1. INTESTINAL OBSTRUCTION
Bernard M. Jaffe, MD
Professor of Surgery, Emeritus

2. INTESTINAL OBSTRUCTION
Common Clinical Problem
Carries 3-5% Mortality Rate/Episode
Some Patients Have Multiple Bouts
Can Involve Small or Large Bowel
Requires Both Operative and Non- Operative Care

3. SYMPTOMS Specifics Depends on Site of Obstruction
Crampy Abdominal Pain
Abdominal Fullness
Nausea, Vomiting
Thirst, Weakness, Dehydration

4. PHYSICAL FINDINGS Abdominal Distention Bowel Sounds Early- Hyperactive
Rushes
High Pitched
Late- Hypoactive to Absent
Tachycardia, Dry Skin

5. DIFFERENTIAL- ILEUS Functional Obstruction
Electrolyte Abnormalities- ↓Na, ↓K, ↓Mg
Meds- Opiates, Anti-Cholinergics, Anti- Psychotics
Intra-Abdominal Infection/Inflammation
Systemic Sepsis
Post-Laparotomy

6. INITIAL MANAGEMENT Done During Evaluation/ Diagnosis
Intravenous Fluid Resuscitation
Ringer’s Lactate
Electrolytes Close to Those Lost
Nasogastric Tube Decompression
Foley Catheter Placement

7. DIAGNOSIS Upright Abdominal X-Ray Air Fluid Levels
Obstruction- Step Ladder Pattern
Ileus- All at Same Level
? Air in Colon- Incomplete Obstruction
? Thumb Printing- Ischemic Bowel

8. CT SCAN Not Always Necessary
Can Localize Site- Transition Point (Change from Distended to Flat Bowel)
Sometimes Diagnose Cause Distinguish Complete from Incomplete Obstruction
Markedly Overused

9. CAUSES Adhesions (60-70%) Neoplasms (20%)
Hernias (10%)- External, Internal
Others- Intussusception
Volvulus
Intra-Abdominal Abcess/Infection
Gallstone Ileus
Stricture, Extrinsic Compression

10. GALLSTONE ILEUS
Fistula Between Biliary Tract (Gallbladder) and Intestine
Stone Passes into Intestine
Travels to Narrowest Point –Distal Ileum
X-Ray Diagnosis- Air in Biliary Tract
Stone Visible in RLQ

11. CARCINOID Malignancy Ileum > Jejunum 30% are Multiple
Metastasizes Nodes, Liver
Syndrome- Flushing
Diarrhea
Bronchoconstriction
Right Sided Cardiac Valvular Lesions

12. OTHER NEOPLASMS
Adenocarcinoma
Lymphoma
Leiomyosarcoma
Other Sarcomas

13. COMPLICATIONS Gangrene- Intraluminal Tension>Venous Pressure
Venous Flow Stops
Venous → Arterial Gangrene
Perforation
Short Gut Syndrome Following Resection

14. EMERGENCY OPERATION Closed Loop Obstruction Complete Obstruction
Impending Gangrene
All Increase Risk of Intestinal Gangrene

15. IMPENDING GANGRENE Very Difficult to Diagnose- Variable, Non-Specific
Abdominal Tenderness
Rebound Tenderness, Guarding
Fever, Tachycardia
Acidosis
Elevated White Blood Cell Count

16. NON-EMERGENCY OPERATIONS
Failure to Respond to Conservative Management
Partial Obstruction
Multiply Recurrent Bouts of Obstruction

17. ACUTE POST-OP OBSTRUCTION
Difficult to Diagnose
Behaves Like Ileus
Enteroclysis is Most Successful Modality
Non-Operative Management Post-Op Days 1-7

18. TREATMENT of ADHESIONS
Adhesiolysis at Site of Obstruction
? Lysis of All Adhesions
Resect Gangrenous Bowel/Re- Anastamose
Run Bowel of Site of Injury
Perforation

19. JEJUNUM Proximal 40% of Intestine Larger Circumference, Thicker Wall
Prominent Plicae Circulares
End-Arterial Blood Supply
Fewer Vascular Arcades (1-2)
Less Lymphatic Material

20. LAPAROSCOPY Mild Abdominal Distention Proximal Obstruction
Partial Obstruction
Anticipated Single Band Obstruction

21. GALLSTONE ILEUS TREATMENT
Enterotomy with Removal of Stone
Try to Identify Site of Fistula
Cholecystectomy with Fistula Closure
ONLY IF
RUQ Not Too Inflamed or Indurated

22. OPERATIVE COMPLICATIONS
Perforation- Missed Injury
Bovie Burn
Delay in Opening Up
Nutrition- Enteral, Parenteral
Wound Failure- Dehiscence, Hernia.
Infection- Superficial Wound
Intraperitoneal
Recurrent Obstruction