1. department of surgery and anesthesiology № 2
INTESTINAL OBSTRUCTION
S. KOSTIV
department of surgery and anesthesiology № 2

2. Intestinal obstruction is a complete or partial disturbance of intestinal evacuation and peristalsis resulting from various causes which manifests by specific clinical course and morphologic changes of involved part of the bowel
Intestinal obstruction occurs approximately in 9.4 % among urgent abdominal pathology, consisting 1.2 % of all surgical diseases.

5. Classification (by D.P.Chuhrienko)
1. Dynamic intestinal obstruction:
a) paralytic;
b) spastic.
2. Mechanical intestinal obstruction:
a) strangulation;
b) obturation;
c) mixed (invagination).
II. According to the course of pathological process.
1. Stage of acute disturbance of intestinal evacuation and peristalsis.
2. Stage of hemodynamic disorders of the bowel wall and its mesentery.
3. Stage of peritonitis.

8. Ileus: Common Etiologies

9. Etiologic and contributing factors
Adhesions (50 %).
Tumours.
Bile stones.
Inflammatory infiltrates in the abdominal cavity.
Internal hernias.
Increasing of abdominal pressure.
Defects of the peritoneum.
Long mesentery of the bowel.

10. Pathogenesis Vomiting Intestinal block
Transudation of intestinal juice
Vomiting
Intestinal block
Accumulation of intestinal contents
Distention of intestinal wall
Loss of electrolytes, dehydratation, loss of potassium, loss of proteins
Necrosis of the bowel
Peritonitis
Intoxication, hemodynamic disturbances
More higher the obstruction, more severe the pathologic changes

11. Pathogenesis

12. Peculiarities of strangulated intestinal obstruction
Transfusion of large quantity of proteins;
Transfusion of erythrocytes and decreasing of volume of circulating blood;
Severe dehydratation, caused by additional edema of the bowel wall;
Rapid necrosis of intestinal wall with subsequent peritonitis and intoxication.

13. Clinical manifestation
It depends on the level of the block, type and degree of obstruction and its cause.
1. Acute onset of the disease.
2. Periodic acute diffuse pain of wavelike character which results in shock.
3. Constant vomiting and nausea without any relief.
4. Signs of dehydratation and intoxication (The patient looks anxious, with drawn features, hollowed-eyed, his lips and tongue are dry, with brown fur).
5. Retention of stool and gases.

14. Objective examination
1. Signs of shock.
2. Distended and asymmetric abdomen.
3. Splashing sound (Sklyarov’s sign).
4. Increased peristalsis in early period with further absence.
5. Wahl’s sign - high tympanic sound over the distended bowel.
6. PR: empty and distended anus and rectal ampoule - (Grekov’s sign).
7. In intestinal strangulation and advanced cases of obstruction - peritoneal signs.

15. X-ray examination 1. Kloiber's cups (air-fluid level)
2. Intestinal pneumatisation

18. CT

19. Differential diagnostics of acute intestinal obstruction with perforative peptic ulcer
Sharp acute diffuse pain
Ulcerative anamnesis
Absence of hepatic dullness
On X-ray of the abdomen air above the liver (air sickle)
Rigidity of anterior abdominal wall
Periodic acute diffuse pain
Constant vomiting and nausea without any relief
Retention of stool and gases
Abdominal distension
On X-ray of the abdomen Kloiber's cups (air-fluid levels)
Splashing sound, increased peristalsis

20. Differential diagnostics of acute intestinal obstruction with acute pancreatitis
Sharp acute constant girdle pain with irradiation into left scapule
Vomiting and nausea without any relief
Mayo-Robson symptom
Increased serum amylase
Increased urinary diastase
No retention of stool and gases
Abdominal distension only in advanced cases.
No increased peristalsis
Periodic acute diffuse pain
Constant vomiting and nausea without any relief
Retention of stool and gases
Abdominal distension
On X-ray of the abdomen Kloiber's cups (air-fluid levels)
Splashing sound, increased peristalsis

22. Conservative treatment
Conservative treatment is indicated only in:
1. Adhesive obstruction without signs of strangulation.
2. Initial stages of invagination.
3. Initial stages of low obturation
Gastric decompression
Siphon enema
Paranephral procaine block
Ganglio- and sympatholytics
Correction of water-electrolyte balance

23. Surgical treatment
is indicated only if no improvement during 3-4 hours of conservative treatment
Wide laparotomy
Procaine block of mesenteric root
Revision of intestine and detecting of the level and cause of obstruction
Decompression of intestine proximal to the obstruction
Assessing of viability of the bowel (peristalsis, colour, vascular pulsation)
Removal of the obstruction (division of adhesions, intestinal resection, collateral anastomosis)
External drainage of intestine (nasogastrointestinal intubation, rectal tube)

25. Strangulation intestinal obstruction
1. Volvulus, (torsion).
2. Nodulus (knots).
3. Hernial strangulation (incarceration).
4.Invagination (refers to mixed forms of intestinal obstruction)
Causes
Elongation of intestinal loop.
Increasing of abdominal pressure.
Long mesentery of the bowel.
Cicatrical shortening of mesenteric root.
Adhesions
Extensive functional overload of the bowel.

26. Volvulus (torsion) Small intestine volvulus
Clinically manifests by high strangulation intestinal obstruction
Cecal volvulus, sigmoid volvulus
Clinically: low strangulation intestinal obstruction
asymmetric abdomen
by palpation enlarged and displaced colon (like balloon)
retracted right or left iliac region
Treatment: detorsion, division of adhesions, cecopexia, colon resection

28. Nodulus
It is the most severe type of strangulation with manifestation of a high strangulated obstruction which rapidly results in shock, bowel necrosis and peritonitis
Treatment:
very short preoperative period (less 1 hour)
untie of the bowel node (till 4-5 hours from the onset)
resection of the bowel

29. Invagination
It is the insertion of one part of the bowel into the lumen of another
Clinically:
signs of obturation and in advanced cases the strangulation ileus
elastic, painful, tumourlike formation in the abdomen
blood in stool (or during rectal examination)
Treatment:
desinvagination or resection

31. Paralytic ileus peritonitis mesenteric thromboses cranial trauma
Abdominal
peritonitis
mesenteric thromboses
hemoperitoneum
pancreatitis
postoperative ileus
Retroperitoneal
phlegmone
hematoma
renal colic
spinal trauma
Other
cranial trauma
acidosis
diminished potassium
hypoproteinemia
uremia

32. Spastic ileus hepatic colic ascaridosis lead poisonong renal colic
Abdominal
hepatic colic
ascaridosis
Retroperitoneal
renal colic
Other
lead poisonong

33. Treatment of dynamic ileus
1. Cholynomymetics (Proserin, ubretid).
2. Intravenous infusion of hypertonic solution (10 % NaCl).
3. Hypertonic enema.
4. Oil enema.
5. Gastric decompression.
6. Paranephral novocaine block.
7. Ultrasound stimulation.