ACUTE ABDOMEN

Prof. Dr. Shahzad Bashir

 ACUTE ABDOMEN
Any abdominal condition of abrupt onset, usually the
pain, due to inflammation, perforation, obstruction,
infarction or rupture of intra – abdominal organs.
 Abdominal Quadrants

To make it easier for medical professionals to study about

abdomen. Abdomen is divided into quadrants.

There are two types of abdominal quadrants schemes.

1) 9 Region scheme
2) 4 Region scheme
9 Region scheme
4 Region scheme
 Contents of abdomen
• Right upper quadrant - liver: right lobe, gallbladder, stomach: pylorus, doudenum:
part 1-3, pancreas: head, right suprarenal gland, right kidney, right colic (hepatic)
flexure, ascending colon: superior part, transverse colon: right half

• Left upper quadrant - liver: left lobe, spleen, stomach, jejunum and proximal
ileum, pancreas: body and tail, left kidney, left suprarenal gland, left colic (splenic)
flexure, transverse colon: left half, descending colon: superior half

• Right lower quadrant - cecum, vermiform appendix, most of ileum, ascending

colon: inferior part, right ovary, right uterine tube, right ureter: abdominal part,
right spermatic cord: abdominal part, uterus (if enlarged), urinary bladder (if very
full)

• Left lower quadrant - sigmoid colon, descending colon: inferior part, left ovary, left
uterine tube, left ureter: abdominal part, left spermatic cord: abdominal part,
uterus (if enlarged), urinary bladder (if very full)
 The Physiology of Abdominal Pain
• Abdominal pain from any cause is mediated by
either visceral or somatic afferent nerves
• Several factors can modify expression of pain
Age extremes
Vascular compromise
Pregnancy
CNS pathology
Neutropenia
 Visceral Pain
• Stimuli
Distention of the gut or other
hollow abdominal organ
Traction on the bowel mesentery
Inflammation
Ischemia
• Sensation
Corresponds to the
embryologic origin of the
diseased organ (foregut,
midgut, hindgut)
 Somatic pain
• Stimuli
Irritation of the
peritoneum
• Sensation
Sharp, localized pain
Easily described
• Cardinal signs
Pain
Guarding
Rebound Example: McBurney’s point
Absent bowel sounds in late appendicitis
Patterns of reffered pain
 Causes of acute abdomen
1) Hemorrhage in the… 2) Perforation of the…
1) GI tract 1) GI tract
Blood vessel Ulcer
2) GU tract Infection
Parasites
cancer
3) Obstruction of the … 4) Inflammation of the…
1) GI tract Appendicitis
Adhesions Cholecystitis
Hernia Diverticulitis
Volvulus IBD
Tumor Pancreatitis
Intussusception Salpingitis
Parasites
2) GU tract
Stone
Tumor
3) Vascular System
Thrombus/Embolus
 Signs & Symptoms
• Signs • Symptoms
Tenderness Pain
Rigidity Anorexia, Nausea,
Masses Vomiting, dysphagia
Altered bowel sounds Weight loss
Bleeding Bloating, Diarrhea,
Jaundice Constipation,
Flatulence
 D/D’s of RUQ Pain

CONDITIONS CLUES
1) Biliary colic, acute, Recurrent attacks, tender over galbladder area
cholecystitis
2) Acute hepatitis Alcohol history, jaundice, medications
3) Right pyelonephritis Dysuria, fever, costovertebral angle tenderness
4) CHF Edema, dyspnea, elevated JVP
5) Retrocecal Shift of pain, tenderness
appendicitis
6) Right lower lobe Fever, tachypnea, bronchial breathing
pneumonia
 D/D’s of LUQ Pain

