Intestinal obstruction symptoms and bowel obstruction treatment

LISTEN YOUR ABDOMEN......

MALFUNCTIONING OF THE BODY THEREBY BLOCKING THE INTESTINE

Undergo HOW to prevent and Treat ?

INTESTINAL OBSTRUCTION

The mall-functioning of the body thereby blocking the gut and preventing the movement of product of digestion. Its a mechanical or  useful impediment  of the gut ,veto the normal transit of the products of digestion. it can become at some level distal to the duodenum of the small gut an is a medical emergency. Although many cases are not treated surgically , is  a surgical problem.

CLASSIFICATION

• ACUTE OBSTRUCTION : Occurs in small intestine.
• CHRONIC OBSTRUCTION :  Occur in large intestine.
• ACUTE-ON-CHRONIC OBSTRUCTION : Spreads from large gut to involved small intestine.

ETIOLOGY

DYNAMIC OBSTRUCTION

  Here an obstructive agent is present.

     LUMINAL OBSTRUCTIONFecal impaction

• Gall stone ileus
• worms eg ascariasis.

     INTRINSIC LESION OF BOWL WALL

•  Inflammatory stricture
• Malignant stricture
• Intussusception

     EXTRINSIC COMPRESSION

•  Adhesions
• Hernias
• Volvulus

ADYNAMIC OBSTRUCTION

Here's no obstructive agent is present.

PARALYTIC ILEUS

• Postoperative
• Peritonitis
• Reflex
• Uremia
• Hpokalemia

 MESENTRIC VASCULAR OCCLUSION

• Embolism
• Thrombosis

SIGNS AND SYMPTOMS

Based on the extent of impediment involved, viscus impediment can result into abdominal pain, abdominal distension, vomiting and regurgitation. (This a information where half-digested concern is remove from the gut into the stomach by contraction and muscle movement, forcefully expelled through the oesophagus and finally outside from the mouth. This is not actually faecal concern that is vomited, but it smells similar). The information of viscus impediment haw be worsen by extraction and electrolyte abnormalities (acid-base imbalance) cod to vomiting. In diminutive gut obstruction, the discompose are cramping and consistent in nature. The discompose is more central and mid-abdominal. Constipation comes after vomiting. In case of large viscus impediment , the discompose is felt in the lower conception of the abdomen. Constipation occurs first and regurgitation haw be irregular.

INVESTIGATIONS

Test that shows obstruction

• Barium enema
• Abdominal CT scan
• Upper GI and small bowl series
• Abdominal film

The field diagnostic tools are blood test, X-rays of the abdomen, CT scanning (computer tomography) and or ultra-sound. In a case of identifying mass, biopsy haw be employed to determine the nature of the mass. Radio logically viscus impediment shows viscus distension and the presence of multiple gas-fluid levels. Contrast enema, diminutive gut series or CT construe can be used to define the level of obstruction, as in either partial or complete and helping to know the cause of the obstruction. In colonoscopy,small gut are diagonalised using ingested camera,while endoscopy is an instrument used to get medical information from inside the embody and laparoscopy is a form of new technique aimed at carrying out abdominal activeness through diminutive incision.unlike the usual large surgical procedure.

TREATMENT

GASTRODUODENAL OR GASROINTESTINAL SUCTION DRAINAGE

REPLACEMENT OF FLUID AND ELECTROLYTES

RELIEF OF OBSTRUCYION BY OPERATION

ANTIBIOTICS 

The treatment for diminutive viscus impediment is both non-surgical called conservative and surgical. Non-surgical treatment involves a nasogastric tub, correction of extraction and electrolyte abnormalities. For patients with cut pain, Opioid discompose reliever haw be used. Antiemetics haw be administered to regurgitation patient. Intestinal Obstruction in Children Intestinal atresia is the main causes of fetal and neonatal viscus obstruction. This is characterised by narrowing or absence of a conception of the intestine. The atresia are usually discovered before birth via Sonagram and treated with using laporotomy after if the area infected is small, surgeon haw be able to remove the damaged conception and the gut is joined back together. In a information where the narrowing is longer and the area is damaged, a temporary stoma haw be placed.

