Prof. L. DamjanovichInstitute of Surgery

A group of diseases with diverse etiology The common feature is obstruction of the

bowel Similar set of symptoms, which may vary

according to site and cause of obstruction Therapy is according to etiology, aiming at

relief from obstruction, and treatment of primary disease

May be mechanical or paralytic (US: ileus)

ClassificationClassification DivisionDivision

EtiologyEtiology IntraluminalIntraluminal

IntramuralIntramural

ExtrinsicExtrinsic

Location within the Location within the

gastrointestinal tractgastrointestinal tractSmall bowelSmall bowel

Large bowelLarge bowel

Speed of onsetSpeed of onset AcuteAcute

SubacuteSubacute

ChronicChronic

DegreeDegree Partial or completePartial or complete

ProgressionProgression Open versus closed loopOpen versus closed loop

Simple versus strangulatedSimple versus strangulated

Site of obstructionSite of obstruction CauseCauseLuminalLuminal Intussusception, Meconium,Intussusception, Meconium,

Polypoid tumor, Gallstone,Polypoid tumor, Gallstone,

Bezoar, Parasites,Bezoar, Parasites,

FecesFeces

MuralMural StrictureStricture (Crohn’s disease, (Crohn’s disease, radiation)radiation)

Small bowel tumorSmall bowel tumor

Congenital atresia, stenosis, Congenital atresia, stenosis, duplicationduplication

ExtrinsicExtrinsic AdhesionAdhesion

HerniaHernia

Malignant or inflammatory Malignant or inflammatory massmass Volvulus Volvulus

Pain Nausea and vomiting Abdominal distension Decreased passage of flatus and stool Possible causes of obstruction:

previous operations, presence of hernias,previous irradiation, previous malignancy

Obstruction-incresased luminal pressure-increased secretion, decreased absorption

Increased peristalsis-stasis-bacterial overgrowth-translocation-septic complications

Sequestration of fluid-third spacing-hypovolemia

Impared perfusion-ischemia-necrosis

Degree of distress Severity of dehydration Evidence of sepsis (if any) Inspection: scars, hernia orifices, distension Auscultation: tinkling, splashing, quiet

abdomen Palpation: location of tenderness, rigidity,

garding Rectal exam

Degree of dehydration Electrolyte imbalance Exclusion of possible other diseases (eg.:

pancreatitis) Imaging: plain abdominal films,

ultrasound CT in special cases (tu. recurrence,

radiation enteritis, Crohn’s disease)

Schematic drawing of X-ray findings in small bowel distension

Longer anamnesis Gradual increase of dull pain (cramping is

rare) No passage of flatus or stool Blood may be found in feces Vomiting comes late, may be feculent if

ileocecal valve is incompetent Cecum is the most prone to perforation

Cancer Diverticulitis - chr. inflammation –

scarring - stenosis Sigmoid-, cecal volvulus

Ogilvie’s syndrom (colonic pseudo-obsruction-paralysis)

Obstructing sigmoid carcinoma

A: Competent valve: closed large bowel loop

B: Incompetent valve: distension reaches the small bowel loops

Unprepared bowel, full of feces, increased bacterial content

Distended, thin walled bowel, compromised circulation

Difficult manipulation because of the distension

Two stage procedure (Hartmann’s) Extended resection, primary anastomosis Subtotal colectomy On table lavage, primary anastomosis Loop colostomy in inoperable cases Non-operative decompression-

semielective operation

Henrik Kehlet

Causes:DM, hypothyroidism, kidney insuff, opiates, antiparkinson drugscong. heartfailure, MS, lupus, amyloidosis, dermatomyositis, scleroderma, sepsis, trauma (head, spine) operation (abdominal, heart, neurosurgery)

Therapy:Eliminate instigating factors (if possible), Enema, laxativesCholinesterase blocker,Ganglion blockersColonoscopy-may be therapeuticSurgery: perforation, failure of cons. meas.