في كلية الطب، ليس الطريق مفروشاً بالشغف دائماً… بل كثيراً ما نسير فيه بالتعب، بما تبقى من طاقة، وبكثير من الصبر والإيمان بأن ما نمر به الآن لن يضيع عند الله.

فلا تجعل الدرجات والتقديرات تختصر قيمتك تحت أي ظرف، وتجاوز ما لا تستطع تغييره، وركز على ما يمكنك تغييره بصبرك، واستمرارك.

وتذكر .. التقديرات والامتيازات ليست الغاية، بل الغاية أن تصل وأنت بخير.
وستصل… بإذن الله.

د. ذا النون القحطاني

@Surgery_Practice

🔴 Bowel Obstruction

🔰Definition
Bowel obstruction is a condition where there is impaired or complete blockage of intestinal contents through the bowel.

🔰Causes Of Obstruction

1. Adhesions (40%)

2. Inflammatory Strictures & Malignancy (15%)

3. Obstructed Hernia (12%)

4. Paralytic Ileus & Pseudo-Obstruction (Adynamic Obstruction 5%)

5. Bolus Obstruction (Faecal impaction 8%/FB/Bezoars/Gallstones)

6. Intussusception & Volvulus

🔰Types Of Obstruction
📍1. Dynamic ➡️ There's Mechanical Obstruction Of The Bowel With Normal Peristalsis

📍2. Adynamic ➡️ Absent Or Weak Peristaltic Activity Without Mechanical Obstruction

🔰Clinical Features Of Bowel Obstruction
🔶A. Dynamic Obstruction

📍1. Abdominal Pain
▪︎Start As Sudden Severe Colicky Abdominal Pain On Umbilicus (SB) Or Lower Abdomen (LB)

▪︎Then Become Mild Diffuse Constant Then Disappears (If No Ischaemia Developed)

📍2. Abdominal Distension

📍3. Vomiting ➡️ Start As Digested Food Then Later Become Faeculent Material (Bacterial Overgrowth)

📍4. Constipation
▪︎Absolute (Complete Obstruction) ➡️ No Faeces Or Flatus
▪︎Relative (Partial Obstruction) ➡️ Passed Flatus

📍5. Increase Bowel Sounds & Visible Peristalsis Then Later Disappears

📍6. Special Features For Proximal (High) SB Obstruction

▪︎Early Profuse Vomiting With Rapid Dehydration
▪︎Minimal Abdominal Distension & Minimal Bowel Loops Dilatation On Xray

📍7. Special Features For Distal (Low) SB Obstruction
▪︎Predominant Abdominal Pain With Central Abdominal Distension
▪︎Delayed Vomiting
▪︎Multiple Dilated Bowel Loops On Xray

📍8. Special Features For LB Obstruction
▪︎Early Predominant Abdominal Distension With Less Severe Pain
▪︎Delayed Vomiting & Dehydration
▪︎On Xray ➡️ Distended Colon Proximal To Obstruction (& SB Loops Dilated if ileo-Caecal Valve Incompetent)

🔶B. Adynamic Obstruction (Paralytic Ileus)

1. No Bowel Sounds & No Passage Of Flatus Or Stool 72h After Abdominal Surgery

2. Abdominal Distension & Pain At Site Of Operation

3. Effortless Vomiting

4. Distended Bowel Loops & Multiple Air-Fluid Levels On Erect Xray

🔰Dx Of Bowel Obstruction
🔶A. Clinical Features

🔶B. Radiology
📍I. SB Obstruction

1. Central Transverse Dilated Bowel Loops With Small Diameter (Near 5cm)

2. No Or Minimal Gas in Lower Abdomen

3. Lines Cross The Full Bowel Width (Vulvulae Coniventae Of Jejunum Like Stack Of Coins) & Regular & Opposite To Each Other

4. Featureless Ileum

5. Multiple Air-Fluid Levels On Erect Position (StepLadder Sign)

6. Strings Of Pearls (Small Amount Of Gas Between The Vulvulae Coniventae)

📍II. LB Obstruction
1. Peripheral Longitudinal Dilated Bowel Loops With Large Diameter (>6cm)

