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Gastrointestinal Pathology > Intestinal Obstruction > Flashcards

Intestinal Obstruction Flashcards

1
Q

Definition of intestinal obstruction

A

Failure of downward passage of intestinal contents

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2
Q

Types of intestinal obstruction

A

Dynamic
Adynamic
Simple
Stragulating

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3
Q

Definition of dynamic intestinal obstruction

A

There is increasing peristalsis working against an obstructing agent

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4
Q

Definition of adynamic intestinal obstruction

A

Peristalsis is absent or ineffective and there are no effective propulsive waves

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5
Q

Definition of simple bowel obstruction

A

Obstruction of the intestinal lumen without interference with its blood supply

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6
Q

Causes of simple bowel obstruction

A 
Gallstones
Impacted faeces 
Strictures (inflammatory or neoplastic)
Adhesions
Tumours (outside of wall)
Obstructed hernia
Pseudo obstruction
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7
Q

Most common cause of a simple bowel obstruction

A

Adhesions

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8
Q

What is an adhesion? Therefore what is their risk factor?

A

Fibrous bands that form between tissues and organs, often as result of an injury during surgery
RF = Previous abdominal surgery

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9
Q

Pathology of a simple bowel obstruction

A 
Above the obstruction 
- peristalsis
- distension (fluid and gas)
Below the obstruction 
- collapsed
- immobile (no peristalsis)
- pale
At site of obstruction
- perforation
Third space loss
Dehydration 
Proliferation of bacteria proximal to the obstruction 
Impairment of the barrier function of the intestinal mucosa
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10
Q

Most common cause of a 50 y/o male with a small bowel obstruction

A

Tumour

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11
Q

What is a virgin abdomen?

A

No previous abdominal surgery

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12
Q

Definition of third space loss

A

Loss of ECF into a space that does not contribute to equilibrium between ICF and ECF

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13
Q

Definition of transition point

A

The transition between dilated and constricted bowel

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14
Q

What does a 3rd space loss result in?

A

The patient will always need more fluid than you calculate they need

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15
Q

Where does the 3rd space loss happen?

A

Above the lesion

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16
Q

Causes of death in simple intestinal obstruction

A

Fluid and electrolyte imbalance

Peritonitis

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17
Q

What does the mucosa in the gut wall prevent?

A

Translocation of bacteria into the peritoneum by an active mechanism

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18
Q

Definition of strangulating IO

A

Intestinal obstruction with persistent interference of blood supply

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19
Q

Causes of strangulating IO

A 
Strangulated hernia
Intussusception 
Adhesive intestinal obstruction (late)
Volvulus
Vascular occlusions
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20
Q

What is the window of time that you can save the bowel in strangulating IO?

A

6 - 8 hours

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21
Q

Pathology of strangulation

A

Artery has the higher pressure, and so this blocks the vein first
So the blood flows in but doesn’t come out
So the bowel has a dark and blue appearance - venous ischaemia
Then results in the artery becoming blocked as well
Serosangious fluid formation - in the peritoneal cavity
Third space loss
Dehydration
Impairment of the barrier function of the intestinal mucosa

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22
Q

What is in 3rd space loss in strangulation?

A

Blood

Fluid

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23
Q

What does blood in the 3rd space loss may mean the patient may require?

A

Cross match

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24
Q

Differences in how the patient feels in simple vs strangulation IO

A

More unwell in strangulation

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25
Q

Causes of death in strangulation IO

A

Peritonitis due to perforation
Hypovolaemic shock
Sepsis

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26
Q

How may perforation occur in strangulation IO?

A

Build up of oedema / fluid due to the venous obstruction

This may perforate the bowel or leak out and cause obstruction

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27
Q

What is closed loop obstruction?

A

Occurs when some part of the gut is closed at both ends

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28
Q

In what % of people is the ileo-caecal valve competent?

A

75%

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29
Q

Function of ileo-caecal valve

A

Moves food from the small bowel to the large bowel

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30
Q

Pathology of closed loop obstruction

A

Bowel will dilate
This could perforate the bowel or the pressure will overcome the ileocaecal valve and will result in decompression of the small bowel

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31
Q

Where is the thinnest part of the large bowel? What is the significance of this?

A

Caecum

Perforation almost always occurs here

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32
Q

What diameter of the caecum indicates perforation? What would need to be done?