SURGERY

The surgery is performed while you are under general anaesthesia. This means you are unconscious and pain-free .A cut is prefabricated  in your abdomen. The disease conception of the super bowl is distant and the digit healthy ends of bowl are seamed back together ( resected ).The cut is winking , if the entire colon and rectum is distant , it is titled a proctocolectomy. A bowl resection haw be performed as a traditional 'open' machine or as a minimally invasive laproscopic procedure.

PREVENTION


It depends on the cause,treatment of conditions ( such as tumor and hernias ) that are attendant to obstruction,may reduce the risk.some causes of obstruction are not preventable.

EXPECTATION

The outcome varies with the cause of obstruction.

Gall stones(cholelithiasis)-Gall bladder problems common in women eat high fibre diet for prevention

PATHOLOGICAL CONDITIONS OF THE GALL BLADDER ARE COMMON SURGICAL PROBLEMS....

GALL STONES ( CHOLELITHIASIS )

In medicine, gallstones (choleliths) are crystalline bodies formed within the embody by increment or concretion of normal or deviant bile components.In 80% of patients gall stones are composed predominantly of cholesterol with smaller amounts of calcium salts and bile pigments . They are referred to as mixed stones , are usually multiple with a faceted surface , and have a characteristic laminated surface on cross section. Only about 10 % of them contain sufficient calcium to be visible on a plain X-ray .Pure cholestrol stones form less than 10% of stones .They are usually solitary ( the cholestrol " solitaire " ) up to 5 cm in diameter ,and have a characteristic radial arrangement of crystals on cross section . Cholestrol stones usually form in bile which is supersaturated with cholestrol. When bile contains more cholestrol than can be solublised in the bile- acid -lecithin micelles ,crystals of cholestrol form in the bile .

The greater the concentration of bile acids and lecithin in bile ,the greater is the amount of cholestrol that can be contained in the mixed micelles .Lecithin is important because lecithin - cholestrol mixed micelles can solubilise more cholestrol than can micelles of bile acids alone .Following Crohn's disease of the terminal ileum or ileal resection thebile salt pool is reduced because of lack of absorption of bile salts ,and the liver can not make good the losses .

Such patients are prone to cholestrol stones. Oestrogen increases the hepatic synthesis of cholestrol ,and this may explain why females of child - bearing age have a higher incidence of cholestrol stones . A high animal fat ,low fibre diet is also associated with cholestrol stones because of excretion in bile of the excess cholestrol absobed from the gut.Clofibrate , a cholestrol-lowering agent ,has been implicated in cholestrol stone formation ,because it increases excretion of cholestrol in the bile . Decreased gall bladder motility probably plays a rle in aetiology of gall stones .

Cholestrol and other substances which form the nuclei for gall stone formation must remain in the gall bladder long enough for crystal growth to occur .Stasis occurs during pregnancy due to the smooth muscle relaxing effect of progesterone.Motility of the gall bladder is also decreased during starvation and total parenteral nutrition , due to decreased stimulation of the gall bladder by CCK.Stones may also form after vagotomy ,because of lack of vagal potentiation of CCK.Bile pigment stones account for about 10 % of stones in the UK.The major constituent is the calcium salt of unconjugated bilirubin.

They are associated with chronic haemolytic disease where there is breakdown of red cells with release of excessive bilirubin.Pure pigment stones occur in sickle cell disease , thalassaemia and hereditary spherocytosis .Pigment stones are found in the Far East ,where they are associated with biliary tract infection with E.coli and Bacteroides fragilis ,These organism produce beta-glucuronidase which splits bilirubin diglucuronide and releses free bilirubin.The latter combines with calcium to form the relatively insoluble calcium bilirubinate.