CONDITIONS CLUES
1) Splenic rupture History of trauma or splenic disease
2) Fractured ribs History of trauma, gross deformity, extreme
tenderness on palpation
3) Pancreatitis History of alcohol consumption, history of
similar event, elevated labs
4) Gastritis/Peptic Recurrent, relationship to meals, relationship
ulcer to posture
5) Pneumonia Fever, XR findings, bronchial breathing
 D/D’s of RLQ Pain
CONDITION CLUES
1) Acute appendicitis Shift of pain, anorexia, localized tenderness
2) Right renal colic Colicky pain, hematuria
3) Torsed right testis Tender swollen testis, usually young age
4) Crohn’s disease Recurrent, several days history
GYNECOLOGIC CAUSES
1) Ruptured follicle Fever, cervical excitation, discharge
2) Torsion of ovary Midcycle, sudden onset
3) Ruptured ectopic Severe pain, vomiting
Pregnancy
4) Pelvic inflammatory Sudden onset, amenorrhea, shock
Disease
 D/D’s of LLQ Pain
CONDITION CLUES
1) Diverticular disease Elderly patient, recurrent
2) Acute urinary Palpable bladder, difficulty passing urine
retention
3) UTI Dysuria, frequency
4) Inflammatory bowel Recurrent attacks, diarrhea (+/- mucus, blood)
disease
5) Large bowel Colicky pain, obstipation
obstruction

GYNECOLOGIC CAUSES SAME AS RLQ

 D/D’s of Periumbilical Pain
CONDITION CLUES
1) Gastroenteritis Vomiting and diarrhea
2) Constipation Colicky pain, hard stool
3) Early appendicitis Nausea, short history
4) Inflammatory bowel Recurrent diarrhea, +/- mucus and blood
disease
5) Small bowel Colicky pain, vomiting, no flatus
obstruction
6) Ischemic bowel Severe pain, tenderness less
marked, rectal bleeding
 Common GI causes of Acute Abdomen

• Appendicitis
• Perforated peptic ulcer
• Intestinal perforation
• Meckel’s diverticulum
• Diverticulitis
• Chronic irritable bowel disease
• Gastroenteritis
 Common Visceral causes of Acute Abdomen

• Acute pancreatitis
• Acute calculous cholecystitis
• Acalculous cholecystitis
• Hepatic abscess
• Ruptured hepatic tumor
• Acute hepatitis
• Splenic rupture
 Common Gynecologic causes of Acute
Abdomen
• Ruptured ovarian cyst
• Ovarian torsion
• Ectopic pregnancy
• Acute salpingitis
• Pyosalpinx
• Endometritis
• Uterine rupture
 Extra abdominal causes of Acute Abdomen

1) Supradiaphragmatic 4) Drugs
• Myocardial infarction 5) Metabolic
• Pericarditis 6) Nervous
• Left lower lobe pneumonia Herpes zooster
• Pneumothorax Tabes dorsalis
• Pulmonary infarction Nerve root compression
2) Hematologic
• Sickle cell disease
• Acute leukemia
3) Endocrine
• Diabetic ketoacidosis
• Addisonian crisis
ACUTE APPENDICITIS
Dr. Shahzad Bashir
K.M.S.M.C.
• " No single evaluation can
substitute for the diagnostic
accuracy of the experienced
physician."
 Acute appendicitis is an inflammation of a
vermiform appendix caused by purulent
microflora.
• Approximately 7 percent of the population will have appendicitis in their lifetime with
the peak incidence occurring between the ages of 10 and 30 years.
• Despite technologic advances, the diagnosis of appendicitis is still based primarily on
the patient's history and the physical examination.
 Etiology and pathogenesis
• Obstruction of the narrow appendiceal lumen initiates the clinical illness of acute
appendicitis.
• Obstruction has multiple causes
• lymphoid hyperplasia
• fecaliths
• Parasites
• Crohn's disease
• primary or metastatic cancer
• carcinoid syndrome.
 Symptoms of simple appendicitis

1. Pain localized in a right iliac area.

In 70 % of patients the pain arises in a epigastric area – it is an epigastric phase of acute
appendicitis. In 2-4 hours it migrates to the area of appendix (the Kocher’s sign).

