1. Management of Bowel Obstruction
Shaheer Abbbara Husam al Huwail Mohammad al hattab

2. Causes Peristalsis subsides  paralytic ileus Dehydration…..
Electrolytes imbalance
Bacterial translocation
Perforation…..
peritonitis

3. Treatment: Hx & PE (Digital rectal examination, Hernial sites, Scars)
Investigation (X-ray, CT, CBC, chemistry)
Underlying cause.
Operation frequently required.
IV fluid, electrolyte correction
bowel rest, decompression

4. Nasogastric suction empty the stomach
Fluid resuscitation and antibiotics
Tube decompression and follow up
They are usually dehydrated and depleted of sodium, chloride, and potassium, requiring aggressive intravenous replacement with an isotonic saline
Urine output: foley’s catheter.
potassium chloride  if needed.
Serial electrolyte measurements, as well as hematocrit and white blood cell count are performed to assess the adequacy of fluid repletion.
Broad spectrum antibiotics: are given prophylactically by some surgeons based on the reported findings of bacterial translocation, and as preoperative preparation.
Nasogastric suction empty the stomach
reducing the risk of pulmonary aspiration
reduce further intestinal distension

5. The treatment is urgent relief of obstruction
Conservative (with exeption)
Indication : adhesive, Ileocaecal intussusception, Feacal impaction, IBD, hernia, acute post-op obstruction and intra abdominal abscess
Reassess patient every 4 hours. Look for change in pain, abdominal findings, and volume and character of nasogastric aspirate. Repeat abdominal x- ray.
Classify patient’s condition as improved, unchanged or worse.
Decide whether operative treatment is necessary and if so, whether it should be done on urgent or elective basis.
Urgent operation: indications include: lack of response to 24 – 48 hrs of nonoperative
The treatment is urgent relief of obstruction

6. Mid line exploration Operation: exploration
Immediate operation indicated in:
peritonitis, hernia complication, suspected or confirmed strangulation, small bowel volvulus
Incarcerated hernia: reduction and repair
Release of adhesions or fibrous band
Untwisting volvulus (viable bowel)
Resection anastomosis (gangrenous bowel, intestinal tumor or pathological stricture)
Reduction of Intussusception
Proximal ileostomy or colostomy.

7. Define the obstructed point operatively:
Follow the distended bowel distally till find the collapsed intestine and define the lesion.
Determine bowel viability:
By color, motility and arterial pulsations.

8. Conservative Vs Surgical management
329 patient
conservative
Surgical
57%
Operatively treated patients had a lower frequency of recurrence and a longer time interval to recurrence; however, they also had a longer hospital stay than that of patients treated nonoperatively
43%
2005
40%
26%

9. Mesenteric ischemia Full resuscitation Embolectomy
Revascularization in early embolic cases

10. Paralytic ileus Treatment: Supportive Correct the underlying condition
Colonoscopy decompress the colon.
(NGT, IV)
(treatment of sepsis, correct metabolic or electrolyte abnormalities, stop drugs that produce ileus)

11. Coecal or transverse colon volvulus:
Sigmoiod volvulus
Sigmoidoscopy and deflation with flatus tube followed by later elective surgery.
If failed, urgent laparotomy, un-twisting of the loop followed by: -fixation or -resection
Coecal or transverse colon volvulus:
Volvuls should be reduced followed by: caecopixy or caecostomy.
If the cecum is ischemic or gangrenous  right hemicolectomy.

12. Colonic Masses Diverticular disease:
Endoscopic dilatation and stenting of obstructed colon:
(palliative for high risk patients with unresctable tumor)
Surgery
Right colon  resection with anastomosis
Left colon  resection without anastomosis or resection with intra-operative lavage and anastomosis
Diverticular disease:
Conservative …… followed by elective surgery
If failed  surgery

13. Acute colonic pseudo obstruction (ogilivie’s syndrome)
If no perforation  conservative (treat underlying disorder for 24hr) ( consider neostigmine, colonic decompression, erythromycin)
If perforation or if conservative failed  surgical

14. Thank you