1. GIS-K-26 INTESTINAL OBSTRUCTION Syahbuddin Harahap Division of Digestive Surgery Department of Surgery Faculty of Medicine University of North Sumatera Adam Malik Hospital

2. DEFINITION Bowel /Intestinal obstruction occurs when the normal propulsion and passage of intestinal contents does not occur BO can involve: – SBO  Small intestine – LBO  Large intestine – Generalized Ileus via systemic alterations involving both the small and large intestine

3.  Etiopathogenesis - Mechanical obstruction - Non mechanical (Functional ) obstruction Mechanical obstruction (Dynamic ) ileus refers to a lack of passage due to an “obstruction of the bowel”, which can be located anywhere in the bowel Non mechanical Obstruction (Paralytic )(adynamic) (Fungsional) ileus Paralytic ileus refers to a lack of passage due to “paralysis of the bowel”

4. Intestinal /Bowel Obstruction can also be classified according to :  Time of presentation and duration of obstruction: - Acute - Chronic  The extent of obstruction -Partial -Complete  The type of obstruction -Simple -Closed-loop -Strangulation

5. Nonmechanical Obstruction  Paralytic (adynamic) (Fungsional) ileus due to : 1.After abdominal operations 2.Inflammation  Peritonitis 3.Systemic disorders e.g. sepsis, hyponatremia, hypokalemia, hypomagnesemia 4.Retroperitoneal disorders e.g. ureter, spine fractures, hematoma 5.Thoracic conditions e.g. pneumonia, rib fractures 6.Drugs e.g opiates, psychotropics, General anesthesie  Pseudo-Obstruction Imbalance in the parasympathetic and sympathetic influences on Colonic motility. Acute colonic pseudo-obstruction, also known as Ogilvie syndrome.

6. MECHANICAL OBSTRUCTION at each age group Neonate Congenital atresia Volvulus neonatum Meconeum ileus Hirschsprung”s disease Imperforate anus Infant Stranggulated inguinal hernia Intussuception Complication of Meckel”s diverticulum Hischsprung”s diseases Young adult Adhesions and bands Strangulated ing.hernia Middle age Adhesesion and band Strangulated Ing.hernia Strangulated fem.hernia Carcinoma colon Volvulus Elderly Adhesion and bands Strangulated Ing.hernia Strangulated fem.hernia Carcinoma colon Volvulus Impacted faece s

7. Incidence Mechanical Obstruction May occur at any age 70 percent small bowel obstruction (SBO) 30 percent large bowel obstruction (LBO)

8. Common Causes SBO Adhesion60% Neoplasma20% Hernia10% Crohn 5% Miscellaneus 5% Common Causes of LBO Colon cancer 65 % Diverticulitis 20 % Volvulus 5 % Miscellaneous 10 %

9. Etiology? Extrinsic (Outside the wall ) Intrinsic (Inside the wall ) Inside the lumen

10. Extrinsic (Outside the wall) Adhesions Hernia -- inguinal, femoral, umbilical Neoplastic – extraintestinal neoplasm Volvulus (sigmoid, cecal)

11. Intrinsic (Inside the wall ) Congenital – Malrotation Neoplastic – Primary neoplasms – Metastatic neoplasms Inflammatory – Crohn's disease Miscellaneous – Intussusception – Radiation

12. Intraluminal (Inside the lumen) Gallstone Enterolith Bezoar Foreign body Parasit  Bolus Ascaris

13. Clinical Picture Mechanical obstruction The classic quartet 1.Colicky abdominal pain 2.Abdominal distension 3.Nausea and Vomiting 4.Decreased passage of stool or flatus

14. Pathophysiology Dependent upon : 1.Degree of obstruction 2.Duration of obstruction 3.Presence and severity of ischaemia Result in : 1. Accumulation of fluid and air(Sequestration within the dilated loop) Fluid disturbances massive third space losses 8 – 10 L of fluid are secreted Hypovolumic shock oliguria, hypotension,hemoconcentration 2. Electrolyte depletion 3. Bacterial overgrowth  Rapid colonisation -Maximal by 24 hrs after obstruction -Bacterial translocation to node and portal system

15. 4.Bowel distension -Chest compression by pushing up diaghragma muscle -Decreases the ability mucosa to absorb,stasis intestinal content of fluids and electrolytes -Increased intraluminal pressure  oedematous  cyanosis  intraperitoneal exudation  necrosis  perforation  peritonitis -ACS  impediment in venous return  arterial insufficiency 5. LBO Ileocaecal valve plays prominent role in pathophysiology of LBO. If competent valve = Closed loop obstruction In 10 – 20 % of individual ICV incompetent Caecal around 10 – 12 cm  the risk of perforation