2. Single nausea and vomiting.

3. Fever to 37.5-380C.
4. Retention of stool or single diarrhea.
5. Muscular tension in a right iliac area.
 Signs of Acute appendicitis
 Tenderness at McBurney's point

 Rbound tenderness

 Rovsing's sign

 Psoas sign

 Obturator sign

 Hamstring Sign
 MANTRELS Score

 Established in 1986
 Migration of pain
 Anorexia
 Nausea / vomiting
 Tenderness RLQ
 Rebound
 Elevated temp.
 Leukocytosis
 Shift to left
 MANTRELS Score, cont'd.

 RLQ tenderness and leukocytosis = 2

points each ; all others 1 point

 Score of 5 to 6 = possible appendicitis

 Score of 7 to 8 = probable appendicitis

 Score of 9 to 10 = very probable

appendicitis
 Investigaions
 CBC
 75 to 85 % have elevated WBC, but it is
nonspecific
 WBC normal in 80 % in the first 24 hrs.
 Can see elevated ANC in up to 89 %
 WBC usually 12 to 18,000 in
appendicitis
 Urinalysis
 Specific gravity, ketones
 Can see WBC’s, RBC’s, bacteria if inflamed
appendix close to ureter
 > 30 WBC’s = probable UTI
 HCG
 Essential in women of child-bearing age
 CRP
 Acute phase reactant
 Ultrasound
 75 to 90 % sensitive, 86 to 100 % specific
 Noninvasive, low cost, but operator-
dependent
 Good for diagnosing GYN disorders
 3 criteria for diagnosis
ƒ Tender, noncompressible appendix

ƒ No peristalsis of appendix

ƒ Overall diameter > 6 mm

 CT
 Criteria for appendicitis :
Diameter > 6 mm
ƒ

ƒ Failure to completely fill with contrast or

air
ƒ Appendicolith

ƒ Wall thickening or enhancement

 Other contributory signs include fat

stranding, fluid, inflammatory mass,
adenopathy
 Symptoms of phlegmonous appendicitis

1. Expressed pain in a right iliac area.

2. Fever to 38-390C.
3. Muscular rigidity in a right iliac area.
 Symptoms of gangrenous appendicitis

1. Pain in a right iliac area.

2. Grave condition of the patient.
3. Signs of local peritonitis.
4. Signs of intoxication
 Symptoms of retrocaecal appendicitis
1. Non-expressive abdominal clinic.
2. Expressed pain in a right lumbar area.
3. Pain and muscular rigidity in a right iliac area during
palpation.
Psoas sign - pain on extension of right thigh
 Complications

1. Appendicular abscess.
3. Diffuse peritonitis.
4. Pilephlebitis
 Differential diagnostics
Gastrointestinal Gynecologic
•Cholecystitis •Ectopic pregnancy
•Crohn's disease •Endometriosis
•Duodenal ulcer •Ovarian torsion
•Gastroenteritis •Pelvic inflammatory
•Intestinal obstruction disease
•Meckel's diverticulitis •Ruptured ovarian cyst
•Mesenteric lymphadenitis •Tubo-ovarian abscess
•Necrotizing enterocolitis
•Neoplasm (carcinoid,
carcinoma, lymphoma)
 Differential diagnostics
Systemic Genitourinary
• Diabetic ketoacidosis • Kidney stone
• Henoch-Schonlein • Pyelonephritis
purpura • Wilms' tumor
Pulmonary Other
• Pleuritis • Parasitic infection
• Pneumonia (basilar) • Psoas abscess
• Pulmonary infarction • Rectus sheath
hematoma
Differential diagnostics of acute appendicitis
with perforated peptic ulcer

