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Surgery > Intestinal Obstruction > Flashcards

Intestinal Obstruction Flashcards

1
Q

2 causes of intestinal obstruction

A
  1. dynamic

2. Adynamic

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2
Q

mechanical blockage of normal propulsion and passage of intestinal contents

A

Dynamic obstruction

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3
Q

Intestines fail to transmit peristalsis due to failure of neuromuscular mechanism

A

Adynamic obstruction

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4
Q

3 causes of dynamic obstruction

A
  1. Intraluminal
  2. Intramural
  3. Extramural
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5
Q

2 causes of adynamic obstruction

A
  1. Paralytic ileus

2. Pseudo obstruction

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6
Q

4 causes of intraluminal obstruction

A
  1. Faecal impaction
  2. Foreign bodies
  3. Bezoars
  4. Gallstones
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7
Q

4 causes of intramural obstruction

A
  1. Stricture
  2. Malignancy
  3. Intussuception
  4. Volvulus
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8
Q

2 causes of extramural obstruction

A
  1. Bands/adhesions

2. Hernia

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9
Q

Classification of intestinal obstruction

A
  1. Acute/Chronic (duration)
  2. Partial/ Complete (extent)
  3. Small bowel/large bowel (sites)
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10
Q

Causes of complete obstruction

A
  1. Simple
  2. Closed loop obstruction
  3. Strangulation
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11
Q

What causes a closed loop obstruction

A

There is a carcinomatous stricture at hepatic flexure and ileocaecal valve is competent causing pressure increases in the caecum

This causes stercoral ulcer in caecum leading to gangrene and perforation - peritonitis

Perfoation also occurs due to malignant growth

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12
Q

3 causes of strangulation

A
  1. Direct pressure of the bowel wall (hernia, adhesions)
  2. Interrupted blood flow (volvulus, intussusception)
  3. Increased intraluminal pressure (closed-loop obstruction)
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13
Q

Systemic effects of obstruction

A 
. Water and electrolytes loss
• Toxic materials and toxemia
• Cardiopulmonary dysfunction 
• Renal failure
• Shock and death
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14
Q

Symptoms of obstruction

A
  1. Abdominal pain (sudden in acute intestinal perforation)
  2. Nausea and vomiting (early in proximal SBO)
  3. Abdominal distention (early in distal BO)
  4. Obstipation (no flatus or stool )
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15
Q

Significant vitals in obstruction

A

Tachycardia

Orthostatic hypotension

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16
Q

Significant general examination in obstruction

A

Dehydration (SBO)

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17
Q

Significant abdominal inspection findings

A
  1. Abdominal Distension
  2. Surgical Scars
  3. Overlying skin changes on the mass if present
18
Q

Significant palpation findings

A
  • Hernia
  • Abnormal mass
  • Tenderness
  • Rigidity
  • Guarding
19
Q

Significant percussion findings

A
  • Hyperresonance or tympany throughout abdomen
  • Tenderness to percussion- peritonitis
  • If tympany over liver instead of dull – free intraabdominal air
20
Q

Significant auscultation findings

A
  • Bowel sound high pitched initially
  • Muffled
  • Hypoactive with progression of obstruction
21
Q

Significant DRE findings

A
  1. Fecal impaction/rectal mass

2. Gross/occult blood- intestinal tumor, ischemia, intussusception

22
Q

Significant investigations to be carried out

A
  • Complete blood count with differentials ( white cell count > 40,000)
  • Electrolytes, including BUN and Creatinine

For patients with systemic signs:
• ABG (metabolic acidosis)
• Serum lactate
• Blood culture

23
Q

Causes of pseudo obstruction / ogilivie syndrome

A
  1. Infection
  2. Surgery
  3. Drugs
  4. Mutation in FLNA or ACTG2 gene
24
Q

Cause of gallstone ileus

A

Repeated cholecystitis, cholecystoenteric fistula

25
Q

Difference between children and adult intersucception

A

Children - most comon, idiopathic, cinical symptos present, non-operative have to do a barium hydrostatic reduction

In adult surgical resection always required

26
Q

Most common causes of adhesions

A
  1. Open surgery
  2. Dirty surgery
  3. Perforated appendix
27
Q

Dirt surgery

A

an incision undertaken during an operation in which the viscera are perforated or when acute inflammation with pus is encountered during the operation (for example, emergency surgery for faecal peritonitis), and for traumatic wounds where treatment is delayed, and there is faecal contamination or devitalised tissue present”

28
Q

What are the changes that occur proximal to bowel obstruction

A

There is an increased peristalsis which then become vigorous.

If the obstruction is not relieved peristalsis ceases causing flaccid, paralysed and dilated bowel.

29
Q

What are the causes of intestinal changes proximal to obstruction

A

1.Gas: (Nitrogen- 90%, Hydrogen sulphide)

2.Fluid
Digestive juices (all in ml/24 hrs) Saliva -500
Bile- 500
Pancreatic secretions -500 Gastric secretions -1000

30
Q

What are the changes that occur at the site of obstruction

A

Initially the venous return is impaired —> congestion and edema of bowel

Later arterial supply is jeopardized —> loss of shineness, blackish discoloration and loss of peristalsis —> gangrene —> perforation—> bacteria and toxin migration causing peritonitis

31
Q

Imaging investigations for obstruction

A

Xray. - Abdominal Supine and Abdominal Erect

CT Scan - with radioiodine contrast and oral contrast
• With water soluble contrast (Adhesive obstruction)

• USG • MRI

32
Q

What to observe in Xray of abdomen

A
  1. Gas fluid levels - The air rises above the fluid and there is a flat surface at the “air-fluid” interface.
  2. Dilated bowel loops
33
Q

Difference between small and large bowel obstruction

A

• Small Bowel Obstruction

  • Central distention (GAS)
  • Valvulae conniventes
  • “Ladder-like dilatation”
  • Small diameter

• Large Bowel Obstruction

  • Peripheral distention “Picture frame”
  • More gross distention
  • Haustral indentation & large diameter
34
Q

When is oral contrast given for imaging

A

for low grade or intermittent small bowel obstruction

35
Q

Predictors of strangulation

A
  1. decreased bowel wall enhancement
  2. leukocytosis
  3. peritoneal signs
  4. inc serum lactate.
36
Q

Management for intestinal obstruction

A
  • Supportive Management
  • Nasogastric decompression with Ryles tube for free drainages
  • Nothing per mouth
  • Foley’s catheterization
  • Intravenous fluid replacement
  • Normal saline
  • Hartmann’s solution
  • Antibiotics- Broad-spectrum - Mandatory for patients going into surgery
37
Q

When is non- operative management contraindicated

A

➢ Suspected ischemia
➢ Perforation
➢ Closed loop obstruction
➢ Strangulated hernia

38
Q

Non operative management for obstruction

A
  • NG decompression
  • IV fluids
  • Urinary catheter
  • Water soluble contrast agent
39
Q

Management’s for complete obstruction without ischemia

A

Resuscitate patient before surgery

40
Q

Management for adhesive obstruction

A

Conservative management till 72 hours (chance of spontaneous resolution)

Water soluble contrast agent

41
Q

Surgical management for obstruction

A

Midline laparotomy

  • Operative Decompression
  • Division of adhesions (Enterolysis)
  • Resection and Anastomosis
  • Bypass
  • Stomas (patient unstable)
42
Q

Difference between viable vs non-viable intestine

A

Circulation - dark becomes lighter in viable

Shiny vs dull appearance

Firm va flabby, thin and friable

Peristalsis vs no peristalsis

Surgery (3 decks)

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