Intestinal Obstruction

by
Dr. GE NJEZE
 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 and
is a surgical emergency
• Signs and symptoms
• Depending on the level of obstruction, bowel
obstruction can present with
• abdominal pain,
• abdominal distension,
• vomiting,
• and constipation.
• Tinkly bowel sounds
• heard with a stethoscope in someone with a small
bowel obstruction.
• In small bowel obstruction (SBO)
• the pain is colicky (cramping and intermittent) ,
• with spasms lasting a few minutes.
• The pain tends to be central and mid-abdominal.
• Vomiting occurs before constipation.
• In large bowel obstruction the pain is felt
lower in the abdomen and the spasms last
longer.
• Constipation occurs earlier and vomiting may
be less prominent.
• Proximal obstruction of the large bowel may
present as small bowel obstruction.
 Pathophysiology Of Intestinal
Obstruction

• In simple mechanical obstruction, blockage occurs

without vascular compromise.
• Ingested fluid and food, digestive secretions, and gas
accumulate above the obstruction.
• The proximal bowel distends, and the distal segment
collapses.
• The normal secretory and absorptive functions of
the mucosa are depressed, and
• the bowel wall becomes edematous and congested.
• This is progressive, intensifying the peristaltic and
secretory derangements and
• increasing the risks of dehydration and progression to
strangulating obstruction.
• Strangulating obstruction is obstruction with
compromised blood flow
• it occurs in nearly 25% of patients with small-bowel
obstruction.
• It is usually associated with hernia, volvulus, and
intussusception.
• Strangulating obstruction can progress to
infarction and gangrene in as little as 6 hrs.
• Venous obstruction occurs first,
• followed by arterial occlusion, resulting in
rapid ischemia of the bowel wall.
• The ischemic bowel becomes edematous and
infarcts, leading to gangrene and perforation.
• In large-bowel obstruction, strangulation is
rare (except with volvulus).
• Perforation may occur in an ischemic segment
(typically small bowel) or
• when marked dilation occurs.
• The risk is high if the caecum is dilated to a
diameter ≥ 13 cm.
• Perforation of a tumor or a diverticulum may
also occur at the obstruction site.
 Closed loop obstruction
• Two points along the course of a bowel are
obstructed,usually at a single location thus forming a
closed loop.
• Usually this is due to adhesions, a twist of the mesentery
or internal herniation.
• In the large bowel it is known as a volvulus.
• In the small bowel it is simply known as small bowel
closed loop obstruction.
• Especially in the small bowel the risk of strangulation and
bowel infarction is high with a mortality rate of 10-35%.
Bowel loop before and after strangulation
Colonic diagram
Colonic tumors can cause closed loop
obstruction
 Complications
• Bowel obstruction may be complicated by
dehydration and electrolyte abnormalities due
to vomiting;
• respiratory compromise from pressure on the
diaphragm by a distended abdomen, or
• aspiration of vomitus;
• bowel ischaemia or perforation from prolonged
distension or
• pressure from a foreign body.
 Causes: Small bowel obstruction

1. Adhesions from previous abdominal surgery

2. Hernias containing bowel
3. Crohn's disease causing adhesions or
inflammatory strictures
4. Neoplasms, benign or malignant
5. Intussusception in children
6. Volvulus
7. Ischaemic strictures; Intestinal atresia
7. Superior mesenteric artery syndrome,(SMA)--
a condition in which the duodenum is
compressed between two arteries (the aorta
and the superior mesenteric artery).
• This SMA causes partial or complete blockage
of the duodenum.
8. Foreign bodies (e.g. gallstones in gallstone
ileus, swallowed objects)
9. Carcinoid, but rare, preferred location: ileum
Superior mesenteric artery syndrome,
(SMA)
Intussusception
Intussusception
 Causes of Large bowel obstruction

• Neoplasms, Hernias
• Inflammatory bowel disease
• Colonic volvulus (sigmoid, caecal, transverse colon)
• Adhesion
• Constipation/Fecal impaction/Fecaloma
• Colon atresia
• Intestinal pseudo-obstruction
• Benign strictures (diverticular disease)
• Endometriosis
 Differential diagnosis

