GENERAL

SURGERY
Dr. Laith Nawafleh
 Definition o High small bowel obstruction → greenish-blue, bile-stained
o Complication: electrolytes imbalance, hypovolaemic shock,
 Partial or complete Blockage in large or small intestine that results in Respiratory complications
the failure of intestinal contracts to pass food or liquid.  Constipation
o More distal obstruction  earlier constipation
Etiology (causes) o classification
 relative Constipation: no feces (only flatus is passed)
 small intestinal-obstruction  absolute Constipation: (Obstipation): no flatus, no feces
 in adult ( adhesion (most common ) / strangulated hernia /CRC)  Distention
 in children (strangulated hernia ( most common )) o More distal obstruction  earlier distention
 infants (Intussusceptions (most common )) o Visible peristalsis may be present
 in neonates (congenital (atresia, volvulus neonatorum, imperforate
anus )) Physical examination
 large intestinal obstruction  most common cause : CRC
 General
Pathophysiology  hypotension
 Signs of dehydration and electrolyte loss (dry
 The bowel proximal to the obstruction: initially  peristalsis → dilation skin and tongue, poor venous filling, sunken
by fluid, gas, secretions →  peristalsis → flaccidity and paralysis eyes and oliguria)
 The bowel distal to the obstruction: normal peristalsis and absorption  Inspection
until it become empty → collapse  Distention, hernias, scars, visible peristalsis
 NOTE: (PYQ) (pic)
 Collapsed caecum → small intestinal obstruction  Palpation
 Distended caecum → large intestinal obstruction.  guarding, rigidity
 tenderness, mass → (tumors or
Presentation (HISTORY) intussusception)
 Auscultation
 4 Cardinal symptoms  frequent and high pitched (early) VS absent
 Colicky abdominal pain. (late/ paralytic ileus)
o first (earliest) symptom  DRE  obstructive mass in the pouch of Douglas
o More severe and continues pain likely of strangulation.
o It may relieve by vomiting. Investigation
o NOTES
 Simple occlusion  colicky intermittent pain  Labs
 Strangulation  sever pain  urea, creatinine and electrolyte (for dehydration), CBC (anemia)
 Paralytic ileus  no pain  Imaging
 Vomiting  x-ray
o More proximal obstruction  earlier vomiting o Erect x-ray  detect air fluid level
o Pyloric obstruction → watery and acid.  small intestine obstruction  stepladder pattern

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 o Supine x-ray (more accurate) distended loops that indicate  CT
obstruction o Localize the site of obstruction, detect
 High obstruction (small intestine)  centrally position, lesions and colonic tumors, and may
Vulvulae coniventae diagnose unusual hernias.
 Low obstruction (large intestine)  peripherally position,
Haustrations which do not extend across the whole width
o 369 rule (PYQ) SUMMERY
 Small bowel: <3 cm
 Large bowel: <6 cm High SBO Low SBO LBO
 Cecum: <9 cm Periumbilical pain (above) Periumbilical pain (bellow) Peripheral pain
Early vomiting & Late In between Early constipation &
constipation Late vomiting
Minimal central distention Moderate Central Early peripheral
distention distention
x-ray finding x-ray finding x-ray finding
1. no air-fluid level 1. multiple air-fluid level 1. fewer air-fluid level
2. centrally position 2. centrally position 2. peripherally position
3. Vulvulae coniventae 3. Vulvulae coniventae 3. Haustrations
NOTE:
Gastric outlet obstruction (PYQ)
- vomiting of undigested food, weight loss sometimes
- physical findings : Succession splash, Visible peristalsis, wasting
& dehydration
- causes : PUD, Gastric CA, Pancreatic pseudo-cyst

Management
 X-RAY- “Barium Follow-Through”  Conservative
o Patient drinks a contrast medium containing  Indication
barium sulfate o Distinction from postoperative paralytic ileus is uncertain.
o Contrast medium  white on x-rays o Obstruction resulted from massive intra abdominal adhesions
o The test is completed when the Barium is rendering Surgery dangerous
visualized at the Caecum o Chronic obstruction
 Barium Enema  Initial management (PYQ)
o Injecting a barium sulfate dye through the o NPO
back passage (rectum) o Gastrointestinal decompression via a nasogastric tube (NGT)
o Taking x-ray views of bowel as the dye fills o IV fluid
the large bowel. o Fluid and electrolyte replacement
o Antibiotics: if Strangulation is found or suspected , and for all
patients undergoing surgery

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 SURGERY (Laparotomy)
 Absolute indication
Classification (according to 
o Peritonitis Location
o Visceral perforation
o Irreducible hernia  Small intestine
o intestinal strangulation  high small intestinal: duodenum or jejunum
 Relative indication  low small intestinal: ileum
o Palpable mass lesion  Large intestine
o 'Virgin' abdomen
o Failure to improve Etiology
 Bowel is inspected and non-viable bowel is removed (PPP-CC)
 Mechanical (dynamic)  intraluminal, intramural, extramural
 Intraluminal
o Fecal impaction
o foreign body
o gallstone ileus (very-rare)
 tends to occur in elderly
 large gallstone directly go through the
gall bladder into the duodenum
o if viable : reduce to the abdomen  most common site (Ileocecal valve)
o if Non-viable : (the surgical procedure according to site):  triad of
 small intestine or right colon :→ resection with  small bowel obstruction
anastomosis.(because less number of bacteria found here)  a gallstone outside the gallbladder ( mainly in the RIF)
 left colon : Hartmann’s technique  air in the bile ducts (pneumobilia)

