OBSTRUCTION

Chris HarmstonConsultant Colorectal Surgeon

UHCW

Learning objectives

• Recognise the types of bowel obstruction

• Understand their symptoms and signs

• Initiate basic management

The GI tract !

• Foregut• Stomach and duodenum

• Midgut • Small bowel

• Hindgut• Colon (well most of it)

Obstruction

• Gastric outlet obstruction

• Small bowel obstruction

• Large bowel obstruction

• Symptoms

• Signs

• Management

• Causes

Gastric outlet obstruction

• What is it?– Mechanical obstruction to the gastric outflow

• How does it present?

– Elective – Emergency

Symptoms

• Vomiting– Nature• Solids, then liquids

– Type• Bile stained or not

– Timing• Usually within an hour of a meal

Symptoms

• Weight loss– Insidious– Can lead to malnutrition– More significant in those with malignant disease

• Early satiety• Epigastric fullnes• Pain?

Signs

• Look at the patient!• Dehydrated• Cachectic

• Basic observations• Tachycardia

• Examination• Often unremarkable • Succusion splash

Investigations

• Biochemical

CO2 + H20 <= H2CO3 => HCO3- + H+

• Loss of– H+, Cl-, Na+

• Hypokalaemic hypochloraemic alkalosis

Imaging

Imaging

Imaging

Initial Management

• Decompress the stomach

• Correct biochemical abnormalities

• Address the nutrition

Definitive management

• Conservative

• Surgical

– Resect

– Bypass

– Stent

Causes

• Benign• PUD• Caustic stricture

• Malignant• Gastric Ca• Pancreatic CA

Small bowel obstruction

• What is it?– Mechanical obstruction of the small bowel

• How does it present?– Usually as an emergency

Symptoms

• Vomiting• Nature

– Usually to solids and liquids– Continuous

• Type– Bile stained

• Abdominal pain– Midgut– Colicky

• Absolute constipation

Signs

• Look at the patient• Abdominal distention• Check for hernias – twice!

• Baseline observations• Be afraid of

– Tachycardia, fever, hypotension

• Examination• Should have a soft abdomen

– Be afraid of peritonism

Investigations

Initial management

• Decompression

• Correct the biochemical abnormalities

• Rule out ischaemia

Definitive management

• Conservative – drip and suck

• Operative

Causes

• Benign– Adhesions– Hernias– Inflammatory bowel disease

• Malignant– Caecal tumour– Disseminated peritoneal disease– Primary small bowel tumour

Large bowel obstruction

• What is it?– Mechanical outflow obstruction of the colon

• How does it present?

– Usually emergency

Symptoms

• Distention

• Abdominal pain– Colicky– Hindgut

• Vomiting• Constipation

Signs

• Look at the patient• Distended

• Baseline observations• Be afraid if tachycardia,Fever,Hypotension

• Examination• Distention• Be afraid of peritonism

Investigations

Investigations

• Confirm large bowel obstruction with,– Contrast enema– CT

Initial management

• Decompression (if possible)

• Correct the biochemical disturbance

• Rule out ischaemia or perforation

Definitive management

– Conservative?– Endoscopically• Scope• Stent

– Surgically• Stoma• Resection

Causes

• Malignant– Colorectal cancer

• Benign– Stricture– Volvulus

Have we met our objectives?

• Do we know the different types of obstuction?

• Do understand the symptomatology?

• Do we know the concepts of initial management?

Questions?