By

Prof. Dr. ISMAIL TANTAWY

 Learning objectives to understand

The pathophysiology of The causes, clinical

dynamic and adynamic Pictures and complications
intestinal obstruction of intestinal obstruction.

The indications and contraindications of either surgical or

conservative treatment of intestinal obstruction.
Definition:
Failure of propulsion of intestinal contents.
Due to either mechanical occlusion of the lumen
(dynamic obstruction) or failure of the propulsive
movement (adynamic obstruction).

Aetiology

Mechanical (Dynamic) Functional (adynamic)

Obstruction

Patent lumen
Due to occluded lumen
 Mechanical (Dynamic) Obstruction

In the lumen In the wall Outside the wall

 Meconium ileus  Congenital atresia.  Bands and adhesions (the

 Gall stone ileus and  Inflammatory stricture. e.g. commonest cause).
bolus obstruction T.B. Crohn’s, ulcerative  Tight rings of hernia sac
 Ascaris mass colitis, diverticulitis.  Tumours and enlarged LNs.
 Faecal impaction, F.B.,  Malignancy: cancer colon,
or enterolith and rectum.

Functional (adynamic)

Paralytic ileus Spastic ileus: Hirschsprung's Mesentric vascular

disease is a good example occlusion (MVO)
 Pathology

Types of intestinal obstruction

Simple Strangulated
obstruction obstruction

Occluded lumen without Obstruction with interference with blood supply of the
interference with blood supply affected loop:

Strangulated hernia Volvolus Intussusception

Adhesive obstruction (some Mesentric vascular

cases e.g. internal herniation) occlusion.
 Patho-pathology
Local effects

Proximal to the site of obstruction Distal to obstruction At the site of obstruction

Proximal to the site of obstruction:

The proximal loop passes through the following phases:
(A) Proximal to the site of obstruction:
The proximal loop passes through the following phases:
Hyperperistaltic with antiperistaltic waves: occurs early in
trial to overcome the obstruction .
Stage of dilatation (due to exhaustion and paralysis) & The
loop becomes distended with:
 Fluids Gases Late

Swallowed, secreted Either swallowed Bacterial proliferation with

& diffused from (70%), diffused breakdown of retained
blood (The secreted from blood (20%) intestinal contents
part alone is more or produced from produces toxins that
than 8 liters per day). putrefaction of
accumulate in the stagnant
food (10%).
fluid and do not pass to the
circulation except after
1000-1500 ml saliva
release of obstruction,
1500 - 2500 ml gastric juice which may lead to
1000 ml bile toxaemia which may be
1500 ml pancreatic secretion. fatal.
3000 ml intestinal secretion
 Distal to obstruction

Early Late
Normal peristalsis to evacuate The distal segment is empty, collapsed,
the residual content. contracted and immobile.

At the site of obstruction

Simple Strangulated obstruction

obstruction  At first, the venous flow is occluded (being of low pressure) leading
to oedema and congestion.
The strangulated loop  Arterial flow is then occluded leading to ischaemia and gangrene.
becomes distended  The devitalized wall of the intestine permits passage of toxins &
with gas & fluid bacteria to the peritoneal cavity & circulation causing toxaemia.
Lastly, perforation leads to peritonitis.
 Complications (general effects)

 Hypovolaemic shock: due to fluid loss by vomiting,

sequestration of fluids in the third space (dilated
loops).
 In strangulated obstruction: shock is more marked
due to additional blood loss into the strangulated
loop.
 Dehydration & electrolytes imbalance:
hyponatraemia & hypokalaemia.
 Toxaemia: in strangulated obstruction.
 Perforation & peritonitis.
 Clinical picture

Symptoms

Pain Vomiting Constipation Distension

 Simple obstruction: The higher the  Absolute constipation to The lower the
colicky pain in attacks obstruction, both faeces and flatus. obstruction
with long free intervals. the earlier the  The lower the the more is
 Strangulated obstruction: vomiting. obstruction, the earlier distension.
colicky pain with short the constipation.
intervals with constant
dull aching pain between
the attacks of colics.
 Paralytic ileus: No colic.
 Signs

General Local

 Signs of dehydration, Inspection Palpation Percussion

shock or toxaemia.
 General signs of the
cause e.g. distant Abdominal Simple obstruction: mild Hyper-resonance
metastasis of GIT distention. tenderness over the distended over the distended
cancer. Visible loops maximum over the site of loops
peristalsis on the the obstruction.
abdominal wall. Strangulated obstruction:
tenderness & rebound tenderness
over the strangulated loop.

Auscultation Per-rectal examination

(PR exam.)

Loud exaggerated intestinal sounds in Empty rectum supports the diagnosis.

the hyperperistaltic stage (early). It may reveal anorectal carcinoma or
Dead silent abdomen in paralytic ileus red currant jelly stool in intussusception.
and during the stage of dilatation (late).
 How to suspect the level of obstruction clinically?

