SMALL INTESTINE

Small Bowel Obstruction (SBO)

DEFINITION
 Cessation, impairment, or reversal of the physiologic
transit of intestinal contents secondary to a
mechanical or functional cause.
 Most common cause is adhesions from prior
abdominal surgery (75%).
ETIOLOGY
Mechanical
 Extrinsic (adhesion, hernia, cancer, abscess).
 Intraluminal (gallstone ileus, foreign body,
intussusception).
 Intramural (Crohn’s disease, lymphoma, radiation
enteritis).
Functional (Paralytic Ileus)
 Postoperative.
 Electrolyte abnormalities (e.g.,
hypokalemia).
 Peritonitis.
 Medications (opiates, anticholinergics).
 Hemoperitoneum/retroperitoneal hematoma.
PATHOPHYSIOLOGY
 Gas and fluid begin to accumulate within
lumen, proximal to site of obstruction.
 As gas and intraluminal contents build up,
the bowel distends, and intramural and
intraluminal pressure rises.
 If intramural pressure exceeds the pressure
in the microvasculature, then perfusion of the
intestine is decreased, resulting in small
bowel ischemia, and ultimately necrosis.
 Impairment of perfusion is termed
strangulation.
TYPES
 Partial SBO—only part of the lumen is
occluded, allowing some passage of
intraluminal contents.
 Complete SBO—no passage of intraluminal
contents distally.
 Closed loop obstruction:
 Blockage of both proximal and distal
segments of small intestine.
 Seen with incarcerated hernia, adhesions,
volvulus.
 Requires emergent surgery because
progression to strangulation is quite rapid.
RISK FACTORS
 Previous abdominal surgery (most common
risk factor).
 Hernia.
 Inflammatory bowel disease (Crohn’s disease
secondary to stricture formation).
 Diverticular disease.
 Cholelithiasis.
 Ingested foreign body.
SIGNS AND SYMPTOMS
 Colicky abdominal pain.
 Abdominal distention.
 Nausea.
 Vomiting.
 Obstipation.
 Hyperactive bowel sounds.
 Signs of decreased intravascular volume
(hemoconcentration, electrolyte
abnormalities) secondary to decreased PO
intake, vomiting, and accumulation of fluid in
bowel lumen and wall (third spacing).
DIAGNOSIS
 Should differentiate between:
 Mechanical vs. functional
 Partial vs. complete
 Simple vs. strangulation
 History should explore possible risk factors that
may point to specific etiology.
 Physical exam should include meticulous
abdominal exam, search for possible hernias, and
examination of stool for gross or occult blood,
which may indicate presence of strangulation.
 Confirm by abdominal series:
 Supine abdominal x-ray: Dilated loops of small
intestine with paucity of air in colon.
 Upright abdominal x-ray: Multiple air-fluid
levels in a “stepladder”.
 Upright chest radiograph: Can detect
presence of free air under the diaphragm and
thus possible bowel perforation.
 Abdominal computed tomographic (CT) scan
more sensitive and specific than x-rays .
 Findings: Transition zone, with dilation of
bowel proximally and decompression of the
bowel distally, no contrast present distal to
transition point, and paucity of gas and fluid
in colon.
 Useful in acute setting to rule out other
diagnoses as well.
TREATMENT
 If the patient is stable or has partial SBO, give a trial of
nonoperative management:
 NPO.
 IV hydration to counter effects of third spacing.
 Nasogastric tube (NGT) for gastric decompression;
decreases nausea, vomiting, distention.
 Foley catheter to monitor urine output.
 Monitor electrolytes for signs of hypokalemia, base
deficit/metabolic acidosis (signs of ischemia).
 Patients with suspected strangulation need to be
resuscitated with fluids prior to surgery.
 If the patient fails conservative management (24 hrs
without improvement, abdominal tenderness worsens,
fever, other signs of clinical deterioration), then
laparotomy should be performed.
The surgical procedure depends on the cause of the
obstruction:
 Adhesions call for lysis of adhesions (LOA).
 Hernias should be reduced and repaired or, if
contents of sac are strangulated, needs intestinal
resection.
