ACUTE INTESTINAL OBSTRUCTION

DR. JONATHAN SANDEJAS September 16, 2010 2. Primary intestinal pseudo-obstruction Chronic motility disorder that frequently mimics mechanical obstruction Exacerbated by narcotic use PATHOPHYSIOLOGY I. II. III. IV. V. VI. Etiology and Classification Pathophysiology Symptoms Physical Findings Laboratory and X-ray Findings Management ETIOLOGY AND CLASSIFICATION 75% of cases results from previous abdominal surgery secondary to adhesive bands or internal or external hernias 5-25% of patients will develop acute intestinal; obstruction that require hospitalization within the first few post-operative weeks Incidence of post-operative intestinal obstruction may be lower following laparoscopic surgery than open procedures However, laparoscopic gastric bypass procedure may be associated with an unexpected high rate of intestinal obstruction for unknown causes Other causes of intestinal obstruction: 1. Intrinsic to the wall of intestines Diverticulitis Carcinoma Regional enteritis 2. Luminal obstruction Gallstone obstruction Intussusception Two other conditions must be differentiated from acute intestinal obstruction: 1. Adynamic ileus Mediated via the hormonal component of the sympathoadrenal system and may occur after any peritoneal insult May be caused by: i. Hydrochloric acid, colonic contents and pancreatic enzymes ii. Retroperitoneal hematoma, particularly associated with vertebral fracture iii. Thoracic diseases like lower-lobe pneumonia, fractured ribs, and myocardial infarction iv. Electrolyte imbalance particularly potassium depletion v. Intestinal ischemia due to vascular occlusion or intestinal distention vi. May also be caused by ureteral calculus and pyelonephritis Accumulation of gas and fluid proximal to and within the segment Intestinal gas is usually consist of swallowed air, mainly nitrogen, which is poorly absorbed from the intestinal lumen Removal of air by continous gastric suction is a useful adjunct in the treatment of intestinal obstruction Accumulation of fluid is due to: 1. Swallowed saliva 2. Gastric juice, biliary and pancreatic secretions 3. Interference with normal sodium and water transport During the first 12-24 hours of obstruction, there is a marked depression on the flux of sodium from the lumen to the blood, and consequently water, in the distended proximal intestine. After 24 hours, sodium and water move into the lumen contributing further to the distention and fluid losses with luminal pressures reaching 8-10cm H2O.

LEGEND Normal text : lecture and recording (basically from the book) th Italics : Harrisons Principles of Internal Medicine 17 ed.

OUTLINE

Closed-loop: the most feared complication of acute intestinal obstruction results from obstruction of the lumen at two points by a single mechanism such as fascial hernia or adhesive band closed loops have blood supply occluded by the hernia or band and once impairment of blood supply to the GI tract occurs, bacterial invasion supervenes and peritonitis develops during peristalsis, when a closed-loop is present, pressures can reach 30-60mm H2O (perforation) Systemic effects of extreme distention include elevation of the diaphragm with restricted ventilation and subsequent atelectasis SYMPTOMS Mechanical intestinal obstruction 1. Cramping, mid-abdominal pain which tends to be more severe the higher the obstruction

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2. Pain occurs in paroxysms and the patient is relatively comfortable in the intervals between the pains 3. Audible borborygmi 4. Pain may become less severe as distention progresses probably because motility is impaired in the edematous intestines 5. Pain is more localized, steady and severe and less colicky when there is strangulation 6. Vomiting is invariable it is earlier and more profuse the higher the obstruction If obstructions are high in the intestines, the vomitus consists of bile and mucus. With low ileal obstuctions, vomitus become feculent i.e. orange-brown in color with a foul odor resulting from the overgrowth of bacteria proximal to the obstruction 7. Hiccups (singultus) are common 8. Obstipation and failure to pass gas by rectum are invariably present when the obstruction is complete

