Intestinal Obstruction Laila Tavazo, REM

Case A 50 year old man presents with abdominal pain, distension and absolute constipation. With repeated episodes of vomiting. Vital sign were stable, abdomen distended with diffuse tenderness but minimal peritonism. Bowel Sounds are hyperactive. The plain abdominal xray was taken on admission.

Definition Lack of transit of intestinal contents is called intestinal obstruction Intestinal obstruction is a very common problem encountered in the ED, accounting for up to 15% of all emergency admissions for abdominal pain.

Classification

Lesions Causing Small Bowel Obstruction Relative to the Intestinal Wall

Causes of Adynamic Ileus

Differentiating SBO from Paralytic Ileus   SBO Ileus Etiology Patient with prior surgery weeks to years prior Recent (hours) post- operative patient Pain Colicky Not a prominent feature Abdominal distension Frequently prominent Sometimes not apparent Bowel sounds Usually increased Usually absent Small bowel dilatation Present Large bowel dilatation Absent

Intestinal obstruction

Clinical Findings 1. History Colicky abdominal pain, vomiting, constipation (absolute), abdominal distension. Colonic Pre-existing change in bowel habit Colicky in the lower abdomen Vomiting is late Distension prominent Distal small bowel Pain: central and colicky Vomitus is feculunt Distension is severe Visible peristalsis May continue to pass flatus and feacus before absolute constipation Proximal small bowel Pain is rapid Vomiting copious and contains bile jejunal content Abdominal distension is limited or localized Rapid dehydration

Clinical Findings 2. Examination Others Systemic examination If deemed necessary. CNS Vascular Gynaecological muscuoloskeltal Abdominal Abdominal distension Previous surgical scar Hernia Visible peristalsis Cecal distension Tenderness, guarding and rebound Organomegaly Bowel sounds High pitched Absent Rectal examination General Vital signs: P, BP, RR, T, Sat dehydration Anaemia, jaundice, LN Assessment of vomitus if possible Full lung and heart examination

Diagnostic Lab: CBC (leukocytosis, anemia, hematocrit, platelets) Clotting profile Arterial blood gasses BUN, Crt, Na, K, Amylase, LFT and glucose CPK, LDH, I-FABP Optional (ESR, CRP, Hepatitis profile)

Diagnostic Plain radiographs can diagnose SBO in 50 to 60% of cases but usually cannot identify the cause of the obstruction. CT scanning is much better for determining the cause and is also very useful in identifying strangulation complicating SBO.

Diagnosis of small bowel obstruction

Diagnosis of large bowel obstruction

Normal Ileus

Sigmoid volvulus Cecal volvulus Bird’s beak volvulus

Other causes Intussusception Gall stone Ileus IBD

Hernia

multiple fluid-filled and dilated loops of small bowel (white arrows) and collapsed right colon (red arrow)

String of pearl sign

Coffee bean sign Whirl sign

Ogilvie’s Syndrome Ogilvie’s syndrome, or acute colonic pseudo-obstruction, is a rare clinical entity that usually accompanies other medical or surgical conditions. It usually responds to non-operative therapy, but occasionally requires surgical intervention. Sir Heneage Ogilvie, first described Ogilvie’s syndrome, or isolated colonic pseudo-obstruction, in 1948 in the British Medical Journal. He postulated that the colonic ileus was secondary to an imbalance between parasympathetic and sympathetic innervation caused by metastatic disease to the celiac plexus.

Treatment Resuscitation. Conservative treatment Previous surgery. Incomplete obstruction. Advanced malignancy. Uncertain diagnosis. C. Indications for surgery Generalized or localized peritonitis. Perforation. Irreducible hernia. Palpable mass. Closed loop Failure to improve.

Treatment

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