Intestinal Obstruction

Presented by Prof. Marek Jackowski

Definition

• Interference with the normal propulsion and passage of intestinal contents.
• Can involve small bowel, colon, or both.
• 5% of all acute surgical admissions.
• Patients often require prompt assessment, resuscitation, and intensive monitoring.

Types of Obstruction

• Mechanical: Blockage due to a structural abnormality.
  • Partial or complete
  • Simple or strangulated
• Ileus: Paralytic or functional obstruction.

Epidemiology

• 1% of all hospitalizations
• 3-5% of emergency surgical admissions
• More frequent in females due to gynecological and pelvic surgeries
• Adhesions are most common cause

Causes of Small Bowel Obstruction

• Adhesion (60%)
• Hernia (20%)
• Neoplasm (5%)
• Others: Volvulus, IBD, gallstones, foreign body, intussusception

Causes of Large Bowel Obstruction

• Cancer (60%)
• Diverticular disease (15%)
• Volvulus (15%)
• Others: Hernia, fecal impaction, inflammatory causes

Mortality and Recurrence

• Simple bowel obstruction: 3%
• Strangulation or perforation: 30%
• Recurrence rate varies by treatment method (conservative vs. surgical)

Classification of Obstruction

• Cause: Mechanical or functional
• Duration: Acute or chronic
• Extent: Partial or complete
• Type: Simple or complex (closed loop and strangulation)

Etiology

Mechanical Obstruction

• Small Bowel: Adhesion, hernia, neoplasm, volvulus
• Large Bowel: Cancer, diverticular disease, volvulus

Functional Obstruction

• Vascular Occlusion Ileus
• Spastic Ileus: Causes include uremia, porphyria, heavy metal poisoning
• Adynamic Ileus: Post-operation, metabolic causes, drugs, infections

Etiology by Age

• Neonates: Congenital atresia, volvulus neonatorum
• Infants: Ileocaecal intussusception, Hirschsprung’s disease
• Adults: Adhesions, strangulated hernia
• Elderly: Colon carcinoma, adhesions

Pathophysiology

• Proximal bowel dilates, reduced peristaltic strength, paralysis
• Distal bowel remains normal, empties, becomes immobile
• Distention due to gas and fluid
• Dehydration and electrolyte loss due to reduced intake and absorption

Diagnosis

Clinical Features

• High Small Bowel Obstruction: Early vomiting, minimal distention
• Low Small Bowel Obstruction: Central pain, delayed vomiting
• Large Bowel Obstruction: Early distention, mild pain, late vomiting

Physical Examination

• Tachycardia, hypotension, fever may indicate strangulation
• Abdominal distention, peristaltic waves, bowel sounds
• Tenderness, rebound, guarding suggest peritonitis

Laboratory Tests

• CBC: Increased PCV, WBC
• KFT: Increased BUN, creatinine
• Imaging: X-rays, CT scans

Treatment

Conservative

• Suitable for incomplete obstruction, previous surgery, advanced malignancy

Surgical Indications

• Peritonitis, perforation, irreducible hernia, palpable mass
• Failure to improve with conservative treatment

Surgical Procedures

• Three-staged: Colostomy, resection, closure
• Two-staged: Hartmann’s procedure
• One-staged: Resection and anastomosis, avoids stoma

Special Cases

Volvulus

• Twisting of bowel leading to closed loop obstruction
• Common in sigmoid colon, may require surgery

Hernia

• 20% of small bowel obstructions
• Types: Femoral, inguinal, umbilical

Ogilvie's Syndrome

• Colonic pseudo-obstruction
• Treated with rectal tube, enemas, or surgery if needed

These notes provide an overview of the key points from the lecture on intestinal obstruction, covering definitions, causes, epidemiology, pathophysiology, diagnosis, and treatment strategies.