INTESTINAL OBSTRUCTION

OTHIENO IVAN
[email protected]
 Learning objectives
By the end of the lesson, learners should be able to understand:

1. The pathophysiology of dynamic and adynamic intestinal

obstruction

2. The cardinal features on history and examination

3. The causes of small and large bowel obstruction

4. The indications for surgery and other treatment options in

bowel obstruction
 CLASSIFICATION OF INTESTINAL
OBSTRUCTION
• Intestinal Obstruction is Failure, reversal or impairment of
the normal transit of intestinal contents.

Intestinal obstruction may be classified into two types:

1. Dynamic, in which peristalsis is working against a
mechanical obstruction. It may occur in an acute or a
chronic form.

2. Adynamic, in which there is no mechanical obstruction;

peristalsis is absent or inadequate (e.g. paralytic ileus or
pseudo-obstruction).
 Epidemiology of Dynamic Intestinal
Obstruction
• Incidence: Dynamic intestinal obstruction is more common than
adynamic types. It accounts for about 80% of all intestinal obstructions.

• Common Causes: The leading cause of dynamic obstruction is

adhesions (50-70%), especially following previous abdominal surgeries.
Hernias, malignancies, volvulus, and intussusception also contribute.

• Demographics:Age: It occurs more frequently in older adults,

particularly those with a history of abdominal surgery.

• Gender: Males may have a slightly higher incidence due to a higher

frequency of hernias.
 Epidemiology of Adynamic Intestinal
Obstruction
Incidence: Adynamic obstruction is less common but occurs frequently
postoperatively. It is a significant complication following abdominal surgery
and in conditions affecting intestinal motility.

Common Causes: Paralytic ileus is often postoperative but can also be

caused by metabolic disturbances (e.g., hypokalemia, uremia), sepsis,
trauma, and medications (e.g., opioids). Pseudo-obstruction (Ogilvie’s
syndrome) is rarer and often associated with underlying conditions like
diabetes, trauma, or neurological disorders.

Demographics:
• Age: Paralytic ileus is common in elderly, critically ill, or bedridden patients,
particularly following surgery.
• Gender: There is no significant gender predilection, but older age is a key risk
factor.
 Causes of intestinal obstruction
Dynamic Adynamic
Intraluminal • Paralytic ileus
• Faecal impaction
• Foreign bodies • Pseudo-obstruction
• Bezoars
• Gallstones
Intramural
• Stricture
• Malignancy
• Intussusception
• Volvulus
Extramural
• Bands/adhesions
• Hernia
 Common causes of intestinal
obstruction and their relative frequencies.
 PATHOPHYSIOLOGY OF INTESTINAL
OBSTRUCTION
• Irrespective of aetiology or acuteness of onset, in dynamic
(mechanical) obstruction the bowel proximal to the obstruction
dilates and the bowel below the obstruction exhibits normal
peristalsis and absorption until it becomes empty and
collapses.

• Initially, proximal peristalsis is increased in an attempt to

overcome the obstruction.

• If the obstruction is not relieved, the bowel continues to dilate;

ultimately there is a reduction in peristaltic strength, resulting
in flaccidity and paralysis
• The distension proximal to an obstruction is
caused by two factors:

• Gas: The majority is made up of nitrogen (90%)

and hydrogen sulphide.

• Fluid: This is made up of the various digestive

juices. (saliva 500mL, bile 500mL, pancreatic
secretions 500mL, gastric secretions 1 litre – all
per 24 hours)
 STRANGULATION
• The consequences of intestinal obstruction are
not immediately life-threatening unless there
is superimposed strangulation.

• When strangulation occurs, the blood supply

is compromised and the bowel becomes
ischaemic.
 Causes of strangulation
Direct pressure on the bowel wall
• Hernial orifices
• Adhesions/bands

Interrupted mesenteric blood flow

• Volvulus
• Intussusception

Increased intraluminal pressure

• Closed-loop obstruction
Distension. Closed-loop obstruction with no proximal (A) or distal (C) distension
and impending strangulation (B).
Carcinomatous stricture A classic form of closed-loop
(X) of the hepatic flexure: obstruction is seen in the presence of
closed-loop obstruction. a malignant stricture of the colon with
a competent ileocaecal valve

This can occur with lesions as far

distally as the rectum.