More abdominal distension when the obstruction is in the colon Tenderness and rigidity are usually minimal during the initial stages of obstruction and temperature is rarely >37.5C Appearance of shock, tenderness, rigidity and fever indicates that there is contamination of the peritoneum with intestinal contents Auscultation may reveal loud, high-pitched borborygmi coincident with colicky pain A quiet abdomen does not eliminate the possibility of obstruction A palpable abdominal mass usually signifies a closed-loop strangulating small bowel obstruction LABORATORY AND XRAY FINDINGS Both used to differentiate strangulation from non-sttrangulation AND partial from complete obstruction Leukocytosis with a shift to the left occurs when there is strangulation but a normal white cell count does not exclude strangulation Elevated serum amylase Step-ladder pattern with air-fluid levels and an absence of colonic gas are pathognomonic for small bowel obstruction

Fig. 1. Air appears black on roentgenogram.

Adynamic ileus and colonic pseudo-obstruction 1. Only the discomfort from distention is evident; no colicky pain 2. Vomiting may be present but rarely profuse 3. Complete obstipation may or may not occur 4. Singultus is common PHYSICAL FINDINGS Abdominal distention is the hallmark of all forms of intestinal obstruction; most marked in colonic obstruction but least marked in small intestine obstruction Less abdominal distension in cases of obstruction in the small intestines

Fig. 2. Step-ladder sign in small bowel obstruction.

Complete obstruction is suggested when passage of gas or stool per rectum has ceased and when gas is absent in the distal intestine by x-ray General haze (due to peritoneal fluid) and coffee bean-shaped mass are seen in strangulating closed loop obstruction Thin barium upper GI series help differentiate between partial from complete (thick barium is avoided since retained barium sulfate may become inspissated)

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CT scan is the most commonly used modality to evaluate postoperative patients for intestinal obstruction because of its ability in differentiating adynamic ileus, partial obstruction, and complete obstruction. However, the sensitivity and specificity of CT scan for strangulating obstruction are low (50 and 80%, respectively). Barium should never be given by mouth to a patient with a possible colonic obstruction until possibility has been excluded. MANAGEMENT Small intestinal obstruction. Strangulating obstruction have higher mortality rates than non-strangulating obstruction Strangulating obstructions are always managed by surgery after suitable preparation (fluid and electrolyte balance restored, decompression by NGT and replacement of potassium) Operation may be done through laparascopic surgery with decreased incidence of wound complications However, laparoscopic lysis of adhesions is associated with a longer operative time and higher conversion to open operation when compared to other laparoscopic procedures Non-operative therapy is only safe in the presence of incomplete obstruction Overall recurrence is 16% Colonic Obstruction Mortality rate is 20% Surgery indicated for complete obstruction Incomplete obstruction 1. Colonoscopic decompression 2. Placement of a metallic stent if a malignant lesion is present; however, this is a temporary solution (ultimate solution is surgery)

Operative management of colonic obstruction are based on the cause of the obstruction and the patients over-all well-being Success rate is almost 90% with left-sided lesion being more successfully stented than rightsided lesions When obstruction is complete, early operation is mandatory especially when the iliocecal valve is incompetent (possibility of cecal perforation) Obstruction on the left side of the colon: 1. Decompression by cecostomy 2. Transverse colostomy 3. Resection with end-colostomy formation (Hartmanns procedure) Lesions on the right or transverse colon: 1. Primary resection and anastomosis

Fig. 4. An example of metallic stent used for decompression.

Adynamic Ileus Usually responds to nonoperative decompression and treatment of the primary disease Good prognosis Correction of electrolyte imbalance should be performed Repetitive colonoscopy has been done to decompress colonic ileus Neostigmine can be used is cases of colonic ileus that have not responded to other conservative treatment

The lecture was basically lifted from Harrisons. Thanks Abi, Ralph, Faye, Paul, Joy, Alex, Ram. You know what was happening when I was making this trans and I couldnt have been more touched and uplifted by what you guys did. Thanks.

Fig. 3. Metallic stent used for decompression indicated by the arrows.

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