A

10cm

Immediate surgery

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33
Q

Presentation of intestinal obstruction

A

Pain
Vomiting
Abdominal distention
Absolute constipation

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34
Q

If symptoms come from up downwards (i.e. pain, vomiting etc before e.g. abdo symptoms) then what does this indicate?

A

Small bowel obstruction

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35
Q

If symptoms come from downwards up (i.e. abdo symptoms first, then nausea vomiting etc) then what does this indicate?

A

Large bowel obstruction

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36
Q

Features of the abdominal pain in intestinal obstruction

A

Generalised abdominal colicky pain
Each attack lasts few minutes then gradually disappears
In between attacks; periods of relief

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37
Q

What gives the pain in intestinal obstruction?

A

Peristalsis

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38
Q

As time goes on, what happens to the pain in intestinal obstruction?

A

Severity increases

Interval between attacks decreases

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39
Q

What happens to the vomiting, the more higher up in the GI tract the obstruction is? Why is this?

A

More severe
Presents earlier
Due to having less time to absorb things

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40
Q

Where do most secretions occur? What does this mean for large bowel obstruction?

A

Proximal gut

May not vomit at all

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41
Q

What is faecal vomiting?

A

Terminal ileum contents vomiting due to enteric bacterial overgrowth
NOT REAL FAECES

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42
Q

Vomiting in jejunal obstruction

A

Vomiting occurs with the first and each attack of pain

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43
Q

Vomiting in ileal obstruction

A

Vomiting delayed for a few hours

Then it occurs with each attack of pain

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44
Q

As vomiting goes on, what is the vomitus?

A

First partly digested food
Then bile stained
Then “faeculent”

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45
Q

What is absaloute constipation?

A

No gas or stools passed

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46
Q

Presentation of high intestinal obstruction

A

Frequent vomiting
No distention
Intermittent pain but not classic crescendo type

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47
Q

Presentation of middle intestinal obstruction

A

Moderate vomiting
Moderate distention
Intermittent pain (crescendo, colicky)
With free intervals

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48
Q

Presentation of low intestinal obstruction

A 
Vomiting late
Flatulent 
Marked distention 
Variable pain 
May not be classic crescendo type
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49
Q

What constipation would be present in a patient with complete intestinal obstruction?

A

Absaloute constipation

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50
Q

What presentation of constipation would be present in a patient with partial obstruction?

A

Continued passage of flatus and/or stool beyond 6 - 12 hours after onset of symptoms

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51
Q

What distension would be present in jejunal obstruction?

A

Minimal

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52
Q

What distention would be present in ileal obstruction?

A

Central

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53
Q

Along with central distension in small bowel obstruction, what would also be present on the abdomen?

A

Collapsed flanks

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54
Q

Presentation of abdomen in colonic obstruction

A

General distention

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55
Q

What does flank distention indicate?

A

Long bowel obstruction with competent ileocaecal valve

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56
Q

What does generalised distention obstruction indicate?

A

Distended small bowel and colon - large bowel obstruction with incompetent ileocaecal valve

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57
Q

Causes of intestinal obstruction WITHOUT absaloute constipation

A

Richter’s hernia
Gallstone ileus
Mesenteric vascular occlusion
Intestinal obstruction associated with pelvic abscess

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58
Q

What % of strangulated hernias are Richters hernia?

A

10%

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59
Q

What is a Richter’s Hernia?

A

Herniation of the anti mesenteric wall of the bowel, usually through a small defect

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60
Q

What happens to Richters hernia more than other strangulated hernias?

A

Progress more rapidly to gangrene

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61
Q

Is complete obstruction frequent in Richters hernia? Why?

A

No, it is less frequent

Still room to pass through

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62
Q

Signs of intestinal obstruction

A

Dehydration
Tachycardia
Shock (strangulation)
Scars of previous surgery (adhesive obstruction)
Visible non reducible hernia
Visible peristalsis
Step ladder appearance of abdomen due to distended loops of bowel over each other
Auscultation
- early; loud and frequent intestinal sound
- late; silent abdomen (ileus/peritonitis)
PR
- empty rectum in most cases

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63
Q

What is absent on examination in simple obstruction?

A

Tenderness

Rigidity

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64
Q

What should be checked for in suspected intestinal obstruction?

A

Hernial orifices

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65
Q

What may a PR exam reveal?

