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Intestinal obstruction Defination A blockade of the flow of intestinal content. Anatomic, functional changes but also systemically physiologic disorders. Clinical manifestations complicated Most common emergency disease Etiology and classification 1.According to its basic causes: mechanical, dynamic obstruction,and obsturction of vascular supply origin 1). Mechanical obstruction from lesions within the wall of the intestine, intrinsic from extra-intestinal lesions , extrinsic from obstructing intra-luminal substances. congenital, inflammatory, neoplastic, or traumatic origin. postoperative adhesions, congenital origin, Henias Intra-luminal foreign bodies 2). Dynamic obstruction（ paralytic） Nerval reflex or toxin stimulation muscle disorder acute diffuse peritonitis, abdominal operation, retroperitoneal hematoma and infection. Spastic obstruction in intestinal functional disorder or toxication. 3). Obstruction of blood supply origin thrombosis or embolism, then intestinal paralysis. 2.According to whether the vascular supply to intestinal wall is compromised, Simple and strangulation obstruction. Simple obstruction, mechanical without threat to the viability Strangulation obstruction, the vascular supply is compromised. Not relieved, leads to infarction 3.According to obstruction level or site. Proximal, distal intestinal, or large bowel obstruction, or high and low obstruction 4.According to the extent of obstruction Incomplete and complete obstruction, 5.According to mode of onset and progression of obstruction. Acute and chronic obstruction Pathophysiology Motility of the small intestine The intestine contracts vigorously The patient crampy abdominal pain Finally the intestine dilated. Absorption and secretion water and electrolytes accumulate. a decrease in absorption, an increase in intestinal secretion. Infection and toxemia The bacteria proliferate, produce toxin. Vascular supply or viability compromised bacteria,toxin diffuse severe peritonitis and toxemia. Shock Severe dehydration, decrease of blood volume electrolytic disturbance, acid-base imbalance, bacterial infection and toxemia, Clinical manifestations Nausea and vomiting Colicky abdominal pain Obstipation Abdominal distention. Their onset varies not only with the duration of established obstruction but also with its anatomic site. 1.Nausea and vomiting: may be the only symptoms. 1).The nature of the vomitus. undigested food particles. becomes bilious. feculent. 2).The onset and character of vomiting-level. Recurrent vomiting of bile-stained fluid (proximal ) Prolonged nausea precedes vomiting, feculent.(distal) Vomiting a late finding if the ileocecal valve prevents 2. Crampy (spastic) abdominal pain: Absent, Most prominent,paroxysmal,crampy,often diffuse, poorly localized, and lasting 1-3min. Between spasms, pain resolves. Borborygmus loud, coincident with cramps Severe ,continuous abdominal pain suggests intestinal ischemia or peritonitis. 3.Abdominal distention: Develop later in the course of obstruction Associated with obstructed site or level. 1)not prominent in proximal intestinal obstruction, 2)prominent and diffuse in distal intestinal obstruction and paralytic obstruction. 3)colon is obstructed, round abdomen. 4)intestinal torsion， asymmetrical. 4.Contispation and obstipation: The onset of obstipation, a late development. Still pass flatus or feces: the distal, unobstructed intestine empties. partial or incomplete obstruction Physical Examination the signs of dehydration, sunken eyes, dry mucous membranes, loss of skin turgor, and before resuscitation, resting tachycardia. Inspection: The degree of abdominal distention varies with both the duration and the location of the obstruction. Peristalsis occasionally visible, scar/hernia Palpation: Localized tenderness or a tender, palpable mass -closed loop Signs of localized or generalized peritonitis-gangrene or rupture Auscultation: Obstructed bowel sounds(borborygmi) high-pitched,metallic with tinkles, splashes, and rushes coincide with the abdominal colic. With late obstruction , it loses its contractile activity, and rushes may be absent. Borborygmus (Bowel sounds) may be absent in paralytic obstruction. Percussion: If the segment of intestine is strangulated, shifting dullness may be evident. Rectal digital examination: Low rectal carcinoma and intussuscepted segment are palpable sometimes Laboratory tests: Serve only to define the fluid and electrolyte status. Abdominal roentgenograms Supine and erect abdominal roentgenograms. When small bowel is obstructed, supine:dilated loops of small intestine erect: multiple air-fluid level ,bladder-like When large bowel is obstructed, the image of dilated colon and haustra of colon Occasionally, confirm the diagnosis reveal the cause. Diagnosis must make clear the following questions: 1.Whether intestinal obstruction exists: Through symptoms and signs, the diagnosis can be made without difficulty. Abdominal roentgenograms is much helpful in diagnosis. 2.Whether the obstruction is mechanical or dynamic: mechanical: typical symptoms and signs. Paralytic: crampy pain absent, distention is prominent 3.Whether the obstruction is simple or strangulation obstruction: Indications for strangulation: 1).Abrupt onset with continuous acute abdominal pain, 2).Shock 3).Manifestation of peritonitis: leukocytosis, hyperthermia. 4).Asymmetrical distention, local bulge, or mass with tenderness. 5).Hemic (hematic) vomitus, drainage 6).Conservative treatment in vain and no improvement in symptoms and signs. 7).Isolated, bulged, and distended intestinal loop on roentgenograms. 4.Whether the obstruction is high or low : Vomiting, in proximal intestinal obstruction. Distention in low obstruction, feculent vomitus Abdominal roentgenograms is helpful. 5.Whether the obstruction is complete or incomplete: frequency of vomiting, extent of distention, and roentgenograms. 6.Which causes leads to obstruction: According to the age, history, symptoms and signs, roentgenograms. Postoperative adhesions Henias Congenital malformations (newborn infants) Intestinal intussusception (children 2years) Obstruction of parasite origin (chilidren) Carcinomas and dry feces (elders) Treatment or Management The principle: correction of systemic disturbance reduction of obstruction. Basic treatment 1).Gastrointestinal decompression: 2).Correction of water-electrolytic disturbance, acid-base imbalance 3).Prevention (Prophylaxis) and treatment of infection and toxemia: Treatment of obstruction 1.Operative treatment strangulation obstruction or obstruction of neoplastic and congenital origin The surgical procedures includes: 1)Lysis of adhesion, reduction of intussusception, torsion. 2)Enterectomy and anastomosis. 3)Bypass procedure for nonresectable lesions. 4)Enterostomy and exteriorization of intestine. Treatment of obstructing carcinoma colon 2.Non-operative treatment simple, adhesive obstruction (incomplete ), paralytic obstruction, obstruction of parasite and bezaor origin, and in the early stage of intestinal intussusception. close observation is very important. exacerbated, transferred to surgical intervention. obstructing carcinoma colon Right colonic carcinoma one-staged operation Left colonic carcinoma two-staged operation-one stage surgical skills, intraoperative lavage, antibiotics
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