BOWEL

OBSTRUCTION
BY Dr Obsa B.
Lecture For C-I medical Students
June 2024, Ambo
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5
 Outlines
Introduction to BO
Definition of BO
Classification of BO
Causes
Pathophysiology
Diagnosis
Treatment principles
Sumary
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 Learning Objectives
At the end of this session students will be able to:
 Define Bowel obstruction
 Classify bowel obstruction
 Identify etiology of bowel obstruction
 Diagnose the presence of bowel obstruction
 Explain the volume and electrolyte derangement in small bowel obstruction
 Interpret a plain abdominal X-ray with bowel obstruction
 Differentiate between LBO and SBO, complicated and simple obstruction
 Describe the principles of management of bowel obstruction

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 Introduction
The description of patients presenting with BO dates back to the 3 rd/4th
C BC.
A better understanding of the pathophysiologic process of BO, surgical
advances, antibiotics, intestinal tube decompression, and use of
isotonic fluid resuscitation have greatly reduced the mortality rate for
patients with a mechanical BO.
However, patients with a BO still represent difficult with regard to
accurate diagnosis, optimal timing of therapy, and appropriate
treatment.

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 Definitions
Bowel obstruction: is defined as lack of aborad transit of intestinal
contents, regardless of etiology.
When mechanical or physiological blockade preventing progression of gut
content.
Bowel obstruction may involve only the SI (SBO), the LI(LBO), or both via
systemic alterations in metabolism, electrolyte balance, or neuroregulatory
mechanisms (generalized ileus).
Traditional perspective of a BO represents a mechanical obstruction.
Ineffective motility causes a functional obstruction or ileus of the intestine.

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 Classification
Based on:

 Location/site :small bowel (80-90%)vs

large bowel(10-20%)
 Duration of presentation: acute, sub acute
vs chronic obstruction )
 Extent of obstruction: partial vs complete
 Type of obstruction: simple vs closed-loop
 Risk of bowel compromise: Viable
strangulated.
 Dynamic/adynamic ( mechanical vs
functional obstruction)

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 Definition of some terms
cont’d…
 Simple” obstruction: the bowel is blocked, compressed or kinked, but its vascular supply
is not threatened.
 Strangulation-obstruction: the vascular supply to the segment of obstructed bowel is
compromised.
 Closed-loop obstruction: a segment of bowel is obstructed at a proximal and distal
point.
 Partial obstruction: there is gas seen in the colon, in addition to the small
bowel distention with fluid levels.
 Complete obstruction: no gas seen in the colon.

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 Epidemiology
1% of all hospitalizations, 3% of emergency surgical admissions to general
hospitals, and 4% of major celiotomies are undertaken because of bowel
obstruction or procedures necessitating adhesiolysis.
About 80% to 90% of bowel obstructions occur in the small intestine; the
other 10% to 20% occur in the colon.
Colorectal cancer is responsible for 60% to 70% of all LBO, while diverticulitis
and volvulus account for the majority of the remaining 30%.
In contrast, SBO is most commonly attributed to adhesions, abdominal wall
hernias, or neoplasms in most advanced Western societies.

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 Pathophysiology
 Distention
 Hypersecretion
 Absorption
 Altered motility
 Dehydration and electrolyte loss
 Strangualtion:
Compromised blood supply,
bowel ischemia
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 Closed loop obstruction
Causes
Hernia
Adhesion
Volvulus

Malignant stricture
of the colon with a competent ICV

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 Pathophysiology cont’d…
Circulatory changes
Extrinsic compression or progressive distention
Esp. Large bowel obstruction with competent ICV (40%)
Water shade areas of the colon
Microbiology and bacterial translocation
Bacterial proliferation: Change in type and number
Translocation: Transmural, vascular and lympatic
When mucosal barrier and integrity is breached.
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 Etiology

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 Etiology cont’d…

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 Commonest cause

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• SPECIFIC CAUSE OF IO

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 Adhesion
Inflammatory-derived, fibrous
attachments of connective tissue
that adhere to organ surfaces.
Congenital or acquired
(inflammatory or Post op)
Spectrum of fibro-inflammatory
changes physiologic mesothelial
healing vs pathologic adhesion

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 Depends on d’t factors
Type of surgery Timing: 1month to several
Pelvic and gynecologic decades after the index op
Open surgeries Vs lap
Types of gloves used
FB
Degree of contamination and
infection
Separate peritoneal closure
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 Hernia
Protrution of intraabdominal
contents through an opening
External hernias
Inguinal, Femoral, Umblical etc
Internal hernias
Congenital eg. Paraduodenal
Acquired eg. After lap RYGB

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 Volvulus
An axial twist of the bowel and its
mesentery
Common in geriatric population
Long mesentry with narrow base.
Lack of fixation of the bowel.
Large bowel(sigmoid 75%, cecal,
Tc, cpd vol.)
Small bowel (primary and
secondary)
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 Neoplasm
Common cause of large
bowel obstruction
Rare in the SI
Could be primary or
secondary peritoneal mets.

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 Intussusception

When one part of the intestine

telescopes into another.
Primary: Ideopathic (90 % of peds
and 20% of adults)
Secondary: identifiable lead point
(80% of adults and 10% of pedi.)