The inability of the distended colon to

decompress itself into the small bowel
results in an increase in luminal
pressure, which is greatest at the
caecum, with subsequent impairment
of blood flow in the wall. Unrelieved,
this results in necrosis and perforation
 SPECIAL TYPES OF MECHANICAL
INTESTINAL OBSTRUCTION
• Internal hernia
• Obstruction from enteric strictures
• Bolus obstruction
• Obstruction by adhesions and bands
• Acute intussusception
• Volvulus
 Internal hernia
• Occurs when a portion of the small intestine
becomes entrapped in one of the retroperitoneal
fossae or in a congenital mesenteric defect

• Internal herniation in the absence of adhesions is

rare and a preoperative diagnosis is unusual.

• The standard treatment of an obstructed hernia

is to release the constricting agent by division.
Obstruction from enteric strictures
• Small bowel strictures usually occur secondary to tuberculosis or
Crohn’s disease. Malignant strictures associated with lymphoma
are uncommon, whereas carcinoma and sarcoma are rare.

• Presentation is usually subacute or chronic.

• Standard surgical management consists of resection and

anastomosis.

• Resection is important to establish a histological diagnosis as this

can be uncertain clinically.
 Bolus obstruction
Bolus obstruction in the small bowel may be
caused by:
 Gallstones
 Food
 Trichobezoar
 Phytobezoar
 Stercoliths
 Worms.
 Obstruction by adhesions and bands
• Most common cause of intestinal obstruction In
Western Countries

• Any source of peritoneal irritation results in local

fibrin production, which produces adhesions
between apposed surfaces.

• Early fibrinous adhesions may disappear when the

cause is removed or they may become vascularised
and be replaced by mature fibrous tissue.
 Bands
Usually only one band is culpable. This may be:
• congenital, e.g. obliterated vitellointestinal
duct.
• a string band following previous bacterial
peritonitis .
• a portion of greater omentum, usually
adherent to the parietes.
 Acute intussusception
• This occurs when one portion of the gut invaginates into an
immediately adjacent segment; almost invariably, it is the proximal
into the distal.

• The condition is encountered most commonly in children, with a peak

incidence between 5 and 10 months of age.

• About 90% of cases are idiopathic but an associated upper respiratory

tract infection or gastroenteritis may precede the condition.

• Adult cases are invariably associated with a lead point, which is

usually a polyp (e.g. Peutz–Jeghers syndrome), a submucosal lipoma
or other tumour
 Pathology of intussusception
• An intussusception is
composed of three
parts:
• The entering or inner
tube (intussusceptum);
• The returning or middle
tube;
• The sheath or outer
tube (intussuscipiens)
 Volvulus
• A volvulus is a twisting or axial rotation of a portion of bowel about its
mesentery

• The rotation causes obstruction to the lumen (>180° torsion) and if tight
enough also causes vascular occlusion in the mesentery (>360° torsion)

• Volvuli may be primary or secondary

• Examples of Primary volvulus include volvulus neonatorum, caecal

volvulus and sigmoid volvulus

• A secondary volvulus, which is the more common variety, is due to

rotation of a segment of bowel around an acquired adhesion or stoma .
 Sigmoid volvulus
• Common in Eastern Europe and Africa.

• Most common cause of large bowel

obstruction in the indigenous black African
population.

• Rotation nearly always occurs in the

anticlockwise direction.
The predisposing clinical features to
Sigmund volvulus
 Compound volvulus
• This is a rare condition also known as ileosigmoid knotting.

• The long pelvic mesocolon allows the ileum to twist around the sigmoid
colon, resulting in gangrene of either or both segments of bowel.

• The patient presents with acute intestinal obstruction, but distension is

comparatively mild.

• Plain radiography reveals distended ileal loops in a distended sigmoid

colon.

• At operation, decompression, resection and anastomosis are required.

 CLINICAL FEATURES OF
INTESTINAL OBSTRUCTION
Dynamic obstruction
• The diagnosis of dynamic intestinal obstruction is based on the classic
quartet of pain, distension, vomiting and absolute constipation.

• Obstruction may be classified clinically into two types:

 small bowel obstruction – high or low;
 large bowel obstruction.

