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Intestinal Obstruction MCQs

Functional Intestinal Obstruction

  • Question 1: Which of the following is a functional intestinal obstruction?
    • a) Impacted stools
    • b) Sigmoid volvulus
    • c) Strangulated hernia
    • d) Paralytic ileus (Correct Answer)

Causes Developed from the Intestinal Wall

  • Question 2: Which of the following causes of intestinal obstruction is developed from the intestinal wall?
    • a) Gall stone ileus
    • b) Volvulus
    • c) Diverticulitis
    • d) Adhesions (Correct Answer)

Common Causes of Intestinal Obstruction in Children and Adults

  • Question 3: Most common cause of intestinal obstruction in children:
    • a) Adhesions
    • b) Cancer Colon
    • c) Strangulated hernia
    • d) Intussusception (Correct Answer)
  • Question 4: Most common cause of small intestinal obstruction in adults:
    • a) Adhesions
    • b) Cancer Colon
    • c) Strangulated hernia
    • d) Intussusception (Correct Answer)
  • Question 5: Most common cause of large intestinal obstruction in adults:
    • a) Adhesions
    • b) Cancer Colon (Correct Answer)
    • c) Strangulated hernia
    • d) Intussusception

Symptoms of Intestinal Obstruction Strangulation

  • Question 6: Intestinal obstruction strangulation is suspected when the patient has:
    • a) Pain that relieved by NGT
    • b) Bradycardia
    • c) Fever
    • d) Mild tenderness (Correct Answer)

Diagnostic Sensitivity of CT Abdomen

  • Question 7: In intestinal obstruction, CT abdomen with contrast has a sensitivity of:
    • a) 70 %
    • b) 80 %
    • c) 90 % (Correct Answer)
    • d) 99 %

Diagnostic Features in Abdominal X-Ray

  • Question 8: Valvulae conniventes in abdominal X-ray is diagnostic for:
    • a) Duodenum
    • b) Jejunum (Correct Answer)
    • c) Ileum
    • d) Colon

Intestinal Obstruction Short Questions

Classification of Intestinal Obstruction

  • Question 11: Classification of intestinal obstruction:
    • Mechanical Obstruction
    • Organic Block
      • Strangulation Obstruction
      • Impairment of blood supply due to:
        • Twisting of intestinal blood supply upon itself (volvulus)
        • Constriction of blood flow by band or hernia defect
        • Thrombosis or embolism of the mesenteric vessels
    • Paralytic Ileus
      • Loss of propulsive power

Causes of Intestinal Obstruction

  • Question 12: Mention causes of intestinal obstruction:
    • In the lumen:
    • Fecal impaction
    • Gall stone ileus
    • From the wall:
    • Tumors
    • Congenital atresia
    • Crohn's disease
    • Chronic diverticulitis
    • Mesenteric vascular occlusion
    • From outside the wall:
    • Adhesions (commonly post-operative)
    • Strangulated hernia
    • Volvulus

Clinical Examination for Strangulation Suspicions

  • Question 13: Describe how to suspect intestinal obstruction strangulation by clinical examination:
    • Toxic patient:
    • Tachycardia
    • Fever
    • Leucocytosis
    • Signs of blood loss:
    • Pallor
    • Tachycardia
    • Hypotension
    • Pain:
    • Ischemic pain not relieved by naso-gastric suction
    • Rigidity:
    • With marked tenderness
    • Rebound tenderness

Symptoms of Intestinal Obstruction

  • Question 14: Describe the clinical picture of intestinal obstruction:
    • Symptoms:
    • Pain:
      • Colicky in hyperperistalsis
      • Constant in ischemia
    • Distension:
      • Marked in colon obstruction
      • Minimal or absent in high obstruction
    • Absolute constipation:
      • Failure to pass flatus in addition to stools
    • Vomiting:
      • Early in high obstruction
      • Late in colon obstruction
      • In neglected cases, vomiting becomes greenish then brown and offensive (feculent)
    • Signs (General Examination):
    • Dehydration signs:
      • Tachycardia
      • Oliguria
      • Dry tongue
      • Hypotension
    • Abdominal Examination:
    • Inspection:
      • Distension and visible peristalsis
      • Strangulated hernia
      • Scars of previous surgery (adhesions)
    • Palpation:
      • Tumor
      • Intussusception
    • Auscultation:
      • Accentuated intestinal sounds
    • Per-Rectal Examination:
      • Empty rectum
      • Hard fecal mass in fecal impaction