• (i) Ileus, (ii) Intra-abdominal sepsis

• (iii) Pneumonia or other systemic illness.
• (iv) Pseudo-obstruction or Ogilvie's syndrome--a
condition characterized by acute massive colonic
distension in the absence of mechanical
• obstruction, probably due to imbalance in the
regulation of colonic motor activity by
• the autonomic nervous system. Varicella zoster virus (
chickenpox and shingles) in the enteric ganglia may be
a cause of Ogilvie syndrome.
 Factors that predispose to psedo-
obstruction
• Idiopathic
• Metabolic-Diabetes Melitus
• Acute hypokalemia
• Uremia
• Myxodema
• Severe trauma (especially to the lumbar spine and
pelvis
• Shock
• Burns
 Factors that predispose to psuedo-
obstruction cont’d
• Myocardial infarction
• Stroke
• Septicaemia
• Retroperitoneal irritation by
• (i) blood
• (ii) urine
• (iii) enzyme(pancreatitis)
• Tumor
 Factors that predispose to psedo-
obstruction cont’d
• Drugs e.g.
1. Tricyclic antidepressants
2. Phenothiazines
3. Laxatives
• Secondary gastrointestinal involvement e.g.
1. Scleroderma
2. Chagas disease
 Diagnosis

• History-obtain a history of pain, vomiting, fever, bowel

movements, flatus, obstipation (a severe form
of constipation), and associated symptoms
• Physical examination in the standard fashion
• Abdominal examination for a mass, tenderness, rigidity
and guarding. Percuss & also auscultate.
• The inguinal and femoral regions are examined for
incarcerated hernias
• Digital rectal examination for low sigmoid or rectal
mass, and hard impacted stools
 The main diagnostic tools are:
• Plain abdominal X-rays-erect and supine views to
show
• (i) bowel distension wider than 2.5 cm
• (ii) multiple air-fluid levels,
• (iii) valvulae conniventes,
• (iv) featureless bowel distension
• (v) haustration
• CT scanning and/or ultrasound
• Blood tests-(i) PCV for dehydration, and (ii) Hb
• (i) Contrast enema or (ii) small bowel series or
(iii) CT scan can be used to define the level of
• obstruction, whether the obstruction is partial
or complete, & to help define the cause of the
obstruction.
• Enteroclysis and CT Enterography
• Enteroclysis is the use of a contrast agent
normally administered through a nasogastric
tube for imaging of the small intestine
• Enteroclysis is valuable in detecting the
presence of obstruction and
• in differentiating partial from complete
blockages.
• This study is useful when plain radiographic
findings are normal in the presence of clinical
signs of small-bowel obstruction (SBO) or
• when plain radiographic findings are
nonspecific.
 CT enterography/CT enteroclysis

• This modality is replacing enteroclysis in

clinical practice. In addition, it is the
• examination of choice for intermittent SBO
and in patients with a complicated surgical
history (e.g., prior surgery, tumors).
• CT enterography displays the entire thickness
of the bowel wall and allows evaluation of
surrounding mesentery and perinephric fat.
 Small bowel
obstruction X-ray erect view. Note multiple air fluid levels.
Valvulae connivantes in jejunal obstruction
Featureless dilated bowel loops- seen ileal
obstruction
Valvulae connivantes and Haustrations
Gas in the caecum
Air in the rectum
Haustrations in large bowel obstruction
 Claw sign in Intussusception

The barium in the intussusception is seen as a claw

around a negative shadow of the intussusception.
Trapping of barium between oedematous
mucosal folds of the returning limb of
intussusceptum intussuscepption
 This chest radiograph demonstrates free air under the
diaphragm, indicating bowel perforation in a patient with large-
bowel obstruction.
 CT Scanning and MRI

• CT scanning is the study of choice if the

patient has fever, tachycardia, localized
• abdominal pain, and/or leukocytosis. CT
scanning is useful in making an early diagnosis
• of strangulated obstruction and in delineating
the myriad other causes of acute abdominal
• pain, particularly when clinical and
radiographic findings are inconclusive.
A small bowel obstruction as seen on CT
 Treatment: Small bowel obstruction

