Obstruksi Intestinal

Pembimbing: dr. Anbiar Manjas, SpB-KBD

Presentan: dr. Hannan Khairu Anami

• Intestinal obstruction
• Dynamic: in which peristalsis is working against a mechanical obstruction
• Adynamic: in which peristalsis may be absent (e.g. paralytic ileus) or it may be
present in a non-propulsive form (e.g. mesenteric vascular occlusion or
pseudo-obstruction). In both types a mechanical element is absent
Cause of intestinal obstruction

Mechanisms of obstruction
Etiology
Dynamic obstruction
• The proximal bowel dilates and develops an altered motility  Below
the obstruction the bowel exhibits normal peristalsis and absorption
until it becomes empty, at which point it contracts and becomes
immobile.
• Initially, proximal peristalsis is increased to overcome the obstruction,
in direct proportion to the distance of the obstruction.
• If the obstruction is not relieved, the bowel begins to dilate, causing a
reduction in peristaltic strength, ultimately resulting in flaccidity and
paralysis.
• This is a protective phenomenon to prevent vascular damage
secondary to increased intraluminal pressure
Dynamic obstruction
• The distension proximal to an obstruction is produced by two factors:
• Gas: there is a significant overgrowth of both aerobic and anaerobic
organisms, resulting in considerable gas production. Following the
reabsorption of oxygen and carbon dioxide, the majority is made up of
nitrogen (90%) and hydrogen sulphide.
• Fluid: this is made up of the various digestive juices. Following obstruction,
fluid accumulates within the bowel wall and any excess is secreted into the
lumen, whilst absorption from the gut is retarded. Dehydration and
electrolyte loss are therefore due to:
• reduced oral intake;
• defective intestinal absorption;
• losses as a result of vomiting;
• sequestration in the bowel lumen.
Strangulation
• When strangulation occurs, the viability of the bowel is threatened
secondary to a compromised blood supply
• Venous return is compromised before arterial supply  capillary
pressure increase  local mural distention  loss of intravascular
fluid and red blood cells intramurally and extraluminally 
haemorrhagic infarction
• As the viability of the bowel is compromised there is marked
translocation and systemic exposure to anaerobic organisms with
their associated toxins
• Bowel involvement is extensive the loss of blood and circulatory
volume will cause peripheral circulatory failure
Closed loop • occurs when the bowel is
obstructed at both the proximal
and distal points
• no early distension of the proximal
intestine
• when gangrene of the strangulated
segment is imminent, retrograde
thrombosis of the mesenteric veins
results in distension on both sides
of the strangulated segment
• seen in the presence of a malignant
stricture of the right colon with a
competent ileocaecal valve
Special type of mechanical
internal obstruction
• Internal hernia  the small intestine becomes entrapped in one of
the retroperitoneal fossae or in a congenital mesenteric defect:
• the foramen of Winslow;
• a hole in the mesentery;
• a hole in the transverse mesocolon;
• defects in the broad ligament;
• congenital or acquired diaphragmatic hernia;
• duodenal retroperitoneal fossae – left paraduodenal and right
duodenojejunal;
• caecal/appendiceal retroperitoneal fossae – superior, inferior and retrocaecal;
• intersigmoid fossa.
Others
• Obstruction from enteric strictures
• Bolus obstruction: food, gallstones, trichobezoar, phytobezoar,
stercoliths and worms
• Obstruction by adhesions and bands
• Acute intussusception
• Volvulus
Clinical Features
Dynamic obstruction
• Classic sign of dynamic intestinal obstruction:
• Pain
• Distension
• Vomiting
• Absolute constipation
• Other syptomps: dehydration, oliguria, hypovolaemic shock, pyrexia,
septicaemia, respiratory embarrassment and peritonism
Intussusception
• The classical presentation of intussusception is with episodes of
screaming and drawing up of the legs in a previously well male infant.
• During attacks the child appears pale
• Vomiting may or may not occur
• Initially, the passage of stool may be normal, whereas, later, blood
and mucus are evacuated – the ‘redcurrant jelly’ stool.
• Lump hardens on palpation
• RT: blood stained mucus
Caecal Volvulus
• This may occur as part of volvulus neonatorum or de novo and is
usually a clockwise twist.
• It is more common in females and usually presents acutely with the
classic features of obstruction.
• At first the obstruction may be partial, with the passage of flatus and
faeces. In 25% of cases, examination may reveal a palpable tympanic
swelling in the midline or left side of the abdomen.
Sigmoid Volvulus
• The symptoms are of large bowel obstruction  intermittent 
followed by the passage of large quantities of flatus and faeces.
• Presentation varies in severity and acuteness, with younger patients
appearing to develop the more acute form.
• Abdominal distension is an early and progressive sign, which may be
associated with hiccough and retching; vomiting occurs late.
• Constipation is absolute.
• In the elderly, a more chronic form maybe seen.
 Fluid levels with gas above; ‘stepladder pattern’. Ileal
Gas-filled small bowel loop; patient supine. obstruction by adhesions; patient erect.
Intussusception imaging
• A plain abdominal field usually reveals evidence of small or large bowel
obstruction with an absent caecal gas shadow in ileocolic cases.
• A soft tissue opacity is often visible in children.
• A barium enema may be used to diagnose the presence of an ileocolic
intussusception (the claw sign)
• An abdominal ultrasound scan has a high diagnostic sensitivity in children,
demonstrating the typical doughnut appearance of concentric rings in
transverse section.
• A computerized tomography (CT) scan is also useful in equivocal cases.
Intussusception:
Sausage appearance
Imaging in volvulus
• In caecal volvulus, radiography may reveal a gas-filled ileum and
occasionally a distended caecum. barium enema  an absence of barium
in the caecum and a bird beak deformity.
• In sigmoid volvulus, a plain radiograph shows massive colonic distension.
 dilated loop of bowel running diagonally across the abdomen from right
to left, with two fluid levels seen, one within each loop of bowel.
• In volvulus neonatorium, the abdominal radiograph shows a variable
appearance.
• Initially, it may appear normal or show evidence of duodenal obstruction
but, as the intestinal strangulation progresses, the abdomen becomes
relatively gasless.
Sigmoid volvulus
Treatment of acute intestinal obstruction
Adynamic Obstruction
• Paralytic Ileus  failure of transmission of peristaltic waves
secondary to neuromuscular failure [i.e. in the myenteric (Auerbach’s)
and submucous (Meissner’s) plexuses].
• Accumulation of fluid and gas within the bowel, with associated
distension, vomiting, absence of bowel sounds and absolute
constipation
• Varieties: Postoperative, infection, reflex ileus, metabolic (uremia and
hypokalemia
• Paralytic ileus
• there has been no return of bowel sounds on auscultation;
• there has been no passage of flatus.
• Abdominal distension becomes more marked and tympanitic.
• Pain is not a feature. In the absence of gastric aspiration, effortless
vomiting may occur.
• Radiologically, the abdomen shows gasfilled loops of intestine with
multiple fluid levels.
Management
• The primary cause must be removed.
• Gastrointestinal distension must be relieved by decompression.
• Close attention to fluid and electrolyte balance is essential.
• There is no place for the routine use of peristaltic stimulants. Rarely, in
resistant cases, medical therapy with an adrenergic blocking agent in
association with cholinergic stimulation, e.g. neostigmine (the Catchpole
regimen), may be used, provided that an intraperitoneal cause has been
excluded.
• If paralytic ileus is prolonged and threatens life, a laparotomy should be
considered to exclude a hidden cause and facilitate bowel decompression.
Thank you