intestinal obstruction bernard m. jaffe, md professor of surgery, emeritus
TRANSCRIPT
INTESTINAL OBSTRUCTION
Bernard M. Jaffe, MDProfessor of Surgery,
Emeritus
INTESTINAL OBSTRUCTION • Common Clinical Problem• Carries 3-5% Mortality Rate/Episode• Some Patients Have Multiple Bouts• Can Involve Small or Large Bowel• Requires Both Operative and Non-
Operative Care
SYMPTOMS• Specifics Depends on Site of
Obstruction• Crampy Abdominal Pain• Abdominal Fullness• Nausea, Vomiting• Thirst, Weakness, Dehydration
PHYSICAL FINDINGS• Abdominal Distention• Bowel Sounds• Early- Hyperactive• Rushes• High Pitched• Late- Hypoactive to Absent• Tachycardia, Dry Skin
DIFFERENTIAL- ILEUS• Functional Obstruction• Electrolyte Abnormalities- ↓Na, ↓K,
↓Mg• Meds- Opiates, Anti-Cholinergics, Anti-
Psychotics• Intra-Abdominal Infection/Inflammation• Systemic Sepsis• Post-Laparotomy
INITIAL MANAGEMENT• Done During Evaluation/ Diagnosis• Intravenous Fluid Resuscitation• Ringer’s Lactate• Electrolytes Close to Those Lost• Nasogastric Tube Decompression• Foley Catheter Placement
DIAGNOSIS• Upright Abdominal X-Ray• Air Fluid Levels• Obstruction- Step Ladder Pattern• Ileus- All at Same Level• ? Air in Colon- Incomplete
Obstruction • ? Thumb Printing- Ischemic Bowel
CT SCAN• Not Always Necessary• Can Localize Site- Transition Point
(Change from Distended to Flat Bowel)• Sometimes Diagnose Cause
Distinguish Complete from Incomplete Obstruction• Markedly Overused
CAUSES• Adhesions (60-70%)• Neoplasms (20%)• Hernias (10%)- External, Internal• Others- Intussusception• Volvulus• Intra-Abdominal Abcess/Infection• Gallstone Ileus• Stricture, Extrinsic Compression
GALLSTONE ILEUS• Fistula Between Biliary Tract
(Gallbladder) and Intestine• Stone Passes into Intestine• Travels to Narrowest Point –Distal
Ileum• X-Ray Diagnosis- Air in Biliary Tract• Stone Visible in RLQ
CARCINOID• Malignancy Ileum > Jejunum• 30% are Multiple• Metastasizes Nodes, Liver• Syndrome- Flushing• Diarrhea• Bronchoconstriction• Right Sided Cardiac
Valvular Lesions
OTHER NEOPLASMS• Adenocarcinoma• Lymphoma• Leiomyosarcoma• Other Sarcomas
COMPLICATIONS• Gangrene- • Intraluminal Tension>Venous
Pressure• Venous Flow Stops• Venous → Arterial Gangrene• Perforation• Short Gut Syndrome Following
Resection
EMERGENCY OPERATION• Closed Loop Obstruction• Complete Obstruction• Impending Gangrene• All Increase Risk of Intestinal
Gangrene
IMPENDING GANGRENE• Very Difficult to Diagnose- Variable,
Non-Specific• Abdominal Tenderness• Rebound Tenderness, Guarding• Fever, Tachycardia• Acidosis• Elevated White Blood Cell Count
NON-EMERGENCY OPERATIONS
• Failure to Respond to Conservative Management
• Partial Obstruction• Multiply Recurrent Bouts of
Obstruction
ACUTE POST-OP OBSTRUCTION
• Difficult to Diagnose• Behaves Like Ileus• Enteroclysis is Most Successful
Modality• Non-Operative Management Post-
Op Days 1-7
TREATMENT of ADHESIONS• Adhesiolysis at Site of Obstruction• ? Lysis of All Adhesions• Resect Gangrenous Bowel/Re-
Anastamose• Run Bowel of Site of Injury• Perforation
JEJUNUM• Proximal 40% of Intestine• Larger Circumference, Thicker Wall• Prominent Plicae Circulares• End-Arterial Blood Supply• Fewer Vascular Arcades (1-2)• Less Lymphatic Material
LAPAROSCOPY• Mild Abdominal Distention• Proximal Obstruction• Partial Obstruction• Anticipated Single Band
Obstruction
GALLSTONE ILEUS TREATMENT • Enterotomy with Removal of Stone• Try to Identify Site of Fistula• Cholecystectomy with Fistula
Closure• ONLY IF• RUQ Not Too Inflamed or Indurated
OPERATIVE COMPLICATIONS• Perforation- Missed Injury• Bovie Burn• Delay in Opening Up• Nutrition- Enteral, Parenteral• Wound Failure- Dehiscence, Hernia. • Infection- Superficial Wound• Intraperitoneal• Recurrent Obstruction