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.