Baghdad College of Medicine / 4
th
grade
Student’s Name :
Dr. Aqeel Shakir
Lec. 6
Intestinal Obstruction
Mon. 29 / 2 / 2016
DONE BY : Ali Kareem
مكتب اشور لالستنساخ
2015 – 2016
Intestinal Obstruction Dr .Aqeel Shakir 29-2-2016
1
Intestinal Obstruction
Objective :
Definition
Review of Basics History and Examination
Differential diagnosis
Investigation
Fluid prescription
Clinical algorithm
Definition :
Clinical condition due to failure of intestine small or large
to pass gas , liquid and solid material
:
Review of the basics
:
Pathophysiology
-
1
Blocked lumen
Distention (solid , liquid , gas) ;pain ; vomit; constipation
Increased wall tension ; perforation Ischemia
Closed and Open loops
Intestinal Obstruction Dr .Aqeel Shakir 29-2-2016
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:
The three pains / the three guts
-
2
The three pains :
Visceral :
Is
a
pain
that
results
from the
activation of
nociceptors of the
thoracic pelvic or
abdominal
viscera (organs)
Referred :
It’s
when the pain
is
located away
from
or
adjacent to the
organ
involved
:
Somatic
When the parietal peritoneum is inflammed;
Pain is severe
Breathing shallow
Movement impaired
Tenderness
Marked
The three Guts :
There are 3 main guts to be aware of when it comes to pain
The 3guts; Based upon arterial
supply
Fore-gut
Mid-gut
Hind-gut
Intestinal Obstruction Dr .Aqeel Shakir 29-2-2016
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The fore gut :
In the distribution of the Coeliac artery Extends from the
lower esophagus to half way down D2 Pain is referred to
the epigastrium
The mid gut :
In the distribution of the Superior Mesenteric artery Extends
from half way down D2 to the distal transverse colon Pain is
referred to the umbilicus
The hind gut :
In the distribution of the Inferior Mesenteric artery Extends from
the distal transverse colon to the rectum Pain is referred to the
Hypogastrium
of intestinal obstruction:
Causes
-
3
Classification based upon;
lumen, wall, outside and combinations
Lumen; Gallstone, Beezoar, Foreign Body
Wall; Stricture
Outside; Volvulus, Hernia, Adhesions,
Metastases
Combinations; Intussusception
Intestinal Obstruction Dr .Aqeel Shakir 29-2-2016
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open and closed loop Identify dangerous types
simple and complex Clinically useful
small intestine, large intestine Clinical and
Radiological
Small intestine :
Post operative adhesions
Stuck onto tumor or inflammatory mass somewhere
Hernia; External, Internal
Volvulus
Intussusception
Crohn’s stricture
Ischaemic stricture
Tumors of the small intestine
Operative Findings; Small bowel volvulus
Large intestine
Colo-rectal cancer
Volvulus; Sigmoid, Caecal
Inflammatory Stricture
Intestinal Obstruction Dr .Aqeel Shakir 29-2-2016
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common and rare (Clinical)
Common;
Post operative adhesions
Herniae; Groin, Femoral and Inguinal, Incisional
Colorectal Cancer
Internal hernia
Rare;
Presenting Complaint :
Abdominal Pain
Vomiting
Distension
Constipation, Complete, obstipation
Pain :
Site
Radiation
Type
Severity
Onset and Duration
Aggravating and Relieving factors
Associated symptoms
Intestinal Obstruction Dr .Aqeel Shakir 29-2-2016
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Whats this?
Past history :
Had this before?
Previous surgery
Other illness (drugs)
Examination :
Overall state; distressed, comfortable, cachexia
Vital signs
State of Hydration
Abdominal Examination; distension, peristalsis,
tenderness, mass
Hernial orifices, Perineum, Rectal, Genitalia, Femoral
Pulses
Intestinal Obstruction Dr .Aqeel Shakir 29-2-2016
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Inspection
Clinical approach
Has the patient got intestinal obstruction?
Is it simple or complicated?
What is the fluid deficit?
What is the level of the obstruction?
What is the cause of the obstruction?
Differential Diagnosis
Obstuction or Pseudo-obstruction
Of the pain; Abdominal, Non Abdominal
Of the distension; Fluid, Flatus, Fat, Faeces, Fetus
Investigation
Blood; U & E, FBC, Amylase, Muscle Enzymes ,
Radiological; PFA, Erect CXR, CT scan, Enemas.
Intestinal Obstruction Dr .Aqeel Shakir 29-2-2016
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Radiology
Quite simple ,
Gaseous distension, what is distended?
Fluid levels, fluid distension
Transition zone, any gas distally?
Contrast wont pass, show mass
Radiology, Small bowel obstruction
Blood; U & E, FBC, Amylase, Muscle Enzymes
,
Radiological; PFA, Erect CXR, CT scan, Enemas.
Operative Findings; Small bowel obstruction
Quite simple
,
Gaseous distension, what is distended?
Fluid levels, fluid distension
Transition zone, any gas distally?
Contrast wont pass, show mass
Intestinal Obstruction Dr .Aqeel Shakir 29-2-2016
9
Radiology; PFA, Large bowel obstruction
Operative Findings; Large bowel obstruction
Done by : Taher Al-Hamadany