A

Cause of obstruction

e.g. rectal tumour, faecal impaction

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66
Q

Does a hernia cause pain?

A

NO
unless complications
However may be tender

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67
Q

Tachycardia + shock = ….

A

Strangulation

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68
Q

What is the most common type of hernia?

A

Femoral

69
Q

What features should make you suspect internal strangulation?

A

Pain
- more severe
- never completely absent in between attacks
Shock
- present and progressive
Tenderness and rigidity
NG suction for 1-2 hours fails to relieve the pain

70
Q

Why would NG suction may relieve an obstruction? In what case would this not work?

A

It would relieve the pressure so make the patient feel better
Not in the case of ischaemia

71
Q

Features of an ischaemic strangulation pain

A

No relief periods

72
Q

What features should make you suspect an external hernia strangulation?

A

Hernia swelling that is

  • tense
  • tender
  • irreducible
  • no expansible impulse on cough
73
Q

Investigations for intestinal obstruction

A 
FBC
U and Es
LFTs
ABG 
AXR
Erect CXR
CT
Water soluble oral contrast
Water soluble enema
74
Q

Why would Hb be done in intestinal obstruction?

A

Indication of bleeding / tumours

75
Q

What does an increased WCC in intestinal obstruction indicate?

A

Strangulation

76
Q

Why do U and Es have to be checked in suspected intestinal obstruction?

A

At risk of pre renal failure due to the fluid loss

Hypokalaemia

77
Q

What may be seen in AXR?

A

Dilated bowel loops

78
Q

What may be seen in erect CXR? What is this an indication of?

A

Free air

  • perforation
  • late
79
Q

Features of distended jejunal loops on AXR

A

Valvulae conniventes (transverse, complete, regular striations) giving concertina effect

80
Q

Features of distended ileal loops on AXR

A

Characterless / featureless tube

81
Q

Features of distended colon on AXR

A

Haustrations

82
Q

Sensitivity of AXR

A

60 - 90%

83
Q

What is the diameter of a dilated small bowel?

A

> 2.5 - 3cm in diameter

84
Q

What does a normal AXR NOT exclude the diagnosis of?

A

Short bowel syndrome

85
Q

If there is a tumour in the left side of the colon, what would this present with?

A

Fresh blood PR

86
Q

If there is a tumour on the right side of the colon, what would this present with?

A

Anaemia

87
Q

What lab results would be indicative of liver metastases?

A

Increased LFTs

Decreased Hb

88
Q

What would a high / proximal small bowel obstruction look like on AXR?

A

Minimal small bowel loops

89
Q

What would a low / distal small bowel obstruction look like on AXR?

A

Dilated small bowel loops

90
Q

What would a large bowel obstruction look like on AXR?

A

Dilated large bowel loops

91
Q

What is looked for in suspected intestinal obstruction on CT?

A

Confirm the diagnosis if transition point is seen
Identify the level (SBO/LBO)
Find the cause
Detection of ischaemia
Detection of bowel perforation
Staging in obstruction secondary to malignancy

92
Q

What does CT have a limited sensitivity in?

A

Partial bowel obstruction

93
Q

How does water soluble oral contrast work?

A

100ml of gastrogaffin orally or through NG tube
Serial AXRs performed to monitor the passage of the contrast medium through the small bowel
Appearance of the contrast in the caecum within 6 hours is predictive of non surgical resolution of adhesive small bowel obstruction

94
Q

What may the contrast of water soluble oral contrast have?

A

Therapeutic effect

95
Q

What can a water soluble enema be used to confirm the diagnosis of?

A

Large bowel obstruction

96
Q

Common causes of IO in the newborn

A

Imperforate anus
Congenital atresia
Stenosis of the gut
Volvulus

97
Q

Cause of 2 - 3 month old with IO

A

Strangulated hernia

98
Q

Cause of a 3 - 12 month old with IO

A

Intussception

99
Q

Cause of young adults with IO

A

Strangulated hernia

Post op adhesions

100
Q

Causes of IO in old age

A

Strangulated hernias
Post op adhesions
Colon cancer
Colonic volvulus

101
Q

Treatment of intestinal obstruction

A

NG tube
Resus with restoration of fluid and electrolyte balance
Surgery - laparotomy / laparoscopy

102
Q

Why would an NG tube be used in treatment of IO?