• In the management of small bowel obstructions it is

often said that "never let the sun rise or set on small-
bowel obstruction“ because they are sometimes fatal if
treatment is delayed.
• This traditional surgical canon is no longer followed,
largely because of
• improvements in radiologic imaging of small bowel
obstruction, which allow confident distinction between
• simple obstructions, that can be treated
conservatively,
• and obstructions associated with surgical
emergencies (volvulus, closed-loop obstructions,
ischemic bowel, incarcerated hernias, etc.).
• A small flexible tube may be inserted from the
nose into the stomach to help decompress the
dilated bowel.
• This tube is uncomfortable but does relieve the
abdominal cramps, distension and vomiting.
 Treatment contd

1. Pass a flexible nasogastric tube to decompress the

stomach.
2. Intravenous fluids- start with normal saline or
Ringer’s solution
3. Broad spectrum antibiotic therapy for anaerobic
and aerobic organisms are utilized e.g.
metronidazole and 3rd generation cephalosporin or
meropenem
4. The urine output is monitored by urinary catheter
attached to a urine bag, aiming @30-60ml/hour.
• Most people with SBO are initially managed
conservatively because in many cases, the bowel
will open up.
• Some adhesions loosen up and the obstruction
resolves.
• However, when conservative management is
undertaken, the patient is examined several times a
day and
• X rays are obtained to ensure that the individual is
not getting clinically worse.
• Conservative treatment involves insertion of a
nasogastric tube, correction of dehydration and
electrolyte abnormalities and antibiotics.
• Opioid pain relievers may be used for patients
with severe pain.
• Adhesive obstructions often settle without
surgery.
• Most patients do improve with conservative
care in 2–5 days.
• If obstruction is complete surgery is required.
• If the cause of obstruction is cancer, surgery is
the only treatment.
• Conversely, a small bowel obstruction in a
"virgin abdomen" (an abdomen that has not
seen an operation) is almost never treated
conservatively.
 Treatment: Large bowel obstruction
1. Pass a flexible nasogastric tube to decompress the
stomach.
2. Intravenous fluids- start with normal saline or Ringer’s
solution
3. Broad spectrum antibiotic therapy for anaerobic and
aerobic organisms are utilized e.g. metronidazole and 3rd
generation cephalosporin or meropenem
4. The urine output is monitored via catheter in the bladder
attached to a urine bag, aiming @30-60ml/hour.
5. Appropriate surgical treatment which may occasionally
include a colostomy, in colonic tumors
 SIGMOID VOLVULUS