Investigations for Diagnosis of Intestinal Obstruction

  • Question 15: Mention investigations done for intestinal obstruction diagnosis:
    • Labs:
    • Blood picture
    • Blood urea and electrolytes
    • Radiology:
    • Plain X-ray of the abdomen:
      • Erect:
      • Multiple gas-fluid levels confirm the diagnosis
      • Supine:
      • Detects the level of obstruction
      • Jejunal loops show the characteristic circular mucosal folds (valvulae conniventes)
      • Ileal loops appear as featureless tubes with no mucosal pattern
      • Colon full of gas shows haustrations that do not reach the other side of the lumen
    • Ultrasound Abdomen:
    • Distended bowel loops
    • Intussusception can be diagnosed
    • CT scan with contrast:
    • Has a sensitivity of 90 %

Treatment of Intestinal Obstruction

  • Question 16: Describe treatment of intestinal obstruction:
    • Pre-operative Preparation (Drip & Suck):
    • IV fluids, electrolytes, blood & plasma if needed
    • Gastric aspiration by a nasogastric tube
    • Antibiotics if strangulation is suspected
    • Urinary catheter to check urine output
    • Operation:
    • A longitudinal exploratory incision is performed
    • The first step is to look at the caecum:
      • Collapsed: indicates small bowel obstruction
      • Distended: indicates large bowel obstruction
    • Detect level of obstruction at junction of dilated and collapsed bowel loops
    • Manage cause of obstruction
    • Conservative Management:
    • Adhesive intestinal obstruction may be relieved by IV drip and nasogastric suction
    • Ileo-caecal intussusception may be reduced by barium enema
    • Sigmoid volvulus untwisting may be done using rectal tube passed through a sigmoidoscope
    • Fecal impaction may be treated with enema to dissolve obstructing hard fecal mass.

Definition and Causes of Intussusception

  • Question 17: Define intussusception:
    • Definition: It is the invagination of an intestinal segment (Intussusceptum) into the lumen of an adjacent one (Intussuscepiens)
    • Composition:
    • An inner tube (Intussusceptum)
    • An outer tube (Intussuscepiens)
    • The blood supply of the intussusceptum is liable to be impaired at the neck of the intussusception.
  • Question 18: Mention causes of intussusception:
    • The infantile ileocaecal intussusception is idiopathic.
    • Adenovirus is a potential etiology, causing swelling of the lymphoid follicles in the terminal ileum, leading to protrusion into the lumen, mimicking a foreign body.
    • Increased occurrences are noted during weaning age and summer, attributing to gastroenteritis.
    • In adult intussusception, an evident cause is often found at the head of the intussusceptum:
    • Polyp
    • Meckel’s diverticulum
    • Submucous haematoma

Types of Intussusception

  • Question 19: Describe intussusception types:
    • Ileo-ileal:
    • A loop of ileum invaginates into an adjacent ileal loop.
    • Ilea-caecal (commonest, mainly in infants):
    • Terminal ileum invaginates into the colon with the ileocaecal valve repressing the apex of the intussusception.
    • Ileocolic:
    • An ileal loop invaginates and then passes to the colon through the ileocaecal valve.
    • Colo-colic:
    • A loop of colon invaginates into an adjacent colonic segment.

Clinical Picture of Intussusception

  • Question 20: Describe clinical picture of intussusception:
    • Symptoms:
    • Typical in children aged 3 - 12 months (age of weaning).
    • Male to female incidence: 2:1.
    • Infants have recurrent attacks of severe abdominal colics, screaming, and drawing knees up to the abdomen.
    • These attacks alternate with apparent well-being during which the infant asks for feeding.
    • Vomiting follows the colic attacks in 85% of cases.
    • Presence of mucous and blood in rectum (red currant jelly stools).
    • Signs:
    • Empty right iliac fossa (Signe de Dance).
    • Distension is usually absent in early cases; if present, it may indicate perforation or gangrene.
    • A sausage-shaped mass may be palpated.
    • Digital rectal examination shows bloody mucus in 60% of cases; sometimes the head of the intussusception may be palpable.

Treatment of Intussusception

  • Question 21: Describe treatment of intussusception:
    • Pre-operative Preparations:
    • IV fluids, electrolytes, antibiotics.
    • A nasogastric tube is inserted.
    • Hydrostatic Reduction:
    • Done in early cases.
    • Maximum pressure of 120 cm of water.
    • Success rate of 90%, confirmed by free flow of barium into small intestine for more than 5 cm.
    • Baby must remain under observation for 24 hours.
    • Surgery:
    • At laparotomy, the head of the intussusception is squeezed backwards out of the containing colon.
    • The proximal ileum should never be pulled backwards to disengage the intussusception due to the risk of intestinal tears.
    • Presence of gangrene or an irreducible intussusception necessitates bowel resection and anastomosis.