A

To prevent the risk of aspiration, especially in SBO due to vomiting

103
Q

Indications for early surgery in IO

A

Obstructed hernia
Suspected strangulation
Small bowel obstruction in a ‘virgin abdomen’
Failure of conservative treatment in adhesive SBO
Obstructing tumours on CT

104
Q

Where is the tumour found when there is small bowel obstruction from the tumour?

A

Ileocaecal valve

105
Q

Definition of intussusception

A

Invagination of an intestinal segment into an adjacent loop

106
Q

Causes of intussusception

A

Polyp
Submucous lipoma
Polypoidal tumours
Inverted Meckel’s diverticulum

107
Q

What does protrusion invite?

A

Intussusception

108
Q

Treatment of intussusception

A

Laparotomy resection

+/- anastomoses

109
Q

What is avoided in treatment of intussusception in children?

A

Surgery

110
Q

Presentation of paediatric intussusception

A

Recurrent episodes of screaming and drawing up legs
Vomiting
Redcurrent jelly stools
Sausage shaped mass on examination

111
Q

Investigations of paediatric intussusception

A

Abdominal USS

GG enema currently rarely used

112
Q

Treatment of paediatric intussusception

A

Reduction by air enema

113
Q

When is surgery used in paediatric intussusception?

A

Failed reduction

Suspected strangulation

114
Q

Definition of volvulus

A

Axial rotation of the gut

115
Q

Types of volvulus

A

Volvulus neonatorum
Volvulus of small intestine in adults
Volvulus of the caecum
Sigmoid volvulus

116
Q

Pathology of volvulus of small intestine in adults

A

Post op adhesions between the antimesenteric border of the intestine and the anterior abdominal wall

117
Q

What type of volvulus is most common?

A

Sigmoid volvulus

118
Q

When does caecal volvulus occur?

A

If the right colon has a long and mobile mesentery

It occurs in a clockwise direction

119
Q

Diagnosis of caecal volvulus

A

AXR

CT

120
Q

Treatment of caecal volvulus

A

Right hemicolectomy

+/- ileo-colic anastomosis

121
Q

Who is sigmoid volvulus common in?

A

Elderly males

122
Q

Presentation of sigmoid volvulus

A

Sudden left sided abdominal pain
Abdominal distension
Absaloute constipation
Vomiting rare

123
Q

What is seen on plain X ray in sigmoid volvulus?

A

Dilated colon - “coffee bean” sign

124
Q

Treatment of sigmoid volvulus

A

Emergency endoscopic decompression

Subsequent sigmoid resection in fit patients

125
Q

What gender gets caecal volvulus more?

A

Females

126
Q

Causes of adhesive intestinal obstructive

A

Post operative adhesions

127
Q

Treatment for adhesive IO

A

NG tube
IVI
Pain relief
Indications for surgery

128
Q

Why is surgery not done routinely for adhesive IO?

A

As the operations in the first place caused the obstruction

129
Q

Indications for surgery in adhesive IO

A

Suspected strangulation

Failure of conservative treatment after 48 HOURS

130
Q

Pathology of gallstone ileus

A

Gallstone impaction at terminal ileum
Erodes all of the walls
Creates a fistula between the duodenum and gallbladder

131
Q

Presentation of gall stone ileus

A

Small bowel obstruction

132
Q

Investigations for gallstone ileus

A

AXR

CT

133
Q

What would be seen on AXR in gallstone ileus?

A

Small bowel obstruction
Air in the biliary tree
Stone may be seen

134
Q

Treatment of gallstone ileus

A

Laparotomy
- enterotomy and removal of the gallstone (enterolithotomy)
+/- cholecystectomy

135
Q

Definition of cholecystectomy

A

Removal of gallbladder

136
Q

What is mesenteric vascular occlusion?

A

Occlusion of the superior (rarely the inferior) mesenteric vessels or one of its branches

137
Q

Causes of mesenteric vascular occlusion

A 
Arterial embolism 
- AF
- SBE
Arterial thrombosis
- polycythaemia
- atherosclerosis
- contraceptive pills
Venous thrombosis
- Portal HTN
138
Q

Who is mesenteric vascular occlusion common in?