1. In order for volvulus to occur, the sigmoid colon must

be freely mobile and not tethered by peritoneal
attachments, and the mesentery must be of sufficient
length to permit at least 180 degrees of rotation.
2. Additionally, the mesosigmoid root must be
disproportionately narrow relative to the mesenteric
length.
3. In non-endemic areas of the world, chronic
constipation is a strongly correlated risk factor. The
increased fecal load is believed to dilate the sigmoid
lumen and produce elongation of the mesentery
Intraoperative Sigmoid Volvulus picture
• In endemic regions, large amounts of dietary fiber
prevent constipation but this undigested fiber may
result in excessively bulky stools.
• Other predisposing factors for sigmoid volvulus
include various causes of megacolon & constipation.
1. Hirschsprung’s disease occasionally can produce the
rare volvulus in children.
2. Trypanosomiasis (Chagas’ disease) causes
degeneration of the myenteric neuronal plexus,
chronic aperistalsis, volvulus is reported in the pts.
3. Patients suffering from multiple sclerosis and spinal cord
injuries have bowel dysfunction with constipation due to
neurological deficit. Volvulus occurs in some.
4. Parkinsonism-because of the associated constipation due
to the use of anticholinergics in the treatment, some of the
patients develop volvulus.
5. Psychiatric institutes- A high prevalence of volvulus seen
among the inmates, is attributed to the effect of
psychotropic medication on the motility of the gut.
6. Diabetic neuropathy can cause chronic constipation which
is a well recognized predisposing factor for colonic volvulus.
7. The presence of a pelvic mass also increases the risk of
developing sigmoid volvulus.
• The mass displaces the sigmoid colon sufficiently to result
in torsion of the mesentery and subsequent volvulus.
• PRESENTATION
• Males predominate. Patients tend to be younger in
developing countries as opposed to developed countries.
• Classically, the patient presents with obstipation(severe
or complete constipation), marked abdominal distention,
nausea and vomiting.
• Generalized abdominal tenderness and peritonitis point
towards the presence of an underlying gangrenous segment
in sigmoid volvulus.
• Investigations
• Plain X ray of the abdomen often reveals a hugely dilated
and rotated sigmoid colon
• Laboratory tests include a complete blood count (CBC) An
elevated white blood cell (WBC) count and left shift indicate
bowel ischemia, peritoneal infection, or systemic sepsis.
• Bowel obstruction may cause significant changes in
electrolyte levels.
 Sigmoid Volvulus. Dilated loop of sigmoid colon has a "coffee-bean" shape and
the wall between the two volvulated loops of sigmoid (black arrow) "points"
towards the right upper quadrant. There is a considerable amount of stool in the
colon from chronic constipation.
 Treatment
• Colonoscopy and attempted endoscopic detorsion of
the sigmoid volvulus should be the initial therapeutic
step for all patients without suspected frank necrosis.
• Once at the spiral transition point of the volvulus,
gentle pressure is applied and the scope advanced
through the volvulus.
• There is typically a rush of gas and fluid as the closed
loop is decompressed.
• Careful inspection of the mucosa can determine
whether ischemia has occurred.
• Immediate laparotomy is indicated for cases
when endoscopic detorsion is not successful
or in patients with signs and symptoms
suggestive of full-thickness necrosis.
• The sigmoid colon involved in volvulus
should be resected back to viable margins
and any contamination thoroughly irrigated
from the peritoneal cavity.
Sigmoid volvulus before untwisting
Sigmoid volvulus after untwisting
• In the presence of gangrene, resection is
followed by a colostomy and mucous fistula,
depending on the surgeon’s experience
• and preference, as well as whether or not it is
possible to bring the distal loop to the skin.
• This appears the best option, as these patients
are often shocked and acidotic.
• Primary resection and anastomosis of
unprepared bowel is controversial.
 Acute Mesenteric Ischaemia
• Mesenteric ischemia is a medical condition in which
injury to the small intestine occurs due
• to blood supply not being enough due to obstruction
from blood clots. Occurs in patients with irregular
heartbeat or heart disease.
• It can come on suddenly, known as acute mesenteric
ischemia, or gradually, known as chronic mesenteric
ischemia.
• The acute form of the disease often presents with
sudden severe abdominal pain and is associated with a
high risk of death.
• The chronic form is a condition in which plaque
builds up in the major arteries that supply blood
• the small intestine. Blood clots in the intestine and
can lead to: unintentional weight loss, vomiting, and
fear of eating
• It typically presents more gradually with abdominal
pain after eating,
• Risk factors for acute mesenteric ischemia include
• atrial fibrillation, heart failure, chronic kidney failure,
• and previous myocardial infarction.
 There are four
mechanisms by which poor blood flow occurs:

• Embolisation,
• Thrombosis forming in an artery,
• Thrombosis in the superior mesenteric vein,
• insufficient blood flow due to low blood
pressure or spasms of arteries
• Chronic disease is a risk factor for acute disease.
• The best method of diagnosis is angiography,
• with computed tomography (CT)
• Treatment of acute ischemia may
include stenting or medications to break down the
clot provided at the site of obstruction
by interventional radiology.
• Open surgery may also be used to remove or
bypass the obstruction and may be required to
remove any intestines that are necrotic.
• If not rapidly treated outcomes are often
poor. Among those affected even with treatment
the risk of death is 70% to 90%.
• In those with chronic disease bypass
surgery is the treatment of choice.
• Those who have thrombosis of the vein
may be treated with anticoagulation such
as heparin and warfarin, with surgery
used if they do not improve
• Most people affected are over 60 years
old. Rates are about equal in males and
females of the same age