INTESTINAL
OBSTRUCTION
Bernard M. Jaffe, MD
Professor of Surgery,
Emeritus
INTESTINAL OBSTRUCTION
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Common Clinical Problem
Carries 3-5% Mortality Rate/Episode
Some Patients Have Multiple Bouts
Can Involve Small or Large Bowel
Requires Both Operative and NonOperative Care
SYMPTOMS
• Specifics Depends on Site of
Obstruction
• Crampy Abdominal Pain
• Abdominal Fullness
• Nausea, Vomiting
• Thirst, Weakness, Dehydration
PHYSICAL FINDINGS
• Abdominal Distention
• Bowel Sounds
• Early- Hyperactive
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Rushes
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High Pitched
• Late- Hypoactive to Absent
• Tachycardia, Dry Skin
DIFFERENTIAL- ILEUS
• Functional Obstruction
• Electrolyte Abnormalities- ↓Na, ↓K,
↓Mg
• Meds- Opiates, Anti-Cholinergics, AntiPsychotics
• Intra-Abdominal Infection/Inflammation
• Systemic Sepsis
• Post-Laparotomy
INITIAL MANAGEMENT
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Done During Evaluation/ Diagnosis
Intravenous Fluid Resuscitation
Ringer’s Lactate
Electrolytes Close to Those Lost
Nasogastric Tube Decompression
Foley Catheter Placement
DIAGNOSIS
• Upright Abdominal X-Ray
• Air Fluid Levels
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Obstruction- Step Ladder Pattern
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Ileus- All at Same Level
• ? Air in Colon- Incomplete
Obstruction
• ? Thumb Printing- Ischemic Bowel
CT SCAN
• Not Always Necessary
• Can Localize Site- Transition Point
(Change from Distended to Flat
Bowel)
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Sometimes Diagnose Cause
Distinguish Complete from
Incomplete Obstruction
• Markedly Overused
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CAUSES
Adhesions (60-70%)
Neoplasms (20%)
Hernias (10%)- External, Internal
Others- Intussusception
Volvulus
Intra-Abdominal Abcess/Infection
Gallstone Ileus
Stricture, Extrinsic Compression
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
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Stone Visible in RLQ
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CARCINOID
Malignancy Ileum > Jejunum
30% are Multiple
Metastasizes Nodes, Liver
Syndrome- Flushing
Diarrhea
Bronchoconstriction
Right Sided Cardiac
Valvular Lesions
OTHER NEOPLASMS
• Adenocarcinoma
• Lymphoma
• Leiomyosarcoma
• Other Sarcomas
COMPLICATIONS
• Gangrene• Intraluminal Tension>Venous
Pressure
• Venous Flow Stops
• Venous → Arterial Gangrene
• Perforation
• Short Gut Syndrome Following
Resection
EMERGENCY OPERATION
• Closed Loop Obstruction
• Complete Obstruction
• Impending Gangrene
• All Increase Risk of Intestinal
Gangrene
IMPENDING GANGRENE
• Very Difficult to Diagnose- Variable,
Non-Specific
• Abdominal Tenderness
• Rebound Tenderness, Guarding
• Fever, Tachycardia
• Acidosis
• Elevated White Blood Cell Count
NON-EMERGENCY OPERATIONS
• Failure to Respond to Conservative
Management
• Partial Obstruction
• Multiply Recurrent Bouts of
Obstruction
ACUTE POST-OP OBSTRUCTION
• Difficult to Diagnose
• Behaves Like Ileus
• Enteroclysis is Most Successful
Modality
• Non-Operative Management
Post-Op Days 1-7
TREATMENT of ADHESIONS
• Adhesiolysis at Site of Obstruction
• ? Lysis of All Adhesions
• Resect Gangrenous Bowel/ReAnastamose
• Run Bowel of Site of Injury
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Perforation
JEJUNUM
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Proximal 40% of Intestine
Larger Circumference, Thicker Wall
Prominent Plicae Circulares
End-Arterial Blood Supply
Fewer Vascular Arcades (1-2)
Less Lymphatic Material
LAPAROSCOPY
• Mild Abdominal Distention
• Proximal Obstruction
• Partial Obstruction
• Anticipated Single Band
Obstruction
GALLSTONE ILEUS TREATMENT
• Enterotomy with Removal of Stone
• Try to Identify Site of Fistula
• Cholecystectomy with Fistula
Closure
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ONLY IF
• RUQ Not Too Inflamed or Indurated
OPERATIVE COMPLICATIONS
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Perforation- Missed Injury
Bovie Burn
Delay in Opening Up
Nutrition- Enteral, Parenteral
Wound Failure- Dehiscence, Hernia.
Infection- Superficial Wound
Intraperitoneal
Recurrent Obstruction