2. Rounded Gas Shadow in RIF (Distended Caecum >9cm)

3. Lines Not Cross The Full Bowel Width (Haustration) & Irregular & Not Opposite To Each Other

4. SB Loops Dilatation

5. Less Air-Fluid Levels On Erect Position

📍III. Check Strangulation Risk By Abdominal CT
▪︎Reduced Bowel Wall Enhancement ➡️ High Suggestion Of Bowel Strangulation & Ischaemia
▪︎No Mesenteric Fluid ➡️ Low Risk Of Bowel Strangulation

#surgery #Bowel Obstruction #part1
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🔰Complications Of Bowel Obstruction

📍1. Dehydration & Hypokalemia ➡️ More With SB Obstruction Due To Repeated Vomiting & Fluid Sequestration

📍2. Strangulation & Ischaemia
▪︎Start As Constant Severe Pain & Pyrexia

▪︎Then Abdominal Tenderness & Rigidity

▪︎Skin Discoloration & Tense Tender Lump & Loss Cough Impulse Over The External Hernia (Obstructed Hernia Causing Bowel Obstruction Then Bowel Ischaemia)

▪︎Then Shock Resistant To Simple Fluid Resuscitation

▪︎Bowel Gangrene Then Perforation Then Peritonitis & Death

▪︎Strangulation Seen More With ➡️ Hernia / Adhesions & Bands / Volvulus & Intussusception / Closed Loop Obstruction

🔰Management (Mx) Of Bowel Obstruction

🔶A. Dynamic Obstruction

📍1. NG Tube Decompression Of Bowel

📍2. Fluids & Electrolytes Correction (Ringer Lactate Or NS)

📍3. Broad Spectrum AB Before Surgery

📍4. Surgical Relief Of Obstruction & Resection Of Gangrenous Loops

📍5. Check Bowel Viability During Surgery
▪︎Viable Bowel
•Dark Color Becomes Lighter After Relief Of Obstruction
•Visible Pulsation & Peristalsis
•Shiny & Firm

▪︎Non-Viable Bowel
•Dark Color Remains Dark
•No Pulsation Or Peristalsis
•Dull Thin & Friable (No Shining)

📍6. Adhesions
▪︎Start Conservative Tx (NG Decompression & Fluids)
▪︎Do Surgery If No Relief Of Obstruction After 72h
▪︎Dissect Only The Specific Adhesion That Causing The Obstruction (Because Too Many Dissection Will Results in More Adhesions)

🔶B. Adynamic Obstruction (Paralytic Ileus)

📍1. NG Tube Decompression Of Bowel

📍2. Fluids & Electrolytes Correction (Ringer Lactate Or NS)

📍3. Laparotomy If ➡️ No Bowel Activity >7 Days Or Bowel Activity Comes Then Disappears

🔰Indications For Early Surgery In Bowel Obstruction:
1. Obstructed External Hernia
2. Bowel Strangulation
3. Virgin Abdomen (Clean Abdomen Not Opened Previously)


🔰Clinical Pearls

▪︎Persistent constant pain (not colicky anymore) = early warning sign of strangulation

▪︎Tachycardia + fever + localized tenderness in obstruction = suspect ischemia until proven otherwise

▪︎Closed loop obstruction is the most dangerous type because it rapidly progresses to gangrene

▪︎“Pain out of proportion” in obstruction → think mesenteric ischemia / strangulation

▪︎In hernia with obstruction: loss of cough impulse + irreducibility = emergency until proven otherwise

▪︎If obstruction + shock not responding to fluids → assume strangulation until proven otherwise

#surgery #Bowel Obstruction #part2
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🔴Specific Causes Of Bowel Obstruction (Part 3)

🔰Abdominal Adhesions (40%)
▪︎Most Common Cause Of Bowel Obstruction After Abdominal Surgery

▪︎Peritoneal Irritation During Abdominal Surgery Results in Local Fibrin Production That Produce Adhesions Between Opposed Surfaces

▪︎Adhesions Start To Form Within Hours Of Abdominal Surgery & Results in Lower Small Bowel Obstruction (No Large Bowel Involvement)

🔹Causes Of Peritoneal Irritation During Abdominal Surgery

1. Acute Inflammation During Surgery

2. Foreign Material Use (Silk Sutures / Gauze / Talc & Starch)

3. Abdominal Infection (Peritonitis / TB)

4. Chronic Abdominal Inflammation (Crohn's)

5. Radiation Enteritis

🔹Prevention Of Adhesions
1. Use Laparoscopic Surgery
2. Washing Peritoneal Cavity With Normal Saline To Remove Clots
3. Decrease Contact With Gauzes
4. Cover Sites Of Anastomosis & Peritoneal Surfaces