A

Elderly

139
Q

Presentation of mesenteric vascular occlusion

A 
Pain 
- sudden 
- severe
- out of proportion to the physical signs 
Occasionally passage of blood and mucous per rectum 
Shock 
Abdominal tenderness and rigidity 
- mild initially but marked later on
140
Q

Investigations of mesenteric vascular occlusion

A

ABG

CT angiogram

141
Q

Prognosis of mesenteric vascular occlusion compared to any other type of intestinal obstruction

A

Higher mortality

142
Q

Treatment of mesenteric vascular occlusion

A 
Pre op 
- GI suction 
- IV fluids
- antibiotics 
Operative 
- laparotomy
143
Q

Definition of paralytic ileus

A

Cessation of peristalsis due to failure of neuromuscular mechanism of the intestine

144
Q

Pathology of paralytic ileus

A

Cessation of peristalsis

Accumulation of fluid and gas in intestine

145
Q

Presentation of paralytic ileus

A 
History of an underlying disorder
Distention - progressive
Vomiting or increased NG tube output
Failure to pass flatus - absolute constipation 
Absent intestinal sounds
NO PAIN (no peristalsis)
False shifting dullness
146
Q

Causes of paralytic ileus

A 
Major abdominal surgery 
Peritonitis
Following fracture of spine
Retroperitoneal haemorrhage 
Uraemia
Hypokalaemia
147
Q

What is absent on CT in paralytic ileus?

A

Transition point

148
Q

Why in paralytic ileus is there false shifting dullness?

A

Fluid accumulated in dilated intestinal loops

149
Q

On auscultation of paralytic ileus, there is a dead silent abdomen. However sometimes high pitched intestinal sounds may be heard. Why is this?

A

Passage of fluid from one distended loop to another

150
Q

Investigations of paralytic ileus

A

AXR - dilated small bowel loops

CT - dilated small bowel loops with NO transition point

151
Q

Treatment of paralytic ileus

A

NG tube
Restoration of fluid and electrolyte balance
Treatment of underlying cause as appropriate

152
Q

Another name for large bowel pseudo-obstruction

A

Ogilvie syndrome

153
Q

Definition of large bowel pseudo-obstruction

A

Clinical syndrome with symptoms, signs and AXR of LBO but with no identifiable mechanical obstruction

154
Q

Who gets large bowel pseudo-obstruction?

A

Elderly patients

+/- recent surgery

155
Q

Causes / associations of large bowel pseudo obstruction

A 
Severe pulmonary of CV disease
Severe electrolyte disturbance 
- hyponatraemia
- hypokalaemia
- hypomagnesaemia
- hypo/hypercalcaemia 
Malignancy 
Systemic infection 
Medications
- opoids
- anticholingergic
- clonidine
- amphetamimnes
- phenothiazines
- steriods
156
Q

What is metabolic acidosis an important feature of? And therefore what test should you do if you suspect it?

A

Ischaemic bowel

ABG

157
Q

First line investigation for acute mesenteric ischaemic

A

Lactate

158
Q

What is the most likely area to be hit with ischaemic colitis?

A

Splenic flexure

159
Q

Investigation of bowel ischaemia

A

CT

160
Q

Types of bowel ischaemia

A

Acute mesenteric ischaemia
Chronic mesenteric ischaemia
Ischaemic colitis

161
Q

Pathology of acute mesenteric ischaemia

A

Embolism resulting in occlusion of an artery which supplies the small bowel for example the superior mesenteric artery

162
Q

What do patients who get acute mesenteric ischaemia classically have a history of?

A

AF

163
Q

Another name for chronic mesenteric ischaemia

A

Ischaemic angina

164
Q

Presentation of chronic mesenteric ischaemia

A

Colicky, intermittent abdominal pain occur

Non specific features

165
Q

Pathology of ischaemic colitis

A

Acute but transient compromise in the blood flow to the large bowel
May lead to inflammation, ulceration and haemorrhage

166
Q

Where is ischaemic colitis most likely to affect?

A

Watershed areas such as the splenic flexure that are located at the borders of the territory supplied by the superior and inferior mesenteric arteries

167
Q

Investigations of ischaemic colitis and what is seen?

A

AXR - thumbprinting due to mucosal oedema/ haemorrhage

168
Q

Management of ischaemic colitis

A

Usually supportive
Surgery in minority of cases if
- conservative measures fail
- generalised peritonitis / perforation / ongoing haemorrhage

Gastrointestinal Pathology (26 decks)

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