PATHOLOGICAL CONSEQUENCES OF GALL STONES ARE :

• Inflammation of the gall bladder ,acute cholecystitis ,chronic cholecystitis ,acute on chronic cholecystitis
• obstructive jaundice due to impaction of a stone at the lower end of the common bile duct : secondary biliary cirrhosis may result .
• ascending cholengitis
• empyema of the gall bladder.
• mucocele
• gall stone ileus __ a fistula occurs between the gall bladder and duodenum ,and a large stone enters the small bowel ,causing obstruction .usually at the terminal ileum .
• pancreatitis ,usually associated with multiple small stones .
• carcinoma of gall bladder .
• perforation of the gall bladder .
  

Medicines titled chenodeoxycholic acids (CDCA) or ursodeoxycholic acid (UDCA, ursodiol) may be given in preventive form to dissolve cholesterin gallstones. However, they may take 2 eld or longer to work, and the stones may return after communication ends.

Rarely, chemicals are passed into the gallbladder finished a catheter. The chemical apace dissolves cholesterin stones. This communication is not used rattling often, because it is difficult to perform, the chemicals can be toxic, and the gallstones may return.

Cholecystectomy (gallbladder removal) has a 99% chance of eliminating the recurrence of cholelithiasis. Only symptomatic patients staleness be indicated to surgery. The lack of a gall bladder does not seem to have any perverse consequences in some people. However, there is a momentous assets of the population — between 5 and 40% — who amend a information called postcholecystectomy syndrome which haw drive gastrointestinal painfulness and persistent discompose in the upper right abdomen. In addition, as some as 20% of patients amend chronic diarrhea.

Electrohydraulic damper wave lithotripsy (ESWL) of the gallbladder has also been utilised for selected patients who cannot have surgery. Because gallstones often become backwards in many patients, this treatment is not utilised very often any more.

Intestinal pain - Acute intussusception if you avoid can lead to death

What Could Happen If You Avoid The TREATMENT ?

IT Will Get So Extreme.........Lead To DEATH

ACUTE INTUSSUSCEPTION :

INTUSSUSCEPTION is an invagination of size of intestine ( intussuscepiens ) into the immediate portion of bowl ( intussusceptum ) and  most of cases occur in children during the first 5 decades of life. This can often result in an obstructio .The part that prolapse into the other is called the INTUSSUSCEPTUM and the part that recieves it is called INTUSSUSCEPIENS.

In some of children with intussuscetion , an anatomic predisposing condition . Such as Meckle's diverticulum , Burkitt lymphoma, or hamartomatous polyps ,can be found .And in most of the cases are associated with hyperplastic lymphoid tissue.suggesting an infectious causes ,which is not confirmed in most of the cases.By using serology and virus isolation from fecal and pharyngeal swabs.Adeno virus , Rotavirus ,Enterovirus , Human herpes virus  ,Cytomegalovirus and Epstien-barr-virus.some bacterial agents can also involved in this condition include Yersinia ,enterocolitis and salmonella typhimurium and candida albican .

TYPES

Ileocolic  ( 77 % ) 

Ileoileocolic ( 12 % ) 

Ileoileal (5 % ) 

Colocolic ( 2 % ) 

Multiple (! % ) 

Retrograde ( 0.2 % )

Others  ( 2.8 % ) .

CLINICAL FEATURES :

SYMPTOMS

• Sudden paroxymsm of abdominal pain ,with drawing up of legs and screaming  :each attack lasts a few minutes and recur about every 15 minutes.
• Facial pallor 
• Vomiting
• Listleness and somewhat drawn between the attacks .
• Stool : intially normal later  blood and mucus are evacuated called  "red currant jelly stool " 
• when not relieved upto 24-36 hours

        a . Pain becomes contineous

          b. Abdomen distends

          c. Vomiting becomes copious

          d. Absolute intestinal obstruction follows

SIGNS

• A lump is felt ,which may harden on palpation .
• PR examination : if intussuscetion has travelled far enough ,its apex ( a conical ) mass will be felt .
• When not relieved ,upto 24 - 36 hours  

         a . Dehydration

         b . Abdominal distension

         c . Abdominal guarding , tenderness and rebound tenderness if gangrene has occured.

