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Small Bowel Obstruction

In This Article

Introduction

Accounts for 80% of cases of intestinal obstruction
Can be partial or complete:
  • About 85% of partial obstruction will resolve with conservative treatment
  •  About 85% of complete obstruction will require surgery
 
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Causes

  • Adhesions
  • Herniae
  • Tumours
  • Crohn’s
  • Volvulus
  • Gallstone ileus
  • Intersusception
  • Radiation strictures
  • Ischaemia
  • TB
  • Trichobezoar (hair ball – sometimes psychiatric patients eat their own hair)
  • Phytobezoar (excess of fibre – often caused by the pith of an orange)
  • Atresia
  • Parlaytic ileus
 
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Hernia

  • Inguinal, femoral, umbilical, paraumbilical
  • Epigastric, spigelian, obturator, lumbar
  • Inscisional
 
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Adhesions

These appear filmly strands of fibrous material
 
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Caecal Carcinoma

This obstructs the ileo-caecal valve and actually obstructs the small intestine. These patients will need surgery. The patient will often be anaemic.
 
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Presentation

  • Colicky abdominal pain – often felt around the umbilucs
    • Tender abdomen only tends to be present in strangulation (complete obstruction)
  • Dilated loops of bowel may be palpable
  • Vomiting – often provides some pain relief
    • Fermentation of the bowel products can produce a foul vomit (faeculant vomit), but faecal vomiting only occurs with fistulae
  • Abdominal distension – increases as the condition progresses
  • Absolute constipation (absence of flatus and stool) – Late sign
  • Auscultation – high pitched ‘tinkling’ bowel sounds
    • ‘Rushing’ sounds may also be heard, and are particularly associated with peristalsis and cramp pain
  • Shock ± oliguria – may be present in late stage disease, and indicate severe, strangulated obstruction.
 
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Pathology

  • Obstruction results in the dilation of proximal bowel, and the collapse of distal bowel. The normal secretory and digestive functions of the mucosa become impaired.
  • Strangulated obstruction occurs when the blood supply to the obstructed region becomes impaired. It can lead to ischaemia and gangrene within 6 hours of onset!
  • Strangulated obstruction occurs in 25% of cases of small bowel obstruction
  • Typically venous obstruction occurs before arterial
  • Perforation typically occurs at the ischaemic segment
 
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Investigations

  • Catheter
  • Analgesia
  • TED stockings
  • NG Tube
  • Erect CXR
  • Abdo x-ray (supine)– look for distended bowel (>5cm – the normal size of the small bowel is 2.5cm)
    • Gas in biliary tree – this is a sign of gallstone ileus. Often, the gallstone has fistulated into the small bowel – usually duodenum.
    • Supine AXR is necessary to get the best view of the gas patterns in the abdomen. When erect, these are more difficult to discern
    • Differentiating small and large bowel loops:
      • Small bowel loops are the width of the lumen
      • Large bowel loops are not the complete width of the lumen
  • Blood tests
    • Full blood count (anaemia? – may be present in caecal carcinoma)
    • U+E's - Fluid and electrolyte disturbance (particularly with potassium) may be present
    • Amylase
    • Likely raised CRP
  • Laparotomy
    • Is the only definitive diagnostic tool, but obviously should not be undertaken lightly!
 
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