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Intestinalobstruction
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Intestinalobstruction
Mechanicalobstruction
Paralytic
Ileus
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Paralytic Ileus
After abdominal surgery (laparotomy) Electrolyte imbalances (hypokalemia)
Abdominal thrauma
Spine fracture
Retroperitoneal hemorrhage Ureter distensionAcute pancreatitis
Ischemia of the intestine
Drugs (Narcotics, Psychotropics)
Peritonitis (ex. Gangrenous cholecystitis)
Diabetic coma
Extra abdominal infections (Lung)Sepsis
IBD (ulcerative colitis)
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Intestinalmechanicalobstruction
Pathogenesis
Stenosis
Obstruction
Compression Invagination
Torsion
Angulation
Strangulation
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IntestinalobstructionPattern in Africa
40%
16%
14%
14%
10%
3% 3%
Adhesions
Hernia
Small Intest volvolus
Intussusception
Sigmoid volvolus
Ascaris
Large bowel tumor
70 % of the patients were below the age of 15 years
80% with gangrenous bowel segments
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Large gallstones -- cholecystoenteric fistulagallstoneileus
Bezoars (children, mentally retarded, toothless, aftergastrectomy)
Congenital lesions (atresia, stenosis, duplication) Neoplasms of small bowelperitoneal carcinosis
Inflammation (Chrons disease- diverticulitis- BK-endometriois)
Fecal impaction (bedridden old patient) Meconium
Foreign bodies
Iatrogenic strictures (intest. Anastomosis o RT)
Intestinal
mechanicalobstruction
Etiology
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http://www-cdu.dc.med.unipi.it/Archives/photogallery/SmallBowelInfarction/images/Diapositiva03_JPG.jpg7/27/2019 intestinal obstruction bs
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Accumulation of fluids and gas proximal to the
obstruction
Simple mechanicalobstructionPATHOGENESIS
Distention of the intestine (self perpetuating)
Increase intestinal secretion
Losses of water, Na, Cl, K, H
Dehydratation, ipokalemia, hypochloremia
Metabolic alkalosis
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Circultory changes
Low central venous pressure
Reduced cardiac output
Hypotention
Hypovolemic shock
Rapid proliferation of intestinal bacteria
Toxiemia
Simple mechanicalobstructionPATHOGENESIS
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Paralytic Ileus
Mechanical
obstruction
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Ischemia of the bowel
Strangulation obstructionPATHOGENESIS
Loss of blood and plasma into the strangulatedsegment
Gangrene Perforation
Peritonitis
Sistemic absorption of toxic materia
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Intestinal obstruction
Clinical aspects
Abdominal pain
Vomiting
Obstipation
Abdominal distention
Failure to pass flatus
Fever
Dehydratation
Hypotentionhypovolemic shock
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Intestinal obstruction
Pain
Typical crampy pain in paroxysm at 4 to 5
minute intervals in proximal obstruction
Less frequently in distal occlusion
After a long period of mechanical obstruction
the crampy pain may subside
A strangulation should be suspected whencontinuus severe pain replace crampy pain
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Intestinal obstruction
Vomiting
Proximal obstruction produce profuse
vomiting and little abdominal distension
Distal obstruction is less frequent but feculent
Initial phase byliary aspect
Late phase feculent
BUT
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Intestinal obstruction - LevelHIGH LOW
PAIN Crampy pain in paroxism Less intensity
VOMITING Early, profuse, biliary Late, feculent may be
absent
METEORISM + +++
BEGINNING Acute Slow, insidious
ABDOMINAL
DISTENTION
Moderate, upper
quadrant
Early, intense
GENERAL CONDIT Early compromission preserved
ELECTOLYTES Cl, K, Na rapid loss Late hydro electrolytic
imbalance
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Intestinal obstruction Clinical examination
Palpation abdominal masses can suggest neoplasms,intussusception, abscess
Incarcerated hernias may be obscure (obese)
Surgical scars can suggest adhesions Abdominal auscultation period of increasing separated by
periods of quite bowel sounds (high pitched, tinkling or
musical) in mechanical obstruction
Rectal examination to seek luminal masses. Blood in the
feces suggest mucosal lesion (cancer, intussusception,
infarction)
Key points
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Intestinal obstruction Clinical examination
Young children and babies
Atresia
Volvolus
Anal imperforation Meconial ileus
Intestinal Duplication
Malrotation Intussusception
Ascaris infestation
Hernia
Patient age and sex
Adults
Hernia
Adhesions
Neoplasm
Inflammation
RT
Endometriosis
Gynecological
pathology
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Intestinal obstruction
Gas abnormally large quantities of gas in the bowel
Multiple gas-fluid levels in the upright or lateral decubitusposition
Abdominal direct X ray
exhamination
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Intestinal obstruction
Multiple gas-fluid levels does not always mean intestinal
obstruction
Abdominal pain and diarrhea can be found in
gastroenteritis (cytomegalovirus infection as well as
salmonellosis) expecially if profuse watery for 12 or morehours.
Abdominal direct X ray exhamination
Remember
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Intestinal obstruction
Identify the distended tract
Small bowel Colon
Both plus stomach
Radiological examination
What can we see
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Intestinal obstruction
Gas in the small bowel
outlines the
valvulae
conniventes, which
usually occupy the
entire trasverse
diameter of the
bowel image
Radiological examination
Small bowel
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Intestinal obstruction
Colonic haustral
marking occupy
only a portion of
the transverse
diameter of the
bowel
Radiological examination
large bowel
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Intestinal obstructionRadiological examination
Typical the small bowel pattern occupies themore central portion of the abdomen, the
colon shadow is on the periphery of the
abdominal film or in the pelvis
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Intestinal obstructionRadiological examination
Duringparalytic ileus gaseous distention
occurs somewhat uniformly in the stomach,
small intestine and colon
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Intestinal obstruction
Helpful in distal occlusion may be
operative in intussusception
Barium Enema
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Intestinal obstruction
Is sensitive for diagnosing complete
obstruction of the small bowel and
determining the localization and causeof obstruction
CT scan
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Proximal
obstruction
Distal
obstruction
http://radiographics.rsnajnls.org/content/vol26/issue3/images/large/g06ma02g12c.jpeghttp://radiographics.rsnajnls.org/content/vol26/issue3/images/large/g06ma02g12b.jpeg7/27/2019 intestinal obstruction bs
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Intestinal obstruction
Hematocrit
WBC Electrolytes
PCR (C reactive protein)
AST -ALTGGT- LDH
Laboratory test
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Intestinal obstruction
Fluid and electrolytes therapy
Intestinal decompression (NG tube) Diuresys monitoring
Correct surgical timing for relief of
obstruction
Treatment
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Intestinal obstruction
Duration of obstruction
Severity of fluid, electrolyte and acidbase abnormalities
Opportunity to improve vital organ
function Consideration of the risk of
strangulation
Timing of operation depends