DIAGNOSTIC INVESTIGATIONS :

INTUSSUSCEPTION is often suspected based on history and physical examination , including observation of Dance's sign .Per rectal examination is particularly helpful in children as part of thintussusceptum may be felt by the finger .A definite  diagnosis often requires confirmation by diagnostis imaging modalities .

ULTRASOUND is today considered the imaging advanced technology of choice for diagnosis and exclusion of intussusception due to its high accuracy and lack of radiation.A target like mass ,usually around 3 cm in diameter confirm the diagnosis.

PLAIN ABDOMINAL X-RAY
Revealed increased gas shadow in small intestine and at times absence of cecal gas shadow .

X-RAY WITH BARIUM ENEMA :
Reveal characteristic " claw sign " in ileocolic intussusception .

TREATMENT :

The condition is not usually immediately life threatning.The intussusception can be treated with either a barium or water soluble contrast enema or an air contrast enema .which both confirms the diagnosis of intussusception, and inmost cases successfully reduce it . The success rate is over 80% .Therefore approximately 5 - 10 % of these recur within 24 hours .If it cannot be reduced by an enema or if the intestine is damaged , then surgical reduction is necessary.

PRELIMINARY TREATMENT 


Gastric aspiration should be carried out and contiued during and after operation.
Give IV dextrose - saline solution.

REDUCTION OF INTUSSUSCEPTION
REDUCTION BY HYDROSTATIC PRESSURE


OPERATIVE REDUCTION :


Abdomen is opened through a right lower paramedian incision .First part of reduction is accomplished by squeezing lower part of sausag like mass ,and little intussusception is reduced.Last part is most difficult to reduce and should br withdrawn and gently compressed in a warm saline soaked pack,to

lessen the edema.
After reduction if a specific cause is revealed appropriate treatment is carried out ,eg Meckle's diverticulum.

PROGNOSIS :

The outlook for intussusception is excellent .when treated immediately .but when untreated it can lead to death within 2-5 days .Quick treatment can avoid this surgery .Prolonged intussusception can lead to ischemia and necrosis and it requires surgical resection.

AFTER TREATMENT


Gastric aspiration should be continued for 12-24 hours
Dextrose-saline is given IV or SC with hyaluronidase.
On 2nd day ,gastric tube is removed and sips of water are given.
Few hours later ,feeding is commenced with mother's milk ( if infant is still being breast-fed ).

COMPLICATIONS:

Intestinal obstruction
Gangrene

Biliary stricture

IT CAN OCCUR AS A RESULT OF A TECHNICAL MISHAP......

DURING CHOLECYSTECTOMY IF IGNORED CAN DRIVE  LIFE- THREATENING COMPLICATIONS

STRICTURE OF BILE DUCT 
  

A bile duct stricture is caused by narrowing of the bile duct. The narrowing bile duct prevents the bile from draining into the intestine. The bile then backs up in the liver and spills over into the blood feat obstructive jaundice  ,it crapper cause through Surgical trauma ( postoperative ) ,Stones ,Primary sclerosing cholangitis ,Carcinoma of bile funiculus Carcinoma of head of pancreas.

Bile duct pathology (biliary stricture) is an uncommon but hard clinical condition that requires a integrated multidisciplinary approach involving gastroenterologists, radiologists, and surgical specialists. Unfortunately, most benign bile duct strictures (biliary strictures) are iatrogenic, resulting from operative trauma , Bile duct strictures (biliary strictures) may be well but, if ignored, can drive life-threatening complications, such as ascending cholangitis,  liver abscess, and secondary biliary cirrhosis

POSTOPERATIVE STRICTURE it is the result of a preventable non achievement in technique , during the performance of cholecystectomy ;Blind plunge application of a hemostat to a bleeding cystic or accessory cystic artery ,or to right hepatic artery.Should cholecystectomy be performed by dissecting from fundus ,too such traction applied to freed gall sac may so tent the bile funiculus that some forceps witting for cystic funiculus apprehension angulated main channel .Failure to identify anatomy in Calot's polygon when there is such inflammation .Common hepatic funiculus is tied instead of cystic duct.Ignorance of anatomical anomalies o bile ducts.Laceration of bile patch explration for stones.Injury to bile funiculus during partial gastrectomy.

