1. Prof. L. Damjanovich Institute of Surgery

2.  A group of diseases with diverse etiology  The common feature is obstruction of the bowel  Similar set of symptoms, which may vary according to site and cause of obstruction  Therapy is according to etiology, aiming at relief from obstruction, and treatment of primary disease  May be mechanical or paralytic (US: ileus)

4. ClassificationDivisionEtiologyIntraluminalIntramuralExtrinsic Location within the gastrointestinal tract Small bowel Large bowel Speed of onset AcuteSubacuteChronic Degree Partial or complete Progression Open versus closed loop Simple versus strangulated

5. Site of obstruction CauseLuminal Intussusception, Meconium, Polypoid tumor, Gallstone, Bezoar, Parasites, Feces Mural Stricture (Crohn’s disease, radiation) Small bowel tumor Congenital atresia, stenosis, duplication ExtrinsicAdhesionHernia Malignant or inflammatory mass Volvulus

6.  Pain  Nausea and vomiting  Abdominal distension  Decreased passage of flatus and stool  Possible causes of obstruction: previous operations, presence of hernias, previous irradiation, previous malignancy

8.  Obstruction-incresased luminal pressure- increased secretion, decreased absorption  Increased peristalsis-stasis-bacterial overgrowth-translocation-septic complications  Sequestration of fluid-third spacing- hypovolemia  Impared perfusion-ischemia-necrosis

9.  Degree of distress  Severity of dehydration  Evidence of sepsis (if any)  Inspection: scars, hernia orifices, distension  Auscultation: tinkling, splashing, quiet abdomen  Palpation: location of tenderness, rigidity, garding  Rectal exam

10.  Degree of dehydration  Electrolyte imbalance  Exclusion of possible other diseases (eg.: pancreatitis)  Imaging: plain abdominal films, ultrasound  CT in special cases (tu. recurrence, radiation enteritis, Crohn’s disease)

11.  Schematic drawing of X-ray findings in small bowel distension

26.  Longer anamnesis  Gradual increase of dull pain (cramping is rare)  No passage of flatus or stool  Blood may be found in feces  Vomiting comes late, may be feculent if ileocecal valve is incompetent  Cecum is the most prone to perforation

27.  Cancer  Diverticulitis - chr. inflammation – scarring - stenosis  Sigmoid-, cecal volvulus  Ogilvie’s syndrom (colonic pseudo-obsruction- paralysis)

28. Obstructing sigmoid carcinoma

32. A: Competent valve: closed large bowel loop B: Incompetent valve: distension reaches the small bowel loops

33.  Unprepared bowel, full of feces, increased bacterial content  Distended, thin walled bowel, compromised circulation  Difficult manipulation because of the distension

34.  Two stage procedure (Hartmann’s)  Extended resection, primary anastomosis  Subtotal colectomy  On table lavage, primary anastomosis  Loop colostomy in inoperable cases  Non-operative decompression-semielective operation  Henrik Kehlet

42.  Causes: DM, hypothyroidism, kidney insuff, opiates, antiparkinson drugs cong. heartfailure, MS, lupus, amyloidosis, dermatomyositis, scleroderma, sepsis, trauma (head, spine) operation (abdominal, heart, neurosurgery)  Therapy: Eliminate instigating factors (if possible), Enema, laxatives Cholinesterase blocker, Ganglion blockers Colonoscopy-may be therapeutic Surgery: perforation, failure of cons. meas.