Items High small bowel Low small bowel Large bowel

above the Around & below Lower

1-Pain
umbilicus it abdominal

-Very early (with 1-2 day after

-1-2h after pain
2-Vomiting pain) pain
-moderate
-Copious mild

3-Constipation Late Intermediate Early

-Mild or absent -Inter mediate -Marked

4-Abd. distension
-central -central -peripheral

5-Dehydration Marked early Intermediate Mild & late

Differences between Simple, strangulated and functional obstruction (P. ileus)

Item Simple obst. Strangulated. Obst. Paralytic ileus

Intermittent Attacks of colicky Mild dull aching
colicky pain with pain with short pain of distension or
1-Pain long free intervals. intervals of constant no pain
dull aching pain.

2-Shock Mild. Severe. Moderate.

Tenderness Tenderness and Very mild
3-Palpation especially over the rebound tenderness. tenderness.
site of obstruction.
Hyperperistalsis Hyperperistalsis Dead silent
4-Auscultation then silent then silent abdomen. abdomen.
abdomen.
It relieves pain in It does not relieve It relieves distention.
5-N/G suction hours. pain.
Not increased Increased Not increased except
6- Leucocytic count in cases secondary to
sepsis
 Investigations
Double enema test:
 Two enemas are given one hour apart.
 If the second enema comes without 3F (Faeces Flatus or Force),
intestinal obstruction is proved.

Radiological investigations:
*Plain X. ray abdomen erect position:
It reveals distended loops with multiple fluid
levels in stepladder pattern.
 Jejunum: shows circular folds called
"valvulae connivents" giving concertina
appearance
 Ileum: shows shapeless characterless tubes.
 Colon: typical haustrations of the colon.
Multiple fluid levels
*Barium enema:
When colonic obstruction is suspected.

*Upper GIT series:

Barium or Gastrograffin meal with follow-through to detect
upper small intestinal obstruction in neonates and infants.

Laboratory investigations:
Total leucocytic count: markedly rises in cases of strangulation.
Serum electrolytes: decreased sodium and potassium levels.

Differential Diagnosis:
From other causes of acute abdomen.
Treatment:
Conservative treatment:
 Correction of fluid & electrolytes imbalance i.e. I.V. fluids
according to the deficit.
 Fluid chart is mandatory.
 Nasogastric suction through Ryle's tube for:
*Preoperative benefits:
 It relieves distension, which may cause cardiac &
respiratory embarrassment.
 It relieves congestion & oedema of the intestines and helps
return of tone & peristalsis.
*Operative benefits:
 For anaesthesia: it prevents vomiting & aspiration
pneumonia.
 For surgeon: it deflates the intestine providing easy
manipulation & easy closure of the abdomen.
*Postoperative benefits:
 It prevents massive toxic absorption after release of obstruction.
 It reduces the incidence of postoperative paralytic ileus
(distention and vomiting).
 Antibiotics: to guard against respiratory infection, peritonitis &
septicemia.
 Repeated enemata are used to break faecal impaction and stimulate
colonic motility.

Surgical treatment:
A part from few cases, in which the previous
conservative measures may be curative, most cases need
emergency exploration.
 Exploration:
In adults, midline incision is preferred.

Deliver the caecum Decompress the bowels if Deal with

and examine greatly distended by the cause

If collapsed, it is  Threading a long Simple obstruction:

small intestinal nasogastric tube through Remove the cause if
obstruction → follow the intestine down to the possible or do bypass or
the ileum to the site of obstruction. colostomy.
distended loops.  Decompression through Strangulated
If distended, it is a small stab in the bowel obstruction: Remove the
large intestinal and introduction of wide cause of strangulation
obstruction → follow bore catheter connected and examine the
the colon to the to a sucker then close the viability of the loop.
collapsed part. stab with sutures.
By this way you can
reach the site of the
obstruction .
 Item Viable loop Gangrenous loop

-luster Present (shining) Absent (dull)

-Inspection -colour Red (light) Dark or black
-peristalsis Seen Absent

-tone Present (firm) Absent (flabby)

-Palpation
-Pulsation Felt in the mesentery Absent

-Operative Doppler U/S + ve -ve

 If the viability of a loop is questionable,
try to improve it by

Increase oxygenation Wrapping the loops with

for 10 minutes. hot fomentations.

If not improved or proved gangrenous,

resection of gangrenous loop is indicated.
If it is :

Small intestine or right Left colon then either resection

colon then do primary ended by colostomy or recently
resection anastomosis. primary resection anastomosis
after on table colonic lavage
(Dudely lavage) is done.
 Common causes of obstruction in
different age groups

Newborn (first month): (see the chapter of pediatric surgery )

Jejuno ileal atresia or stenosis (the commonest cause).
Malrotation or volvolus neonatorum.
Congenital duodenal obstruction (atresia).
Duplication of the intestine
Hirchsprung's disease
Imperforate anus.
Meconium ileus

Infancy (1 month – 2 years) & Childhood (2y-12y):

Intussusception (the commonest cause in infants).
Strangulated external hernia (the commonest cause in children) .
Ascaris mass obstruction.
Young adult and middle age:
Adhesive intestinal obstruction (the commonest cause).
Strangulated hernia. (see the chapter of hernias)
Paralytic ileus.
Stricture obstruction e.g. T.B.
Gall stone obstruction.