 Cancer requires en bloc resection with lymph node
sampling.
 Crohn’s disease requires resection or
stricturoplasty of affected area only.
 Whatever the cause, the entire small bowel should
be examined, and nonviable intestine should be
resected.
 Primary anastomosis should be performed in
hemodynamically stable patients who have had
The common causes As opposed to large
of bowel obstruction,
SBO are: SBO is rarely
Hernia caused by
Adhesions neoplasm. If
Volvulus neoplasm is the
Intussusception/ cause, it is most
Ileus likely secondary to
Crohn’s disease extrinsic
Gallstone ileus compression as
SMA syndrome opposed to
Neoplasm intraluminal
obstruction.
Features associated with strangulated SBO
include:
 Tenderness
 Tachycardia
 Fever
 Markedly elevated WBC count
 Acidosis with elevated lactate level
Beware: These indicators are NOT present in
5–15% of patients with intestinal infarction,
especially the elderly.
MECKEL’S DIVERTICULUM
 It is a congenital diverticulum arising from the terminal
ileum and is part of the unobliterated proximal portion of
the vitello intestinal duct.
It is:
 2% common.
 2 feet from the ileocaecal valve.
 2 inch in length.
 2% of Meckel’s diverticulum only will be symptomatic.
 50% of symptomatic are below 2 years of age.
 2:1 female preponderance .
 It is congenital, results from incomplete closure of
vitellointestinal duct.
 It is the most common congenital anomaly of small
intestine.
 contains all three layers of the bowel with independent
blood supply.
In 20% of cases mucosa
contains heterotopic
epithelium like gastric
(commonest—50%),
colonic and pancreatic
tissues (5%).
 It may be connected to
or communicated with
the umbilicus through a
band or fistula.
 It may be associated
with esophageal
atresia, exomphalos,
and anorectal
malformations.
Presentations in Meckel’s Diverticulum
 Asymptomatic—in majority cases.
 Severe haemorrhage most common, seen in
children aged 2 years or younger (Maroon
coloured blood)..
 Perforation.
 Intussusception, volvulus of small bowel.
 Peptic ulceration.
 Diverticulitis (20%)—features mimic acute
appendicitis.
 Silent Meckel’s diverticulum found during
laparotomy or laparoscopy or by radioisotope
study.
Diagnosis
 Technetium (Tc99) radioisotope scan is very
useful (90-95% accuracy).
95% of heterotrophic gastric mucosa can be
identified in Meckel’s diverticulum by
radioisotope study. It can detect Meckel’s
diverticulum with minimal bleeding also (0.1
ml/minute). So it is very useful investigation in
children presenting with bleeding.
 X-ray abdomen to see complications like
obstruction, perforation.
 Laparoscopy is very useful.
 Enteroclysis/small bowel enema under
fluoroscopy may show the Meckel’s diverticulum.
It is probably the most accurate investigation.
Treatment
 Asymptomatic Meckel’s diverticulum can be
left alone when identified during laparotomy.
 Resection of a short segment of ileum
containing Meckel’s diverticulum and end-to-
end anastomosis is done.
 Meckelian diverticulectomy with closure of
enterotomy also can be done, but chances of
retaining heterotopic tissues and stenosis are
higher.
Indications for Surgery
 the base is narrow, and in lengthy
diverticulum.
 Presence of adhesions or band which may
precipitate obstruction, intussusception or
volvulus.
 Symptomatic patients or presence of
complications.
 If it is found in children below 2 years.
Meckel‘s diverticulum—surgical treatment.
Meckelian diverticulectomy is done by obliquely
clamping beyond the base of the Meckel‘s
diverticulum. Care should be taken not to retain
heterotopic gastric (or other) epithelium which
can be felt like indurated area. Enough
precaution should be taken so that stricture will
not form later.
When heterotopic tissues extend beyond the
Meckel‘s diverticulum into the ileum, then
resection of ileum with Meckel‘s and anastomosis
is done. Clamping distal to the base of the
Meckel‘s diverticulum like appendicectomy
should not be done. It will cause stricture, leak or
retaining heterotopic tissues in the part.