history of cancer or polyps:
women who have had cancer of breast,
ovary and uterus are at high risk of
colorectal cancer
History of inflammatory bowel disease
Obesity
Exposure to virus: like HPV increase risk
of cancer
Smoking and alcohol
Staging of colorectal cancer

Stage 0: Carcinoma of situ, abnormal

cells are shown in the mucosa of the colon
wall
Stage 1: Cancer has begun to spread,
but is still in the inner lining
Stage 2: Cancer has spread to other
organs near the colon or rectum. It has
not reached lymph nodes.
 Stage 3: Cancer has spread to lymph
nodes, but has not been carried to distal
part of the body.
Stage 4: Cancer has been through the
lymph system to distant part of the body.
This is known as metastasis. The most
likely organs to experience metastasis
from colorectal cancer are the lungs and
liver.
Clinical manifestation
Symptoms are nonspecific and numerous.
Symptoms are greatly determine location
of the tumour and stage and function of
intestinal function.
Change in bowel habit
Blood in stool
Weakness
Shortness of breath
Fatigue
 Ribbon like stool
Anorexia
Anaemia
Nausea
Vomiting
Weight loss
Rectal pain
Right sided lesions are dull abdominal
pain and melena
Distension
Cramps
Diagnostic evalution
Screening: For asymptomatic and high risk
patient
Digital rectal examination: the doctor inserts
a lubricated, gloved finger into the rectum to
feel for abnormal areas. It only detects
tumours large enough to be felt in the distal
part of the rectum but it is useful as an initial
screening test.
Fecal occult blood test: It is used to detect
microscopic blood in stool, which may
indicate early colorectal cancer.
 Laboratory test: Such as urinalysis, blood
test like carcinoembryonic antigen level,
CBC, electrolyte and chemical panel are
done. In a particular high level of
carcinoembryonic antigen level in the
blood indicate metastasis of
adenocarcinoma.
Double contrast barium enema: In this air
and barium introduce into the large
intestine and fluoroscope is used to
produce real time images of the size,
shape and movement of the colon and
rectum.
 Flexible Sigmoidoscopy: It allows the physician
to look for early sign of colorectal cancer that is
polyps and bleeding. If suspicious tissue found,
the physician insert special instruments through
the tube to remove a sample for examination.
Total colonoscopy: It allows the physician to view
images of entire colon and rectum using a long
flexible tube with light and camera. Biopsy of
suspicious tissue can be performed by using
special instruments through the tube.
Genetic counselling and genetic testing
Staging of cancer identify by using chest x-ray,
USG, CT scan of the lungs, liver and abdomen
Management
Radiation therapy: It is used high energy x-
rays to destroy cancer cell and shrink
tumours.
Chemo therapy: It is often used as first line
treatment for metastatic colorectal cancer to
destroy cancer cell that have metastasized. It
also may be used prior to surgery to shrink
the tumor.
Newer combination of chemotherapy drugs,
such as FOLFOX (5-Flurocil, leucovorin and
Oxaliplatin) and FOFIRI (5-Flurocil,
leucovorin and irinotecan) may be used to
prevent recurrence following surgery or
shrink the tumour prior surgery.
 Immunotherapy: It is attempt to
stimulates the immune system to fight
disease and protect the body from side
effect of chemotherapy. examples are
BCG (bacilli Calmette Guerin) and
levamisol
Adjuvant therapy: External beam
radiation therapy, chemotherapy may be
used in addition to surgery to treat
colorectal cancer
Surgical management
Radical bowel resection: It is also called
partial colectomy, is used to treat 80-90%
of colorectal cancer.
 Colostomy
 End to end anastomosis with
lymphadenectomy
 Construction of coloanal reservoir: called
a colonic j pouch: temporary loop
ileostomy is constructed to divert
intestinal flow.
Newly constructed j pouch (made from 6-
10 cm colon) is reattached to the anal
stump.
About 3 months after initial stage
ileostomy is reversed and intestinal
continuity is restored
Complication
Intra-peritoneal infection
Complete large bowel obstruction
GI bleeding
Bowel perforation
Peritonitis, abscess and sepsis