CLINICAL PRESENTATION OF POSTOPERATIVE STRICTURE

Bile funiculus injuries may be rcognized at the instance of surgery .

Postoperatively by profuse and persistent discharge of bile if evacuation has been provided.Bile peritonitis if evacuation

has not been provided.Deepening obstructive jaundice.

In the absence of symptoms of the primary disease, most patients with bile funiculus strictures (biliary strictures) rest asymptomatic until the lumen of the bile funiculus is sufficiently narrowed to drive position to the flow of bile. Occasionally, patients may hit intermittent episodes of right upper line pain (biliary colic), with or without laboratory features of biliary obstruction. Patients most often inform with features of obstructive jaundice. On occasion, a patient may inform dramatically with sepsis and hypotension due to ascending cholangitis.

Cholangitis occurs in the proximity of partial or complete obstruction of the common bile funiculus , with accumulated intraluminal pressures, bacterial infection of the bile with procreation of the organisms within the duct, and seeding of the bloodstream with bacteria or endotoxin. Cholangitis can apace embellish a life-threatening condition. Clinical show varies, with the Charcot set of fever and chills, jaundice, and right upper line abdominal pain occurring in most patients. A smaller proportion of those with cholangitis may also hit altered mental position and hypotension (ie, Reynold pentad). In the epilepsy of previous instrumentation, cholangitis is uncommon with malignant strictures.

Tests that shows stricture in the bile duct: ERCP (endoscopic retrograde cholangiopancreatography) , PTC (percutaneous transhepatic cholangiogram)  ,MRCP (magnetic kinship cholangiopancreatography)

Blood tests that indicate deviant function of biliary system:

Bilirubin level is higher than normal
ALP (alkaline phosphatase) is higher than normal

TREATMENT 

PREOPERATIVE TREATMENT temporary external biliary drainage ,by passing a cather percutaneously into an intrahepatic duct ,or by passing a cather through stricture at ERCP and left to drain through mouth.

OPERATIONS

Roux-en-Y choledochojejunostomy

Cholecystojejunostomy

Choledochoduodenostomy

Insertion of a stent  

COMPLICATIONS 

Recurrent inflammation of the biliary duct and stricture can occur in whatever patients. Patients are at risk for infection developing above the stricture. Long-standing strictures can advance to cirrhosis.

Complications of bile duct strictures (biliary strictures) include development of stones in the gallbladder and bile ducts proximal to the stricture, pyogenic liver abscess due to recurrent episodes of ascending cholangitis, secondary biliary cirrhosis, and weight loss and malnutrition from steatorrhea with fat-soluble vitamin deficiency.

Diverticulum common birth defect in about 2% of all infants

MECKLE'S DIVERTICULUM  The vitello-intestinal funiculus is the remnant of the yolk cover which is attached to the primitive midgut in the first some weeks of embryonic development .

It was first described by FABRICIUS HILDANUS in the sixteenth century and later named after Jhann friedrich meckle , who described the embryological origin of this type of diverticulum in 1809.

It should completely obliterate during the six week ,but haw persist completely or in conception .if it persist completely , there is a diverticulum ,the Meckle's diverticulum ,which arises from the terminal ileum .The classical description in adults is that it is present in 2% of he population , is 2 inches ( 5 cm ) daylong and 2 feet (60 cm )from the ileocaecal valve .

The diverticulum is usually supplied by the omphalomesenteric artery (a remnant of the vitelline artery), which arises from the ileal branch of the superior mesenteric artery. Usually, the artery terminates in the diverticulum; however, it has been reported to continue up to the abdominal wall in some cases. Rarely, these blood vessels persist in the form of fibrous remnants that run between the Meckel diverticulum and the abdominal wall or small bowel mesentery.