• The nature of the presentation will also be influenced by whether the

obstruction is:
 complete
 incomplete.
 Late manifestations of intestinal
obstruction
• Dehydration
• Oliguria
• Hypovolaemic shock
• Pyrexia
• Septicaemia
• Respiratory embarrassment and
• Peritonism
• Hypokalaemia
• Abdominal tenderness
• High-pitched bowel sounds

In all cases of suspected intestinal obstruction, the hernial orifices must be

examined.
 Clinical features of strangulation
• Constant pain, severe pain
• Tenderness with rigidity and peritonism
• Shock
 IMAGING
• Erect abdominal films are no longer routinely
obtained. Only requested when further doubt exists.

• The radiological diagnosis is based on a supine

abdominal film

• When distended with gas, the jejunum, ileum, caecum

and remaining colon have a characteristic appearance
in adults and older children that allows them to be
distinguished radiologically.
 Radiological features of obstruction (on
plain x-ray)
• The obstructed small bowel is characterised by straight segments that are generally
central and lie transversely. No/ minimal gas is seen in the colon

• The jejunum is characterised by its valvulae conniventes, which completely pass

across the width of the bowel and are regularly spaced, giving a ‘concertina’ or
ladder effect

• Ileum – the distal ileum has been piquantly described by Wangensteen as featureless

• Caecum – a distended caecum is shown by a rounded gas shadow in the right iliac
fossa

• Large bowel, except for the caecum, shows haustral folds, which, unlike valvulae
conniventes, are spaced irregularly, do not cross the whole diameter of the bowel
and do not have indentations placed opposite one another
 TREATMENT OF ACUTE
INTESTINAL OBSTRUCTION
There are three main measures used to treat acute intestinal obstruction.

1. Gastrointestinal drainage via a nasogastric tube

2. Fluid and electrolyte replacement

3. Relief of obstruction

Surgical treatment is necessary for most cases of intestinal obstruction but

should be delayed until resuscitation is complete, provided there is no sign of
strangulation or evidence of closed-loop obstruction

The first two steps are always necessary before attempting the surgical relief of
obstruction and are the mainstay of postoperative management.
 Principles of surgical intervention for
obstruction
Management of:
• The segment at the site of obstruction
• The distended proximal bowel
• The underlying cause of obstruction
 Supportive management
• Nasogastric decompression is achieved by the
passage of a nonvented (Ryle) or vented (Salem)
tube.

• Antibiotics are not mandatory but many clinicians

initiate broad-spectrum antibiotics early in therapy
because of bacterial overgrowth.

• Antibiotic therapy is mandatory for all patients

undergoing surgery for intestinal obstruction.
 Surgical treatment
The timing of surgical intervention is dependent
on the clinical picture.

There are several indications for early surgical

intervention:
1. Obstructed external hernia
2. Clinical features suspicious of intestinal
strangulation
3. Obstruction in a ‘virgin’ abdomen
 Acute intestinal obstruction of the
newborn
Neonatal intestinal obstruction has many potential
causes;
• Congenital atresia and stenosis are the most common.
• Intestinal malrotation with midgut volvulus,
• Meconium ileus
• Hirschprung’s disease
• Imperforate anus
• Necrotising enterocolitis
• An incarcerated inguinal hernia
 Management of left-sided large bowel
obstruction
Contraindications to immediate resection
include:
• Inexperienced surgeon

• Moribund patient

• Advanced disease
 CHRONIC LARGE BOWEL
OBSTRUCTION
Symptoms of chronic intestinal obstruction may arise from two sources – the
cause and the subsequent obstruction.

The causes of obstruction may be organic:

• intraluminal (rare) – faecal impaction;

• intrinsic intramural – strictures (Crohn’s disease, ischaemia, diverticular),

anastomotic stenosis;

• extrinsic intramural (rare) – metastatic deposits (ovarian), endometriosis,

stomal stenosis

• or functional:
• Hirschsprung’s disease, idiopathic megacolon, pseudoobstruction.
 Investigation of possible large bowel
obstruction
• In the presence of large bowel obstruction, a single-contrast water-
soluble enema or CT should be undertaken to exclude a functional
cause.

• Organic disease requires decompression with either a laparotomy or

stent

• Functional disease requires colonoscopic decompression in the first

instance and conservative management.

• Intestinal perforation can occur in patients with functional

obstruction. Those at risk have such gross distension that the
abdomen is rigid on palpation.
 ADYNAMIC OBSTRUCTION
Paralytic ileus
• This may be defined as a state in which there is failure of
transmission of peristaltic waves secondary to
neuromuscular failure (i.e. in the myenteric (Auerbach’s)
and submucous (Meissner’s) plexuses).