🔰Bolus Obstruction

🔶A. Gallstones ileus
▪︎Large Stone Causes Direct Erosion Into The Wall Of Gallbladder Then Descends Into The Duodenum & Results in Recurrent Attacks Of Small Bowel Obstruction (Intermittent Incomplete Obstruction)

▪︎More in Elderly

🔹Radiological Features Of Gallstones ileus (Rigler's Triad)

1. Small Bowel Obstruction (Air-Fluid Level & Bowel Loops Distension)


2. Pneumobilia (Air in Biliary Ducts)

3. Mineral Shadow Of Abdomen (Calcified Gallstones in Abdomen Outside The Gallbladder)

🔶B. Food impaction
➡️ Total Or Partial Gastrectomy (Stomach Removal) Results in Unchewed Food Pass Directly Into The Duodenum & Results in Food Impaction & Small Bowel Obstruction

🔶C. Trichobezoars
➡️ Hair Digestion in Psychiatric Patients (Eating Hair)

🔶D. Phytobezoars
➡️ High Fibers & Vegetables Intake With (Previous Gastric Surgery Or Hypochlorhydria Or Loss Gastric Peristalsis) Results in Undigested Fibers Accumulates in Small Bowel & Causing Obstruction

🔶E. Stercoliths (Fecolith)
➡️ Hard Fecal Material Accumulation Results in Bowel Obstruction

🔶F. Worms
➡️ Accumulation Of Ascaris lumbricoides Results in Small Bowel Obstruction & Risk Of Bowel Perforation & Peritonitis (Specially in Amoebiasis)

🔰Strictures (15%)
▪︎Inflammatory (Small Bowel TB Or Crohn's) & Malignant (Lymphoma) Strictures Results in Subacute & Chronic Bowel Obstruction

🔰Hernia (12%)
▪︎External Or Internal Hernias Contain Bowel Loops Can Undergo Obstruction If The Neck Of Hernia is Narrow

🔰Closed-Loop Obstruction
▪︎Obstruction Occurs At Both Proximal & Distal Points Of Bowel
▪︎Mostly Due To Malignant Stricture Of Colon
▪︎No Distension At Proximal & Distal Bowel Loops (Distension Only At Site Of Closed Loop)


🔰Adynamic Obstruction

🔶A. Paralytic Ileus (Some Known Causes)
▪︎Failure Transmission Of Peristaltic Waves Due To Neuromuscular Failure Leads To Fluid & Gas Accumulation & Absolute Constipation (Nothing Pass)

🔹Causes Of Paralytic Ileus

1. Postoperative After Abdominal Surgery ➡️ Spontaneous Resolution in 24-72h

2. Intra-Abdominal Sepsis

3. Reflex Ileus ➡️ After Spine Or Ribs Fracture / Retroperitoneal Hemorrhage / Plaster Jacket Application

4. Uremia & Hypokalemia (Low K)

🔶B. Pseudo-Obstruction (Unknown Causes)
▪︎Bowel Obstruction in Absence Of Mechanical Or Acute Abdominal Causes

🔹Types Of Pseudo-Obstruction

📍1. Small Bowel Pseudo-Obstruction
▪︎Present As Recurrent Episodes Of Subacute Obstruction
▪︎Dx By Exclusion
▪︎Mx By Metoclopramide & Erythromycin

📍2. Large Bowel Pseudo-Obstruction (Ogilvie's Syndrome)
▪︎More Common
▪︎Present As Acute Or Chronic Large Bowel Obstruction & Caecal Distension
▪︎High Risk Of Caecal Perforation (When Diameter >14 cm)
▪︎Need Immediate Mx By ➡️ Neostigmine Or Colonoscopic Decompression

🔰Clinical Pearls

▪︎Persistent constant abdominal pain (loss of colicky pattern) = STRANGULATION until proven otherwise

▪︎Caecal diameter >12–14 cm in large bowel obstruction = high risk of perforation (emergency decompression needed)

#surgery #Bowel Obstruction #part3
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