1. Intestinal Obstruction
Laila Tavazo, REM

2. 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.

3. 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.

4. Classification

5. Lesions Causing Small Bowel Obstruction Relative to the Intestinal Wall

6. Causes of Adynamic Ileus

7. 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

8. Intestinal obstruction

11. 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

12. 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

13. 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)

14. 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.

15. Diagnosis of small bowel obstruction

16. Diagnosis of large bowel obstruction

17. Normal Ileus

18. Sigmoid volvulus Cecal volvulus Bird’s beak volvulus

19. Other causes
Intussusception
Gall stone Ileus
IBD

20. Hernia

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

22. String of pearl sign

23. Coffee bean sign Whirl sign

24. 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.

25. 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.

26. Treatment

27. Thank you for your attention