Diagnosis

Gastrointestinal obstruction

Etiology

Cause [pfn]

1. Mechanical:

   • Extrinsic: Adhesion, hernia, cancer, abscess, ovarian torsion

   • Intraluminal: Gallstone ileus, foreign body, intussusception

   • Intramural: Crohns disease, lymphoma, radiation enteritis

   • Congenital: Meckel, malrotation, inguinal hernia, intussusception, atresia/stenosis

   • Inflammatory: Appendicitis, Crohn disease, ulcerative colitis, endometriosis

   • Iatrogenic: Adhesion, acquired or iatrogenic hernia

   • Vascular: Mesenteric ischemia

   • Colon: Cancer, diverticulitis, volvulus

2. Functional (Paralytic Ileus):

   • Postoperative, electrolyte (hypokalemia), peritonitis, drug side effects (opiate, anticholinergic), hemoperitoneum/retroperitoneal hematoma, pseudoobstruction/Ogilvie syndrome (intestinal dysmotility without a physical blockage due to enteric neuropathy)

Pathophysiology [pfn]

1. Bowel obstruction --> proximal bowel distension and distal bowel decompression

2. Intermittent pain

3. Impaired venous return --> bowel wall edema/inflammation --> mucosal ischemia

4. Dehydration: Vomiting + increased bowel wall permeability --> Fluid loss into GI lumen

5. Bacterial translocation (E.coli) from GI lumen into the bloodstream or peritoneal cavity

Complications [pfn]

• Peritonitis

• Strangulation

• Necrosis if prolonged ischemia

• Perforation

• Bacteremia/sepsis

• Multi organ failure

• Anastomotic leak, wound infection and dehiscence

• Fistula formation

• Recurrent obstruction

Epidemiology

Incidence per 100.000 [d3y][7bg]

Approach

• Blood tests: Complete blood count, electrolytes, renal function, lactate, amylase/lipase

• Arterial blood gas

• Blood culture

• Abdominal x-ray

• CT abdomen

• Abdominal ultrasound: serial examinations in children and pregnant women

• Barium enema

• Coloscopy + histopathology

• Gastroscopy

Treatment

1. Resuscitation with intravenous fluids (ringer lactate) till urine output is normal [kod][pfn]

2. Nasogastric decompression

3. Antibiotic prophylaxis

4. Observation: pulse rate, BP, RR, urine output, abdominal girth, bowel sounds, tenderness

5. If reduction in abdominal distension, improvement in general condition and bowel movements especially in individuals with adhesions --> conservative management

6. Surgery (laparoscopic or open) if: Severe pain, strangulation, peritonitis, ischemia

   • Adhesiolysis

   • Resection of the necrotic bowel and primary anastomosis or stoma

   • Hernia reduction and repair

   • Tumor and bowel resection

   • Palliative stoma

   • If questionable bowel viability: stoma and temporary vacuum-assisted closure

Differential diagnoses

Abdominal abscess, Adhesion, Appendicitis, Benign neoplasm of the small intestine, Celiac disease, Cholelithiasis, Colorectal cancer, Crohn disease, Diverticulitis, Drug side effects, Femoral hernia, Foreign body, Hypokalemia, Incisional hernia, Infectious colitis, Inguinal hernia, Intussusception, Ischemic colitis, Lymphoma, Meckels diverticulum, Ovarian torsion, Peutz-Jeghers syndrome, Postoperative paralytic ileus, Radiation enteritis, Ruptured ectopic pregnancy, Small bowel cancer, Umbillical hernia, Volvulus