• Pain in the right iliac • Sharp acute diffuse pain

region • Ulcerative anamnesis
• Muscular tenderness in • Absence of hepatic
the right iliac region dullness
• Single vomiting and • On X-ray of the
diarrhea abdomen air above the
liver (air sickle)
• Rigidity of anterior
abdominal wall
 Differential diagnostics of acute appendicitis
with intestinal obstruction
• Constant pain in the right • Periodic acute diffuse pain
iliac region • Constant vomiting and
• Muscular tenderness in the nausea without any relief
right iliac region • Retention of stool and gases
• Single vomiting and diarrhea • Abdominal distension
• On X-ray of the abdomen
Kloiber's cups (air-fluid
levels)
• Splashing sound, increased
peristalsis
Differential diagnostics of acute appendicitis with
acute cholecystitis

• Constant pain in the • Acute pain in a right

right iliac region hypohondrium with
• Muscular tenderness in irradiation to the scapula
the right iliac region • Muscular tenderness in a
• Single vomiting and right hypohondrium
diarrhea • Vomiting by bile and nausea
without any relief
• Ortner's symptom, phrenic
symptom, Murphy’s sign
• Increased serum bilirubin
 Differential diagnostics of acute appendicitis
with gynecologic disorders

• Constant pain in the • Acute pain in a lower part

right iliac region of the abdomen
• Muscular tenderness • Dependence on menstrual
in the right iliac region cycle
• Single vomiting and • Vaginal discharge
diarrhea • Blood by punction of
vaginal vault
• Bimanual vaginal
investigation
 Differential diagnostics of acute appendicitis
with renal colic
• Constant pain in the • Periodic acute pain in the
right iliac region lumbar region with
• Muscular tenderness irradiation to thigh
in the right iliac region • Vomiting and nausea
• Single vomiting and • Pasternatsky’s sign
diarrhea • Fresh erythrocytes in
urine analysis
Steps of operation in appendicitis
Steps of operation in appendicitis
Steps of operation in appendicitis
Steps of operation in appendicitis
Intestinal Obstruction
INTESTINAL OBSTRUCTION is a mechanical
or functional obstruction of the intestines,
preventing the normal transit of the
products of digestion. It can occur at any
level distal to the duodenum of the small
intestine and is an emergency.
 CLASSIFICATION

Intestinal obstruction may be classified into

two types:
• Dynamic:- in which peristalsis is working against a
mechanical obstruction. It may occur in an acute or a chronic
form
• Adynamic:- in which there is no mechanical obstruction;
peristalsis is absent or inadequate (e.g. paralytic ileus or
pseudo-obstruction).
 Causes of intestinal obstruction
• Dynamic • Adynamic
– Intraluminal – Paralytic ileus
• Faecal impaction – Pseudo-obstruction
• Foreign bodies
• Bezoars
• Gallstones
– Intramural
• Stricture
• Malignancy
• Intussusception
• Volvulus
– Extramural
• Bands/adhesions
• Hernia
 PATHOPHYSIOLOGY
• Irrespective of aetiology or acuteness of onset, in
dynamic (mechanical) obstruction the bowel proximal
to the obstruction dilates and the bowel below the
obstruction exhibits normal peristalsis and absorption
• Until it becomes empty and collapses.
• Initially, proximal peristalsis is increased in an
attempt to overcome the obstruction. If the
obstruction is not relieved, the bowel continues to
dilate, ultimately there is a reduction in peristaltic
strength, resulting in flaccidity and paralysis.
Pie chart showing the common causes of dynamic
intestinal obstruction and their relative frequencies.
 STRANGULATION
It is important to appreciate that the
consequences of intestinal obstruction are not
immediately life-threatening unless there is
superimposed strangulation. When
strangulation occurs, the blood supply is
compromised and the bowel becomes
ischaemic. Ischaemia from direct pressure on
the bowel wall from a constricting band
 CAUSES OF STRANGULATION
• Direct pressure on the bowel wall
• Hernial orifices
• Adhesions/bands
• Interrupted mesenteric blood flow
• Volvulus
• Intussusception
• Increased intraluminal pressure
• Closed-loop obstruction
Distension. Closed-loop obstruction with no proximal (A)
or distal (C) distension and impending strangulation (B).
Carcinomatous stricture (X) of the hepatic
flexure: closedloop obstruction.
 SPECIAL TYPES OF MECHANICAL
INTESTINAL OBSTRUCTION
• Internal hernia
• Obstruction from enteric strictures
• Bolus obstruction
• Obstruction by adhesions and bands
• Volvulus
 Internal hernia
Internal herniation occurs when a portion of the small
intestine becomes entrapped in one of the
retroperitoneal fossae or in a congenital mesenteric
defect.
• the foramen of Winslow;
• defect in the mesentery;
• defect in the transverse mesocolon;
• defects in the broad ligament;
• congenital or acquired diaphragmatic hernia;
• duodenal retroperitoneal fossae – left paraduodenal and
rightduodenojejunal;
• caecal/appendiceal retroperitoneal fossae – superior, inferior and
retrocaecal;
• intersigmoid fossa.
Obstruction from enteric strictures