Old age:
Malignant obstruction (the commonest).
Volvolus sigmoid.
Faecal impaction.
The commonest causes of intestinal
obstruction as a whole are

Adhesive intestinal Strangulated external

obstruction hernia

Malignant obstruction Paralytic ileus

Aetiology
Peritoneal irritation leading to fibrinous exudate that
causes fibrinous adhesions between adjacent intestinal
loops.
They may resolve or change into mature permanent
fibrous tissue causing fibrous adhesions.

The irritating causes may be (theories)

Foreign
Infection Trauma Vascular
bodies

Peritonitis Talk powder Mechanical or Ischaemia or

& TB. (over surgical thermal e.g. congestion.
gloves) & silk diathermy or hot
sutures fomentations
Pathology:
Types:

Fibrinous Fibrous
adhesions adhesions

Occurs early, which is easily Which is firm and needs sharp

broken by blunt dissection dissection (adhesolysis).

Clinical picture

Fibrinous Fibrous
adhesions adhesions

There is a history of previous operation Picture of simple obstruction but the adhesions
e.g. appendicectomy or gynecological may compress the blood supply and cause
operations or past history of peritonitis strangulated intestinal obstruction
 Treatment

Conservative Surgical

Conservative

 Should be tried first even for few days so long as there is no

Suspicion of strangulation.
 I.V. fluids, N/G suction may be beneficial and the intestinal
movement may break down fibrinous adhesions.

Surgical

Exploration and division of Prevention of recurrence

the offending adhesions.
Exploration and division of the offending adhesions:

If adhesions are extensive → bypass by lateral anastomosis.

Prevention of recurrence:
 Instillation of different substances: to reduce the fibrous tissue
formation e.g. hyaluronidase, heparin, steroids, fibrinolysin,
dextran…etc. is usually useless.
 Noble's plication: The adjacent loops are sutured along their anti-
mesenteric border in ordered fashion.
 Charle-Phillip's transmesenteric plication: In which placation is
done in the mesentery few centimeters from the bowel that looks
like a pouch of sausage
 Baker's tube: intraluminal tube splinting the loops gentle curves.
This tube is removed 12 days later.
Aetiology:
Obstruction of the terminal ileum by aggregation of Ascaris
lumbricoides worms forming a mass, usually following
antihelminthic treatment.

Incidence:
Rarely seen nowadays.
Common in children below 10 years in tropics.

Clinical picture:
 History of Ascaris infestation or intake of antihelminthics may
be positive.
 The vomitus may contain worms.
 Picture of simple intestinal obstruction.
Investigations:
Leucocytic count may show marked esinophilia.

Treatment

Conservative Exploration

(N/G suction +  The mass is identified and trial is done to knead it

IV. Fluids) may along the ileum to the colon without opening the
succeed. bowel.
 If kneading fails, remove the mass through
transverse incision in the bowel.
 The bowel incision should be sutured with silk sutures
because the worms tend to eat the catgut sutures and
re-open the sutured wound of the intestine, through
their way to the peritoneum.
Aetiology:
Obstruction of the distal colon and rectum by inspissated faeces
(forming a mass).

Incidence:
It is common in elderly bed ridden patients with chronic constipation.

Clinical picture:
Clinical picture of simple distal intestinal obstruction.
Indentible mass may be felt in the Lt. iliac fossa and the faecal mass is
felt per-rectum

Treatment:
 Conservative measures + repeated enemata may succeed to loosen the
mass and relieve obstruction.
 If failed, anal dilatation under anaesthesia and manual removal of the
mass is done.
Aetiology:
 Obstruction of the terminal ileum by large gall stone ( 2.5 cm or more
in diameter) which had ulcerated through the gall bladder wall into
the duodenum.
 It passes down to be impacted usually 2 feet from the ileocaecal valve
causing simple intestinal obstruction.

Incidence:
It is a rare condition, common in old obese multiparous females with
long history of dyspepsia.

Clinical picture:
Clinical picture of simple intestinal obstruction:
 Usually there is a long history of chronic cholecystitis with recent
exacerbation.
 The diagnosis is usually delayed because it's clinical pictures
resemble exacerbation attacks of gall bladder disease.
Investigations:
Plain X ray of abdomen in erect position: It may show:

The classic multiple fluid level but the stone is rarely seen.
Gas in the gall bladder or biliary tree (pneumobilia) is diagnostic.

Treatment “Surgical”:
Exploration after good preoperative preparation:
 Try to crush the stone between fingers without opening the
bowel.
 If failed, open the ileum above the stone, and remove it then
close the incision transversely
 Avoid any manipulation in the region of the gall bladder, which
may break down the cholecyto-enteric fistula and results in
external duodenal or biliary fistula.