PK "x\_rels/PK "x\ docProps/PK "x\ppt/PK "x\ ppt/_rels/PK "x\ ppt/charts/PK "x\ppt/charts/_rels/PK "x\ppt/embeddings/PK "x\ ppt/media/PK "x\ppt/slideLayouts/PK "x\ppt/slideLayouts/_rels/PK "x\ppt/slideMasters/PK "x\ppt/slideMasters/_rels/PK "x\ ppt/slides/PK "x\ppt/slides/_rels/PK "x\ ppt/theme/PK "x\ppt/notesMasters/PK "x\ppt/notesMasters/_rels/PK "x\ppt/notesSlides/PK "x\ppt/notesSlides/_rels/PK "x\.tw1w1[Content_Types].xml PK "x\]] _rels/.rels PK "x\ydocProps/app.xml 0 0 Microsoft Office PowerPoint On-screen Show (16:9) 0 25 25 0 0 false Fonts Used 2 Theme 1 Slide Titles 25 Arial Calibri Office Theme Slide 1Slide 2Slide 3Slide 4Slide 5Slide 6Slide 7Slide 8Slide 9Slide 10Slide 11Slide 12Slide 13Slide 14Slide 15Slide 16Slide 17Slide 18Slide 19Slide 20Slide 21Slide 22Slide 23Slide 24Slide 25 PptxGenJS false false false 16.0000 PK "x\񪏀  docProps/core.xml Intestinal Obstruction – Bailey & Love 28e PptxGenJS Presentation PptxGenJS PptxGenJS 1 2026-03-24T04:20:56Z 2026-03-24T04:20:56Z PK "x\rKppt/_rels/presentation.xml.rels PK "x\Oݨ ppt/theme/theme1.xmlPK "x\ppt/presentation.xml PK "x\Xppt/presProps.xml PK "x\ppt/tableStyles.xml PK "x\D >00ppt/viewProps.xml PK "x\H7t!ppt/slideLayouts/slideLayout1.xml PK "x\ђ77,ppt/slideLayouts/_rels/slideLayout1.xml.rels PK "x\ձXBppt/slides/slide1.xml INTESTINAL OBSTRUCTIONA Comprehensive Clinical Review for Final Year MBBSBailey & Love's Short Practice of Surgery — 28th Edition | Chapter 78High-Yield Content • Exam-Oriented • Viva ReadyPK "x\3 ppt/slides/_rels/slide1.xml.rels PK "x\.ppt/notesSlides/notesSlide1.xml 1PK "x\:A*ppt/notesSlides/_rels/notesSlide1.xml.rels PK "x\㱠L!L!ppt/slides/slide2.xml ⚡ CLINICAL SCENARIOThe Surgical Emergency60yr male — post-appendicectomy scarColicky central pain since early morningProfuse vomiting; not passed flatusAXR: dilated central small bowel loopsWhat is your diagnosis & management??Most common cause of SBO?ADHESIONS (40%)PK "x\2- ppt/slides/_rels/slide2.xml.rels PK "x\ppt/notesSlides/notesSlide2.xml 2PK "x\xշ*ppt/notesSlides/_rels/notesSlide2.xml.rels PK "x\98%8%ppt/slides/slide3.xml DEFINITION & CLASSIFICATION DYNAMIC (MECHANICAL OBSTRUCTION)Peristalsis works against a physical blockageTypes: intraluminal, intramural, extramuralAdhesions 40% SBO; risk of strangulation ADYNAMIC (FUNCTIONAL OBSTRUCTION)No physical block — peristalsis is absentParalytic ileus: post-op, sepsis, metabolicPseudo-obstruction = Ogilvie's syndromePK "x\W/ ppt/slides/_rels/slide3.xml.rels PK "x\K |Őppt/notesSlides/notesSlide3.xml 3PK "x\9 Y*ppt/notesSlides/_rels/notesSlide3.xml.rels PK "x\tttppt/slides/slide4.xml AETIOLOGY — SBO vs LBO 📊SMALL BOWEL OBSTRUCTION CAUSE FREQ Adhesions & Bands 40% External Hernia 12% Crohn's / Inflammatory 15% Carcinoma 15% Faecal Impaction 8% Pseudo-obstruction 5% Miscellaneous 5% LARGE BOWEL OBSTRUCTION CAUSE NOTES Carcinoma (~60%) Most common Diverticular Disease Stricture Sigmoid Volvulus Elderly Pseudo-obstruction Ogilvie's Faecal Impaction Elderly Hernia / Other Rare ⭐ Adhesions = #1 SBO | Carcinoma = #1 LBO | Both carry strangulation riskPK "x\` ppt/slides/_rels/slide4.xml.rels PK "x\vsppt/notesSlides/notesSlide4.xml 4PK "x\J *ppt/notesSlides/_rels/notesSlide4.xml.rels PK "x\gPuuuuppt/slides/slide5.xml PATHOPHYSIOLOGY — MECHANICAL OBSTRUCTIONProximal dilates; distal emptiesGas = 90% N₂ + H₂S (bacteria)Untreated → strangulationFLUID / 24 HOURS Source Volume Saliva 500 mL Bile 500 mL Pancreatic 500 mL Gastric 1,000 mL Intestinal ~4,500 mL TOTAL ~7 Litres DEHYDRATION CAUSES: ↓ oral intake • defective absorption • vomiting • bowel sequestration • peritoneal