• Small bowel strictures usually occur

secondary to tuberculosis or Crohn’s
disease.
• Malignant strictures associated with
lymphoma are uncommon,
• whereas carcinoma and sarcoma are rare.
• Presentation is usually subacute or chronic.
 Bolus obstruction

Bolus obstruction in the small bowel may

be caused by gallstones, food, trichobezoar,
phytobezoar, stercoliths and worms.
Obstruction by adhesions and
bands
• Adhesions
• Bands
• Intussusception
 Adhesions
• where abdominal operations are common,
adhesions and bands are the most common
cause of intestinal obstruction.
• The lifetime risk of requiring an admission to
hospital for adhesional small bowel obstruction
subsequent to abdominal surgery is
• around 4 per cent
• the risk of requiring a laparotomy around 2 per cent.
• Adhesions start to form within hours of
abdominal surgery.
 The common causes of intra-
abdominal adhesions.
Acute inflammation Sites of anastomoses,
reperitonealisation of raw
areas, trauma, ischaemia

Foreign material Talc, starch, gauze, silk

Infection Peritonitis, tuberculosis
Chronic inflammatory Crohn’s disease
conditions
Radiation enteritis
 Prevention of adhesions

Factors that may limit adhesion formation

include:
• Good surgical technique
• Washing of the peritoneal cavity with saline to remove
clots
• Minimising contact with gauze
• Covering anastomosis and raw peritoneal surfaces
 Bands
Usually only one band is culpable. This may be:
• congenital, e.g. obliterated vitellointestinal duct;
• a string band following previous bacterial peritonitis;
• a portion of greater omentum, usually adherent to the
parietes.
 Acute intussusception
• This occurs when one portion of the gut
invaginates into an immediately adjacent
segment; almost invariably, it is the proximal
into the distal.
• About 90 per cent of cases are idiopathic, but
an associated upper respiratory tract infection
or gastroenteritis may precede the condition.
Pathology of intussusception
An intussusception is composed of three parts
• the entering or inner tube (intussusceptum);
• the returning or middle tube;
• the sheath or outer tube (intussuscipiens).
Mechanism and nomenclature of
intussusception.
 Intussusception
– Most common in children
– Adult cases are secondary to intestinal pathology,
e.g. polyp, Meckel’s diverticulum
– Ileocolic is the most common variety
– Can lead to an ischaemic segment
– Radiological reduction is indicated in most
paediatric cases
– Adults require surgery
 Volvulus
A volvulus is a twisting or axial rotation of a
portion of bowel about its mesentery. The
rotation causes obstruction to the lumen
(>180° torsion) and if tight enough also
causes vascular occlusion in the mesentery
(>360° torsion).
 Volvulus