16. Clinical Manifestations Altered mental stateltered mental state Vital Sign Hypovolumic shock Tachicardia Hypotension Tachipnoe Fever Oliguria

17. Abdominal Examination Patient  Supine position with the legs flexed at the hip Abdominal Colicky pain The periodicity of pain: 3 to 4 minutes pain from proximal intestinal obstruction 15 to 20 minutes pain from distal small bowel or colon On Inspection Abdominal distension Proximal obstructions may cause little or no distention Distended small bowel loops usually occupy the central abdomen Distended large bowel loops are typically seen around the periphery. Visible peristalsis which are indicative of acute small bowel obstruction Abdominal Scars  Adhesion

18. On Auscultation Performed for at least 3 to 4 minutes  Metallic sound  Borborygmi  The absence of bowel tones : Is typical of intestinal paralysis. Late  Quiet abdomen (may also indicate intestinal fatigue from long-standing obstruction).

19. On Palpation Inguinal,Femoral, Umbilical,Incisional Hernias Palpable mass Abdominal asymmetry or a protruding mass suggests an underlying malignancy, an abscess, or closed-loop obstruction. Peritoneal irritation On Percuss Dull  Fluid or Mass Tympanic  Air (Intraluminal or not ) Peritoneal irritation DRE (Digital Rectal Examination ) For Mass, Impacted faeces

20. Vomiting – NG Aspirates Consists  food and gastric chyme  bile  faeculent  GOO  Clear, food and gastric chyme  Mid to distal SBO  Bilious/Bile  Distal SBO to LBO  Feculent

21. Mechanical ObstructionNonmechanical Obstruction Abdominal Pain colicky pain severity may decrease over time as a result of bowel fatigue and atony. 3 to 4 minutes from proximal SBO 15 to 20 minutes distal SBO or LBO Diffuse, usually mild InspectionAbdominal distension Visible peristalsis Abdominal distension AuscultationMetalic Sound Borborygme Late  Quiet Abdomen Quiet abdomen Abd.X Ray Erect Supine Large small intestinal loops gas less in colon Step ladder A/F levels Gas diffusely through intestine, incl. colon May have large diffuse A/F levels Barium Enema Obvious transition point on contrast studyNo obvious transition point on contrast study ExudateNo peritoneal exudatePeritoneal exudate if peritonitis

22. Fluid resuscitation HYPOVOLEMIC SHOCK ARF ACUTE RENAL FAILURE PRERENAL INTRARENAL POSTRENAL ARF : OLIGURIA < 500 ML/d SERUM CREATININ > 3MG/dL

23. TREATMENT PRE RENAL ARF INITIAL FLUID THERAPY  RESPON TO URINARY OUTPUT  0,5 – 1 cc /kg bw  Return of normal vital sign but NO RESPON TO URINARY OUTPUT  OLIGURIA CVP ------CVP 8-12 cm of water (or 10-15 cm of water in mechanically ventilated patients). VC RENAL VASCULATURE TREATMENT DIURESIS --  FUROSEMIDE 80-200 MG IV/TWD INOTROPIC AGENTS  LOW DOSE DOPAMIN /DOBUTAMIN 0,5 -3 ug/kg bw/min VD RENAL VASCULATURE INCREASE MYOCARDIAL CONTRACTILITY

24. EVALUATION OF FLUID RESUSCITATION RETURN OF NORMAL VITAL SIGNS MENTAL STATUS URINARY OUTPUT ACID/BASE BALANCE CVP

25. Diagnoctic Studies  Laboratory test Fecal Occult Blood Test CBC Serum electrolyte concentrations The serum creatinine concentration / BUN The coagulation profile Urinalysis should be done to check for hematuria Liver function profile

26.  Sigmoidoscopy Exclude a rectal or distal sigmoid obstruction.

27.  Imaging / X ray examination  Chest x-ray Exclude a pneumonic process To look for subdiaphragmatic air.  Plain abdominal X ray Erect and lying down  routinely  Water soluble enema to exclude colonic obstruction. Colonic pseudo obstuction LBO + incompetent ileocecal thereby mimicking small bowel obstruction.

28. Barium enema X ray transition point on contrast study

29. bent inner tube = Coffe bean” appearance “Bird Beak “ SIGMOID VOLVULUS

30. Management of Bowel Obstruction Principles Fluid resuscitation Requirements = Deficit + Maintenance + Ongoing losses Close monitoring hemodinamic – Foley catheter  urine output – CVP Electrolyte, acid-base correction NGT decompression Antibiotics Diagnostic study Informed concent Exploratory laporotomy