Meckel's diverticulum occurs on the antimesenteric abut of the ileum, commonly 40-60 cm proximal to the ileocecal valve. On average, the diverticulum is 3 cm long and 2 cm wide. Slightly more than one half include ectopic mucosa. Meckel diverticulum is typically lined by ileal mucosa, but another paper types are also institute with varied frequency.

The heterotopic membrane is most commonly gastric. This is important because peptic ulceration of this or conterminous membrane can lead to painless bleeding, perforation, or both. In one study, heterotropic viscus membrane was institute in 62% of cases, pancreatic paper was institute in 6%, both pancreatic paper and viscus membrane were institute in 5%, jejunal membrane was institute in 2%, Brunner paper was institute in 2% and both viscus and duodenal membrane were institute in 2%.2 Rarely, colonic, rectal, endometrial, and hepatobiliary tissues have been noted.

A persistent vitello-intestinal funiculus can present at birth , as a swelling at the base of the umbilical cord ,or as a fistulous connection to the umblicus ,or as an umblical polyp, which does not move like simple granulation tissue to cautery , because it has a mucosal surface , Surgical excision is required .It haw be lined by ileal membrane ,or contain ectopic gastric membrane ,which haw unergo peptic lesion with ensuant bleeding .

Most people who have a Meckel's diverticulum have no symptoms or problems. Only about 1 in 25 persons who are born with it will have problems. These problems vary by age. In infants and children, the problem is commonly injury from the rectum. Sometimes blood stained stool can be seen .

In adults, the gut may become blocked. If this happens, the mortal may have breadbasket pain and vomiting. Other symptoms allow fever, degradation and swelling of the stomach.

It haw present with

SEVERE HAEMORRHAGE blood is passed per rectum , and is blakish red in colouration.


INTUSSUSCEPTION ,MECKALIAN DIVERTICULITIS ( Without Perforation ) clinical features simulate those of acute appendicitis ,(With Perforation ) clical features simulate those of cut ulcer  .

CHRONIC PEPTIC ULCERATION symptomatic peptic ulcer pain , related to meals , but is felt around the umblicus ( because diverticulum is conception of midgut ).


INTESTINAL OBSTRUCTION a adornment present between apex of diverticulum and umblicus , haw cause obstruction either by adornment itself or by a volvulus around it .


LITTER's HERNIA meckle's diverticulum is found in an inguinal or femoral hernial cover .


SILENT MECKLE's DIVERTICULUM encouraged in barium meal follow-through or during an abdominal operation . 

DIAGNOSTIC INVESTIGATIONS 1 . X-RAY with BARIUM MEAL  may demonstrate Meckle's diverticlum  ,and failure to visualize is of no significance ,because so often the entrance of diverticulum is blocked by edema .

TECHNETIUM (Tc ) SCANNING may localize heterotopic gastric mucosa in a diverticulum .There is no definitive scan or investigation to confirm the existence of a Meckle's diverticulum .A radiolabelled technetium  scan looking for ectopic gastric mucosa ( that is outside the stomach ) is only positive in about 70 % of patients with a Meckle's diverticulum who present with rectal bleeding .

TREATMENT : management is by excision after the diagnosis has been made - which is often only at laparotomy , although it may be suspected beforehand.

MECKELIAN DIVERTICULECTOMY a broad base Meckle's diverticulum is resected with invagination technique in the same way as a vermiform appendix ,If the base of Meckle's diverticulum is indurated  and especially .when such induration  extends into neighboring ileum ,resect a short segment  of ileum containing the Meckle's diverticulum ,and restore the continuity of bowel by end-to-end anastomosis .

FREQUENCY

The figure of Meckel diverticulum is usually noted to be approximately 2% of the population,3 but publicised program arrange from 0.2-4%.4 Complications are only seen in about 5% of those with the anomaly.