• May involve the small intestine, caecum or

sigmoid colon; neonatal midgut volvulus
secondary to midgut malrotation is life-
threatening
• The most common spontaneous type in adults is
sigmoid
• Sigmoid volvulus can be relieved by
decompression per anum
• Surgery is required to prevent or relieve
ischaemia
Causes predisposing to volvulus of the sigmoid colon.
Idiopathic megacolon usually precedes the volvulus in
African people.
 CLINICAL FEATURES OF INTESTINAL
OBSTRUCTION
The diagnosis of dynamic intestinal
obstruction is based on the classic quartet of
• Pain
• Distension
• Vomiting
• and absolute constipation.
Obstruction may be classified clinically into
two types:
• small bowel obstruction – high or low;
• large bowel obstruction
The nature of the presentation will also be
influenced by whether the obstruction is:
• complete
• incomplete.
Presentation will be further influenced by
whether the obstruction is:
• simple – in which the blood supply is intact;
• strangulating/strangulated – in which there is
interference to blood flow.
The clinical features vary according to:
• the location of the obstruction;
• the duration of the obstruction;
• the underlying pathology;
• the presence or absence of intestinal ischaemia.

Late manifestations of intestinal

obstruction that may be encountered
include dehydration, oliguria, hypovolaemic
shock, pyrexia, septicaemia, and peritonitis.
• Pain
Pain is the first symptom encountered; it occurs suddenly
and is usually severe. It is colicky in nature and usually
centred on the umbilicus (small bowel) or lower abdomen
(large bowel).
• Vomiting
The more distal the obstruction, the longer the interval
between the onset of symptoms and the appearance of
nausea and vomiting.
• Distension
In the small bowel, the degree of distension is dependent
on the site of the obstruction and is greater the more
distal the lesion.
• Constipation
This may be classified as absolute (i.e. neither faeces nor
flatus is passed) or relative (where only flatus is passed).
Absolute constipation is a cardinal feature of complete
intestinal obstruction.

The rule that absolute constipation is present in intestinal

obstruction does not apply in:
• Richter’s hernia;
• gallstone ileus;
• mesenteric vascular occlusion;
• functional obstruction associated with pelvic
abscess;
• all cases of partial obstruction (in which diarrhoea
may occur).
Other manifestations
• Dehydration
• Hypokalaemia
• Pyrexia
• Abdominal tenderness
• Bowel sounds
 Clinical features of strangulation

It is vital to distinguish strangulating from

non-strangulating intestinal obstruction
because the former is a surgical emergency.
• Constant pain, severe pain
• Tenderness with rigidity and peritonism
• Shock
Skin
discolouration
over a
strangulated
incisional
hernia.
Ischaemic small and large bowel in the strangulated
incisional hernia.
 Clinical features of intussusception

• The classical presentation of intussusception is with episodes

of screaming and drawing up of the legs in a previously well
male infant.
• The attacks last for a few minutes and recur repeatedly.
• During attacks the child appears pale; between episodes he
may be listless.
• Vomiting may or may not occur at the outset but becomes
conspicuous and bile-stained with time.
• Initially, the passage of stool may be normal, whereas, later,
blood and mucus are evacuated – the ‘redcurrant jelly’ stool.
The physical signs as recorded by Hamilton Bailey in
a typical case of intussusception in an infant.
 IMAGING
• Erect abdominal films are no longer routinely
obtained and the radiological diagnosis is
based on a supine abdominal film
• In intestinal obstruction, fluid levels appear
later than gas shadows as it takes time for gas
and fluid to separate
 Radiological features of obstruction (on plain x-ray)

