Surgical Care at the District Hospital
Part 1 2 3 4 5 6 Primary Trauma Care Manual
The Abdomen
Laparotomy and Abdominal Trauma
Labarotomy
Abdominal trauma
Acute Abdominal Conditions
Assessment and diagnosis
Intestinal obstruction
Peritonitis
Stomac and duodenum
Gallbladder
Appendix
Abdominal Wall Hernia
Groin hernia
Surgical repair of inguinal hernia
Surgical repair of femoral hernia
Surgical treatment of strangulated groin hernia
Surgical repair of umbilical and para-umbilical hernia
Surgical repair of epigastric hernia
Incisional hernia
Urinary Tract and Perineum
The urinary bladder
The male urethra
The perineum
Intestinal Obstruction
 






Assessment

A number of different conditions can cause intestinal obstruction. Intestinal obstruction may be mechanical or non-mechanical (paralytic ileus). Attention to hydration with intravenous fluid resuscitation is vital in all patients with intestinal obstruction. If the obstruction is not resolved, either by non-operative or operative treatment, intestinal gangrene or perforation will occur and lead to peritonitis. Bowel obstruction presents with:

:: Abdominal pain, which may be colicky
:: Vomiting
:: Obstipation (absence of bowel movements and flatus)
:: Abdominal distension.


Bowel obstruction is a clinical diagnosis but it is greatly aided by plain erect and supine abdominal X-rays. The normal small bowel does not contain air and is therefore not visualized on X-ray. Distended loops of small bowel with air fluid levels are diagnostic of obstruction. Valvule coniventes cross the entire small bowel lumen and, when seen on X-ray, also indicate that the obstruction is intestinal.

Chart

Non-operative management of Intestinal Obstruction

The treatment of simple mechanical small bowel obstruction is initially non-operative. Failure of non-operative management at 48 hours is an indication for laparotomy. Non-mechanical obstruction should be treated non-operatively. However, an obstruction caused by an underlying problem like abdominal abscess or generalized peritonitis will require surgery. The resuscitation procedure in non-operative management prepares the patient for surgery if it becomes necessary.

:: Administer intravenous fluids, starting with normal saline or Ringer’s lactate and changing on the basis of serum electrolyte results.
:: Insert a nasogastric tube and commence aspirations.
:: Relieve pain with narcotic analgesics.
:: Monitor the response to fluids with vital signs and urinary output. Remember that intestinal obstruction causes dehydration so relatively large volumes of fluid are required to assure adequate urine output.
:: Ascertain from the history, physical examination and plain X-rays the cause of the obstruction.
:: Observe the patient’s condition with serial physical examination to determine whether the obstruction is getting better or worse. Do this at least two times per day.


Evidence of improvement includes:

:: Reduction in abdominal distension
:: Reduction in peristaltic waves (which become less visible)
:: Progressive reduction in nasogastric aspirates.


Evidence of deterioration includes:

:: Colicky pain that becomes persistent
:: Rigid, tender and silent abdomen
:: Increasing abdominal distension
:: Visible peristaltic waves.


Operative Management of Small Intestinal Obstruction

The operative management of intestinal obstruction is laparotomy, with specific surgical intervention depending on the findings. Laparotomy should be performed using a midline incision (see pages 6–1 to 6–3).

Division of adhesions to release the obstruction is often the treatment in mechanical small bowel obstruction when non-operative management has failed. If the small intestine is not viable (gangrenous) it should be resected and an anastomosis performed (see pages 6–12 to 6–13).
If the small bowel obstruction is due to inguinal hernia, the hernia should be repaired (see Unit 8: Abdominal Wall Hernia). If the small bowel is not viable, it must be resected. If this cannot easily be done through the groin incision, make a lower midline incision and perform the resection through the abdominal approach.

Intestinal gangrene is:

:: An indication for laparotomy and intestinal resection
:: Suspected when there is continuous abdominal pain
:: Associated with tachycardia and fever
:: Often associated with reduced blood pressure (shock is a late sign)
:: Associated with abdominal tenderness, guarding and absent bowel sounds.

 



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  Kep Points  
In small bowel obstruction, pain is mid-abdominal while in large bowel obstruction the pain is below the umbilicus


The more proximal the bowel obstruction, the more frequent the vomiting

 
The more distal the bowel obstruction, the more distended the abdomen

 
For paralytic ileus (non-mechanical obstruction):
– Provide nasogastric suction and intravenous fluids until gut function returns
– Maintain fluid and electrolyte balance
– Treat the underlying cause.
 
 

 

 

 

 

Kep Points

 
  In ileus (non-mechanical obstruction):

 
Treat the underlying medical cause

 
Treat the underlying surgical cause with operation, as indicated.

 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
  Kep Points  
Gangrene is an indication for small bowel resection

 
Strangulated hernia and small bowel obstructions from adhesions can lead to gangrene

 
The technique for anastomosis of the small bowel is the same for all indications.