transudationPK "x\5 ppt/slides/_rels/slide5.xml.rels PK "x\W8ppt/notesSlides/notesSlide5.xml 5PK "x\Qe*ppt/notesSlides/_rels/notesSlide5.xml.rels PK "x\.WMMppt/slides/slide6.xml PATHOPHYSIOLOGY — PROGRESSION FLOWCHART 🔄 Mechanical Obstruction Proximal Dilation + Gas Accumulation Fluid Sequestration + Bacterial Growth Dehydration + Electrolyte Imbalance Raised Intraluminal Pressure Strangulation → Gangrene → PeritonitisCONSEQUENCES• Dehydration & shock• Electrolyte imbalance• Bowel ischaemia• Bacterial translocation• Systemic sepsis• Multi-organ failureKEY FACTS• N₂ = 90% bowel gas• Venous before arterial• Caecum highest risk• Closed-loop = danger• Reperfusion injury• No colic in ileusPK "x\ج+ ppt/slides/_rels/slide6.xml.rels PK "x\zppt/notesSlides/notesSlide6.xml 6PK "x\=|*ppt/notesSlides/_rels/notesSlide6.xml.rels PK "x\W88ppt/slides/slide7.xml STRANGULATION — SURGICAL EMERGENCY ⚠️ CAUSESHernial orifices — direct wall pressureAdhesions / bands; volvulus; intussusceptionClosed-loop — raised intraluminal pressure CLINICAL FEATURES• Constant pain — opiates don't help• Tenderness + rigidity + peritonism• Shock: tachycardia + hypotension• Pyrexia + ↑WBC + ↑LDH/amylase SEQUENCE OF EVENTSVenous block → ↑ capillary pressure→ Arterial impairment → Infarction→ Gangrene → Sepsis → Death ⭐ EXAM PEARLDiagnosis is primarily CLINICAL.NEVER delay surgery to wait for CT.PK "x\F ppt/slides/_rels/slide7.xml.rels PK "x\)lppt/notesSlides/notesSlide7.xml 7PK "x\|g*ppt/notesSlides/_rels/notesSlide7.xml.rels PK "x\Z!fEfEppt/slides/slide8.xml SPECIAL TYPES OF MECHANICAL OBSTRUCTION 📋 ADHESIONSPost-op; 40% SBO; divide culprit band only HERNIAExternal orifice; Richter's = partial wall VOLVULUSAxial rotation; sigmoid most common adult INTUSSUSCEPTIONProximal into distal; ileocolic 77% GALLSTONE ILEUSElderly; Rigler's triad; 60 cm from ICV CLOSED LOOPBoth ends blocked; caecum perforatesPK "x\6 ppt/slides/_rels/slide8.xml.rels PK "x\iސppt/notesSlides/notesSlide8.xml 8PK "x\pO*ppt/notesSlides/_rels/notesSlide8.xml.rels PK "x\dn׉ppt/slides/slide9.xml INTUSSUSCEPTIONProximal invaginates into distal segmentPeak: 5–10 months; 90% idiopathicRedcurrant jelly stool = late sign🖼 [Insert: Intussusception anatomy — intussusceptum, middle tube, intussuscipiens (outer sheath), lead point, apex and neck labelled] TREATMENT: Air/barium enema >70% success • Contraindicated: peritonitis/shock/lead point • Surgery if reduction fails • Recurrence up to 10%PK "x\>$ ppt/slides/_rels/slide9.xml.rels PK "x\qppt/notesSlides/notesSlide9.xml 9PK "x\1*ppt/notesSlides/_rels/notesSlide9.xml.rels PK "x\VFbbppt/slides/slide10.xml VOLVULUS — AXIAL ROTATIONSigmoid: most common adult volvulus>360° torsion = mesenteric occlusionSigmoidoscopy + flatus tube first🖼 [Insert: AXR — sigmoid volvulus coffee bean / omega loop / inverted-U sign; two limbs running diagonally right-to-left] TYPE POPULATION TREATMENT Volvulus Neonatorum Neonates Emergency surgery (malrotation) Sigmoid Volvulus Elderly Sigmoidoscopy → elective resection Caecal Volvulus 4th–5th decade Resection or caecopexy PK "x\Ѳ!ppt/slides/_rels/slide10.xml.rels PK "x\O ppt/notesSlides/notesSlide10.xml 10PK "x\T+ppt/notesSlides/_rels/notesSlide10.xml.rels PK "x\ζ--ppt/slides/slide11.xml CLINICAL FEATURES — THE CARDINAL QUARTET1. PAINSudden; colicky; central (SBO) or lower abdomen. Constant pain = strangulation.2. VOMITINGEarlier the higher the obstruction. Profuse in high SBO. Late = faeculent.3. DISTENSIONGreater the more distal the level. Visible peristalsis in thin patients.4. ABSOLUTE CONSTIPATIONNeither faeces nor flatus passed. Cardinal