 Specific Management ‫كل هاي المواضيع رح نحكي عنها تحت‬

o bezoars
 Hernia → Operation (herniotomy , hernioraphy , hernioplasty)
 firm masses of undigested hair ball and
 Adhesions → Conservative first then adhenolysis
fruit/vegetable fibers
 Volvulus → Untwisting and or operate
 associated with an underlying psychiatric
 Mesenteric ischemia → Anti-coagulant , Embolectomy ,
abnormality
Revascularization , Colectomy
 Abscess or Peritonitis → Drain and Treat
 Intussusception → Pneumatic or Barium
Reduction or Operate o Worms
 Strangulation in large bowel (after splenic  Ascaris lumbricoides
flexure)
o Hartmann’s procedure

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 Intramural EXAMPLES
o Stricture (mostly due to TB or IBD)
 adults  sigmoid volvulus (PYQ)
o Malignancy (apple core sign on x-ray)  Barium enema
o intussusception  x-ray: Omega loop (grossly
 occurs when one portion of the gut invaginates dilated sigmoid colon / coffee
into an immediately adjacent segment bean sign)
(telescoping).  definitive tt : surgery (operative
 Almost always, it is the proximal into the distal. reduction)
 90 % is idiopathic  complication : bowel ischemia and perforation
 more common in children
 pediatrics  midgut volvulus (PYQ)
 Site
 Malrotation of the midgut
 Children: mostly ileocolic
 Adult : mostly colocolic  life-threatening
 Causes  history of 6 week old child Vomits (bile-
 Children: Meckel’s diverticulum, polyp stained blood)
 Adult: polyp (Peutz–Jeghers syndrome), submucosal lipoma  diagnosis
or other tumors  CT: whirloop sign
 Diagnosis  Barium swallow (gold standard): corkscrew sign
 clinical presentation (PYQ)
severe paroxysmal colicky abdominal
pain with currant jelly stool (mixture of
mucus and blood).
Bilious vomiting in infants, abdominal
distention, fever + shock, sausage
shaped mass palpable in abdomen
 Investigation :  Extramural
Barium: Claw’ sign of o Adhesion
iliac intussusception  40% of all common causes of
US: target sign obstruction
 75% of small bowel obstruction cases
o Volvulus (MCC)
 twisting or axial rotation of a portion of bowel  Most commonly caused by previous
about its mesentery (rotation) surgery
 obstruction to the lumen (>180° torsion)  Prevention
 obstruction and strangulation (>360 torsion)  Good surgical technique
 Types:  washing the peritoneal
- Primary due to congenital malrotation of the gut or cavity with saline to
congenital bands. remove clots
- Secondary form (more common) secondary to rotation  Minimizing contact with gauze
around an acquired adhesion or stoma  Treatment: adhenolysis
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 o Band  Pseudo-obstruction
 Types: o Autonomic imbalance resulting from
-Congenital: (obliterated vitellointestinal duct) decreased parasympathetic tone or
-Acquired: String band following previous excessive sympathetic output
bacterial peritonitis. o Usually in the colon
-portion of greater omentum o Ogilvie's syndrome (Acute colonic
o Hernia pseudo-obstruction)
 External hernia, through abdominal wall  Affects large intestine
 Internal hernia, rare  Dilated colon
o Neoplasm  Tx: conservative, Erythromycin, IV
neostigmine, surgery
 Functional: (adynamic)
 Paralytic Ileus
 Hirschsprung disease o failure of transmission of peristaltic waves
o congenital megacolon characterized by the absence of secondary to neuromuscular failure
myenteric and submucosal ganglion cells in the distal o causes (5Ps+drugs)
alimentary tract  Postoperative duration of 24–72 hours.
o 1 per 5000 live births.  Peritonitis
o 4 times more common in males than females.  Pelvic/spinal fractures (reflex ileus)
o Types ‫قراءة‬  low Potassium (hypokalaemia ).
 Classical HD (75% of cases): Rectosegmoid area and distally  Pseudo-obstruction
 Long segment HD (20% of cases): any part of the colon  Drugs: Tricyclic antidepressants,
beyond the recto sigmoid area is affected. Lithium therapy, Excessive opiate use
 Total colonic aganglionosis (3-12% of cases): Affects the and Anti-cholinergics
entire colon and often extends to the terminal ileum.
 Mesenteric artery occlusion
 Rare variants include the following:
 Total intestinal aganglionosis: it’s incompatible with life
because the whole GI tract don’t have ganglion
 Ultra-short-segment HD: limited to internal anal Degree of obstruction
sphincter
 Complete: No passage of luminal contents beyond the
o Management:
surgery obstruction point
 Partial: Some intestinal contents pass through

 Note:
closed loop obstruction: the bowel is obstructed at
both the proximal and distal points (seen in volvulus)

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 Complications
 Simple
 Intact blood supply
 Hyperperistalsis to overcome the obstruction → colics
 Powerful antiperistalsis → vomiting
 Complicated
 Compromised blood supply (Strangulation)
 Features of strangulation (PYQ)
• General: tachycardia, pyrexia, toxic appearance, leukocytosis
• Pain becomes constant rather than colicky.
• Signs of peritonitis: abdominal wall rigidity, absent bowel sounds,
and can lead to toxic or septic shock

 Paralytic ileus: Paralysis of intestinal movements  Neurogenic

obstruction THE MOST common form

Nature of presentation
 Acute: Sudden onset, seen usually in SBO
 Chronic: Gradual onset, seen usually in LBO
 Subacute: On and Off obstruction