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 Strictures
Trans mural scarring and
narrowing due to
Crohn’s disease
TB
Actinomycosis
malignancy

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 Diagnosis
History
Cardinal symptoms/manifestation
 Colicky crampy abdominal pain
 Abdominal distention
 Nausea and vomitting
 Obstipation( EXCEPTION?)
Characterize the pain:
Adynamic obstruction presents with diffuse mild pain with out waves of colic.
Dynamic obstruction: Severe truly colicky, Recurrent paroxysms of crescendo- decrescendo (10-30 sec in SI and 1-2
min in LI)
Visceral, poorly localized
Persistent pain: Strangulation

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 Late manifestation
 Dehydration,
 Oliguria,
 Hypovolaemic
Shock,
 Pyrexia,
 Septicaemia,
 Respiratory embarrassment and
 peritonism.

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 Compare SI vs LI obstruction
SI LI
 Vomiting and pain prominent Abdominal distention and
and early sx obistipation are early and
prominent
 Abdominal distention and
obistipation are late.
Vomiting is rare and late
 Vomitus is usually bilous or Vomitus is fecal
feculent ( distal ileum) Pain is usually peripheral and
lower abdominal.
 Pain is periumblical
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 Diagnosis cont’d…
 Associated symptoms
 Aggravating and alleviating factors.
 Previous operations, current medications, a history of chronic
constipation,
 Recent changes in the caliber of stools, bloody stool and a history of
cancer including its stage at presentation and related treatments
 Diet
 Risk factors like TB, crhon’s disease
 Pertinent positive and negative statements to R/O ddx
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 Physical Examination
G/A- Acutely or Chronically sick
V/s: Tachycardia, Hypotention, Fever..
HEENT: Dry tongue and buccal mucosa, pale conjunctiva ( malignancy)
Abdominal exam
Inspection: Distended/protuberent abdomen
Visible peristalsis
Previous surgical scars
Hernial sites
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 P/E cont’d…
Auscultation:
Mechanical obstruction:
Hyperactive bowel sounds.
Metallic tinkling sound/High pitched sound
Ileus and strangualted IO:
Hypoactive bowel sounds
Succussion splash: Dilated stomach or SI with air fluid interface

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 P/E cont’d…
 Palpation:
Signs of peritonism like direct and rebound tenderness, guarding and rigidity in cases of
strangulation and perforation (suggestive of the need for an emergent operation)
Mass
Hernial defects
 Percussion:
Hypertympanitic percussion note
 DRE:
Fecal impaction, rectal mass
Blood; dark (strangulated bowel)
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 Investigations

Lab
 CBC with differential
 Electrolyte panel
 BUN & Cr
 Arterial Ph,
 serum lactate,
 LDH and
 D dimers level.
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 Imaging(radiology)

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 Plain erect and supine abdominal X
Ray Imaging
 -Air fluid levels
 -Distended bowel loops
 -Paucity of air distal to the obstruction
(Rectum)
SBO
Distal:
 Multiple A-F levels
 Centrally located distended bowel
loop with VC/PC.
 Caliber 3-5 cms
Proximal:
 Few if any A-F levels
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 Imaging cont’d…
LBO
 Few A-F level
 Peripherally located
 Haustral markings only partially
cross the bowel
 Caliber 6-10cms
 Fecalization of the small bowel
content – Chronic obstruction

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 Sigmoid volvulus (coffee Cecal volvulus
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bean or omega sign (kidney shaped)
 Contrast studies
 Barium swallow for esophageal studies
 Barium meal for stomach
 Barium follow through for SI
 Barium enema for LI
 Contraindicated in complete obstruction
with possible strangulation or perforation –
it can result in barium peritonitis
 Gastrografin (water soluble contrast) is
preferred in such cases.
 Enteroclysis (double contrast)
 Advantage: intraluminal and intramural
pathologies can be identified
Contrast held up at the level of
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the AC
 Contrast studies

• Diagnostic
• Therapeutic
Barium swallow consistent with
possible small bowel obstruction
(SBO). The figure illustrates a
barium swallow study showing
distention of stomach and
proximal duodenum (white
arrows) with abrupt narrowing of
the third part of the duodenum
(red arrow). Radiographic
findings with slow passage of
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contrast led to high suspicion of

SBO
 CT scan
Bowel obstruction is considered
to be present at CT when
distended bowel loops are seen
proximal to collapsed loops.
When a point of transition from
dilated small bowel to normal-
caliber bowel
Closed loop obstruction Vs
simple obstruction
Strangulated
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 Management principles
 Double large bore IV lines Definitive Management
 Resuscitate with boluses of • Surgical
crystalloids ‘’The sun should not both
 NG tube decompression rise and set’ on a case of unrelieved
acute intestinal obstruction’’
 Rectal tube decompression
 Keep NPO • Non operative
 Broad spectrum antibiotics
 Catheterize and monitor urine out
put
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 Summary
 Bowel obstruction is defined as lack of aborad transit of intestinal
contents, regardless of etiology.
 About 3% of emergency surgical admissions to general hospitals
 Classified based site, duration, type, extent, risk of vascular compromise
etc…
 Commonest etiology differ for large and small intestine.
 Pain, vomiting, distension and absolute constipation are cardinal symptoms.
 Diagnosis based on Hx, P/E, Lab and Imaging
 Supportive
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 References
Bailey –loves short practice of surgery, 27th edition
Schwartz Principles of general surgery 2019, 11th edition
Maingot’s abdominal operation, 12th edition
Schein emergency abdominal operation
Sabiston text book of surgery, 21st edition
ACS 2011

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 Thank you
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