Causes of Adhesive Intestinal Obstruction

  • Question 22: Mention causes of adhesive intestinal obstruction:
    • Post-operative adhesions:
    • Most common cause of intestinal obstruction in adults.
    • Results from previous abdominal surgery with unknown exact etiology.
    • Post-inflammatory adhesions:
    • May follow previous septic or tuberculous peritonitis.

Treatment of Adhesive Intestinal Obstruction

  • Question 23: Describe treatment of adhesive intestinal obstruction:
    • Conservative Management:
    • Implemented in early cases without evidence of strangulation.
    • Naso-gastric tube insertion.
    • IV fluids, electrolytes, antibiotics.
    • Close observation to assess success based on:
      • Resolution of pain and distension
      • Passage of flatus and stools
      • Clear gastric aspirate.
    • Should not be prolonged more than 48 hours if there is no response.
    • Surgical Management:
    • Indicated for:
      • Failure of conservative management.
      • Development of strangulation or gangrene signs.
    • Adhesions are divided, and the bowel is assessed:
      • If viable: No additional procedures are necessary.
      • If gangrenous: Resection and anastomosis are performed.

Predisposing Factors of Sigmoid Volvulus

  • Question 24: Mention predisposing factors of sigmoid volvulus:
    • Elderly males.
    • Chronic constipation.
    • Long sigmoid colon.
    • Narrow base of sigmoid mesocolon.
    • Heavy loading of sigmoid due to chronic constipation.
    • Adhesions at the apex of the sigmoid leading to twisting.

Investigations of Sigmoid Volvulus

  • Question 25: Describe investigations of sigmoid volvulus:
    • Labs:
    • Blood picture, electrolytes.
    • X-ray Abdomen:
    • Shows huge gas-filled sigmoid loop resembling the inner tube of a car tire (omega loop).
    • Base of the distended loop points to the left lower abdomen.
    • CT Abdomen:
    • The most accurate investigation to confirm diagnosis.

Treatment of Sigmoid Volvulus

  • Question 26: Describe treatment of sigmoid volvulus:
    • Conservative Management:
    • Implemented in early cases.
    • A rectal tube is passed through a sigmoidoscope to untwist the sigmoid loop.
    • Success confirmed by passing a gush of gas and fluid stools.
    • The tube is left in place, and the patient is prepared for elective resection of the long sigmoid.
    • Surgical Management:
    • Indications include:
      • Failure of conservative management.
      • Development of signs indicating possible gangrene.
    • Laparotomy performed:
      • If viable sigmoid, it is untwisted and may be fixed to the posterior abdominal wall or resected.
      • If gangrenous sigmoid, Hartmann's procedure is performed.

Causes of Paralytic Ileus

  • Question 27: Describe causes of paralytic ileus:
    • Reflex inhibition of intestinal motility due to:
    • Abdominal operations.
    • Spine fractures.
    • Retroperitoneal hemorrhage.
    • The exact mechanism of bowel paralysis is unknown, potentially linked to sympathetic overactivity.
    • Normally, bowel atony after abdominal operations lasts for 24-48 hours; if it extends beyond 3 days, consider other causes (e.g., hypokalaemia, peritonitis).
    • Metabolic Abnormalities:
    • Hypokalaemia, uraemia, diabetic ketoacidosis.
    • Peritonitis:
    • Direct toxic effect on nerve plexuses of the intestine.
    • Drugs:
    • Anticholinergics (Probanthine).
    • Tricyclic antidepressants.

Clinical Picture of Paralytic Ileus

  • Question 28: Describe clinical picture of paralytic ileus:
    • Typically occurs after major abdominal surgery.
    • Symptoms:
    • Vomiting.
    • Abdominal distension.
    • Absolute constipation.
    • Absence of colicky abdominal pains.
    • Signs:
    • Abdominal distension.
    • Absence of intestinal sounds (silent abdomen).
    • Possible signs of peritonitis.

Prevention of Paralytic Ileus

  • Question 29: Describe how to prevent paralytic ileus:
    • Manage hypokalaemia with IV potassium guided by serum levels.
    • Gentle handling of the intestine during surgery.
    • Naso-gastric tube insertion should be performed during major abdominal surgeries.

Treatment of Paralytic Ileus

  • Question 30: Describe treatment of paralytic ileus:
    • Primarily conservative:
    • IV fluids and electrolytes.
    • Naso-gastric tube insertion.
    • If postoperative ileus is prolonged, investigate for peritonitis (due to anastomotic leakage); if indicated, surgery is required.
    • Parasympathomimetics (Prostigmine) may be beneficial.