• The obstructed small bowel is characterised by straight segments

that are generally central and lie transversely. No/minimal gas is
seen in the colon
• The jejunum is characterised by its valvulae conniventes, which
completely pass across the width of the bowel and are regularly
spaced, giving a ‘concertina’ or ladder effect
• Ileum – the distal ileum has been piquantly described by
Wangensteen as featureless
• Caecum – a distended caecum is shown by a rounded gas shadow
in the right iliac fossa
• Large bowel, except for the caecum, shows haustral folds, which,
unlike valvulae conniventes, are spaced irregularly, do not cross the
whole diameter of the bowel and do not have indentations placed
opposite one another
Gas-filled small bowel loop; patient supine.
Fluid levels with gas above; ‘stepladder pattern’.
Ileal obstruction by adhesions; patient erect.
 Imaging in intussusception
• A plain abdominal field usually reveals evidence of
small or large bowel obstruction with an absent caecal
gas shadow in ileocolic cases.
• A barium enema may be used to diagnose the
presence of an ileocolic intussusception (the claw sign)
• CT scan is currently considered the most sensitive
radiologic method to confirm intussusception, with a
reported diagnostic accuracy of 58–100 per cent.
• The characteristic features of CT scan include a ‘target’
or ‘sausage’- shaped soft-tissue mass with a layering
effect, mesenteric vessels within the bowel lumen are
also typical.
Claw’ sign of iliac intussusception. The barium in the
intussusception is seen as a claw around a negative shadow of the
intussusception
 Imaging in volvulus
• Caecal volvulus, radiological abnormalities are
identifiable in nearly all patients A barium enema
may be used to confirm the diagnosis if there are
no concerns about ischaemia, with an absence of
barium in the caecum and a bird beak deformity.
• Sigmoid volvulus, a plain radiograph shows
massive colonic distension.
• Volvulus neonatorium, the abdominal radiograph
shows a variable appearance. but, as the
intestinal strangulation progresses, the abdomen
becomes relatively gasless.
 Treatment of acute intestinal
obstruction
• Gastrointestinal drainage via a nasogastric
tube
• Fluid and electrolyte replacement
• Relief of obstruction
• Surgical treatment is necessary for most cases
of intestinal obstruction but should be delayed
until resuscitation is complete, provided there
is no sign of strangulation or evidence of
closed-loop obstruction
Principles of surgical intervention for
obstruction

Management of:
– The segment at the site of
obstruction
– The distended proximal bowel
– The underlying cause of obstruction
Indications for early surgical
intervention

• Obstructed external hernia

• Clinical features suspicious of
intestinal strangulation
• Obstruction in a ‘virgin’ abdomen
Differentiation between viable and non
viable intestine.
Viable Non-viable

Circulation Dark colour becomes Dark colour remains

Lighter

Visible pulsation in No detectable

mesenteric arteries Pulsation

General appearance Shiny Dull and lustreless

Intestinal musculature Firm Flabby, thin and

Friable

Peristalsis may be No peristalsis

observed
 Treatment of adhesive obstruction

• Initially treat conservatively provided there are

no signs of strangulation; should rarely continue
conservative treatment for longer than 72 hours
• At operation, divide only the causative
adhesion(s) and limit dissection
• Repair serosal tears; invaginate (or resect) areas
of doubtful viability
• Laparoscopic adhesiolysis in the hands of
advanced laparoscopic practitioners
Band adhesion causing closed-loop obstruction.
Treatment of recurrent intestinal obstruction
caused by adhesions
Several procedures may be considered in the
presence of recurrent obstruction including:
• repeat adhesiolysis (enterolysis) alone;
• Noble’s plication operation;
• Charles–Phillips transmesenteric plication;
• intestinal intubation.

The latter three operations are now very rarely

performed and can probably be consigned to the
history books
 Treatment of intussusception
• Non-operative reduction can be attempted using an air
or barium enema. Successful reduction can only be
accepted if there is free reflux of air or barium into the
small bowel, together with resolution of symptoms and
signs in the patient. contraindicated if there are signs of
peritonitis or perforation. Perforation of the colon during
pneumatic or hydrostatic reduction is a recognised hazard
• Surgery is required when radiological reduction has failed
or is contraindicated. After resuscitation, a transverse
rightsided abdominal incision provides good access.
Reduction is achieved by gently compressing the most
distal part of the intussusception toward its origin
Diagram showing the method used to reduce
an intussusception.
Reducing the terminal part of the
intussusception