• The resultant stasis leads to accumulation of fluid and gas

within the bowel, with associated distension, vomiting,
absence of bowel sounds and absolute constipation.

• Varieties: Postoperative, Infection, Reflex ileus, Metabolic

 Clinical features of Paralytic Ileus
Paralytic ileus takes on a clinical significance if, 72 hours after laparotomy:
• There has been no return of bowel sounds on auscultation;
• There has been no passage of flatus.

Abdominal distension becomes more marked and tympanitic. Colicky pain is

not a feature.

Distension increases pain from the abdominal wound.

In the absence of gastric aspiration, effortless vomiting may occur.

Radiologically, the abdomen shows gas-filled loops of intestine with multiple

fluid levels (if an erect film is felt necessary).
 Management of paralytic Ileus
• Use of nasogastric suction and restriction of
oral intake until bowel sounds and the passage
of flatus return.

• Electrolyte balance must be maintained.

• The use of an enhanced recovery programme

with early introduction of fluids and solids is,
however, becoming increasingly popular
 Pseudo-obstruction
• This condition describes an obstruction,
usually of the colon, that occurs in the
absence of a mechanical cause or acute intra-
abdominal disease.

• It is associated with a variety of syndromes in

which there is an underlying neuropathy
and/or myopathy and a range of other factors.
 Small intestinal pseudo-obstruction
• This condition may be primary (i.e. idiopathic or associated
with familial visceral myopathy) or secondary.

• The clinical picture consists of recurrent subacute obstruction.

• The diagnosis is made by the exclusion of a mechanical cause.

• Treatment consists of initial correction of any underlying

disorder. Metoclopramide and erythromycin may be of use.
 Colonic pseudo-obstruction
• This may occur in an acute or a chronic form. The former, also known as
Ogilvie’s syndrome, presents as acute large bowel obstruction.

• Abdominal radiographs show evidence of colonic obstruction, with marked

caecal distension being a common feature.

• Indeed, caecal perforation is a wellrecognised complication. The absence

of a mechanical cause requires urgent confirmation by colonoscopy or a
single contrast water-soluble barium enema or CT.

• Once confirmed, pseudo-obstruction requires treatment of any identifiable

cause. If this is ineffective, intravenous neostigmine should be given (1mg
intravenously), with a further 1 mg given intravenously within a few
minutes if the first dose is ineffective.
Factors associated with pseudo-obstruction

• Metabolic e.g. Diabetes

• Severe trauma (especially to the lumbar spine and pelvis)

• Idiopathic

• Septicaemia

• Postoperative (for example fractured neck of femur)

• Retroperitoneal irritation e.g. Blood

• Drugs eg Laxatives

• Secondary gastrointestinal involvement e.g. Chagas’ disease

 References
• Watkinson, J. C., & Gilbert, R. W. (Eds.). (2018).
Bailey & Love's short practice of surgery (27th
ed.). CRC Press

• Sriram, B. (4th ed). SRB's clinical methods in

surgery (Edition). Jaypee Brothers Medical
Publishers.
 Case Scenario:
Mr. Balwana Joel, 72 years old male, with a History of Previous abdominal surgery for hernia repair, known
hypertension, and type 2 diabetes, presents to the emergency department of Mulago National Referral Hospital
with a 48-hour history of abdominal pain, distension, vomiting, and inability to pass stool or gas. The pain started
as mild cramping but has progressively worsened. He reports no fever or chills. His last bowel movement was two
days ago, and he recalls having similar but less severe symptoms six months ago that resolved on their own.

On Examination:
General appearance: Distressed, with an intermittent moaning due to pain.
Vital signs: BP 140/90 mmHg, HR 110 bpm, RR 22, Temp 37.1°C.
Abdominal examination: Distended abdomen with visible peristalsis, tenderness, and hyperactive bowel sounds.
Hernia scars noted. No signs of peritonism.
Rectal examination: No stool in the rectum.

Investigations:
X-ray abdomen (supine): Distended small bowel loops with multiple air-fluid levels, absence of gas in the colon.
CT scan of the abdomen: Dilated small bowel loops with a transition point near adhesions from previous surgery.

What the Diagnosis?

What is the management Plan for this Patient?
Thank you!