sign of complete obstruction.PK "x\;!ppt/slides/_rels/slide11.xml.rels PK "x\s6ӑ ppt/notesSlides/notesSlide11.xml 11PK "x\O+ppt/notesSlides/_rels/notesSlide11.xml.rels PK "x\ppt/slides/slide12.xml HIGH SBO vs LOW SBO vs LARGE BOWEL 📊 FEATURE HIGH SBO LOW SBO LARGE BOWEL Pain Epigastric; early Central; colicky Lower abdomen; mild Vomiting Early & profuse Moderate; later Very late Distension Minimal Central; prominent Peripheral; marked Constipation Late feature Present Early; absolute Dehydration Rapid; severe Moderate Less severe AXR finding Few central loops Multiple ladders Peripheral colon gas PK "x\c!ppt/slides/_rels/slide12.xml.rels PK "x\*)@ ppt/notesSlides/notesSlide12.xml 12PK "x\Fb+ppt/notesSlides/_rels/notesSlide12.xml.rels PK "x\ippt/slides/slide13.xml CLINICAL FEATURES OF STRANGULATIONConstant pain — opiates don't relieveShock + rigidity + skin discolourationCLINICAL diagnosis — CT must not delay🖼 [Insert: Skin discolouration — purplish/erythema over strangulated incisional hernia, ischaemia confirmed intraop] ⭐ PEARLS: Venous before arterial • ↑K⁺ + ↑amylase + ↑LDH = suggestive • Persistent pain = presume strangulation • CT must NOT delay surgeryPK "x\x!ppt/slides/_rels/slide13.xml.rels PK "x\Ї ppt/notesSlides/notesSlide13.xml 13PK "x\yv+ppt/notesSlides/_rels/notesSlide13.xml.rels PK "x\g %%ppt/slides/slide14.xml INVESTIGATIONS BLOOD INVESTIGATIONSFBC: leukocytosis = strangulation / sepsisU&E: ↑urea; electrolyte imbalance (↓K⁺)↑Amylase + ↑LDH = strangulation markers IMAGING INVESTIGATIONSPlain AXR supine: first-line in all casesCT abdomen: gold standard; identifies cause⚠️ Barium follow-through CONTRAINDICATEDPK "x\O!ppt/slides/_rels/slide14.xml.rels PK "x\0 ppt/notesSlides/notesSlide14.xml 14PK "x\?ݤ+ppt/notesSlides/_rels/notesSlide14.xml.rels PK "x\bggppt/slides/slide15.xml RADIOLOGICAL FEATURES — PLAIN X-RAY 🔬🖼 [Insert: AXR supine — central dilated loops; valvulae conniventes 'concertina' pattern; erect AXR stepladder fluid levels] STRUCTURE RADIOLOGICAL APPEARANCE Jejunum Valvulae conniventes; full-width; concertina Ileum Featureless; central; transverse; no markings Caecum Rounded gas shadow — right iliac fossa Colon Haustral folds; peripheral; irregular spacing Sigmoid Volvulus Coffee bean / omega loop / inverted-U Gallstone Ileus Rigler's triad: SBO + pneumobilia + stone PK "x\*R!ppt/slides/_rels/slide15.xml.rels PK "x\Qz ppt/notesSlides/notesSlide15.xml 15PK "x\$Q+ppt/notesSlides/_rels/notesSlide15.xml.rels PK "x\gIIppt/slides/slide16.xml CT ABDOMEN — GOLD STANDARD INVESTIGATIONIdentifies site, level and cause↓ Enhancement → strangulation likelyNEVER delay surgery to wait for CT🖼 [Insert: CT abdomen — 'target sign' of ileocolic intussusception; concentric rings on axial cross-section] CT SIGN INTERPRETATION ↓ Bowel wall enhancement ↑ Probability of strangulation Absent mesenteric oedema ↓ Probability of strangulation Pneumatosis intestinalis Advanced ischaemia / necrosis PK "x\ !ppt/slides/_rels/slide16.xml.rels PK "x\  ppt/notesSlides/notesSlide16.xml 16PK "x\ y+ppt/notesSlides/_rels/notesSlide16.xml.rels PK "x\))ppt/slides/slide17.xml MANAGEMENT — THREE PILLARS 1. RESUSCITATE IV Hartmann's/Saline • Correct K⁺ & Na⁺ • Catheter + urine output • Analgesia + O₂ 2. DECOMPRESS Nasogastric tube (Salem/Ryle's) • Free drainage + 4-hourly aspiration • Essential BEFORE anaesthesia 3. RELIEVE CAUSE Conservative (adhesions) max 72h • Surgery if strangulation • Assess viability; resect necrotic bowelPK "x\檋!ppt/slides/_rels/slide17.xml.rels PK "x\r. ppt/notesSlides/notesSlide17.xml 17PK "x\BI+ppt/notesSlides/_rels/notesSlide17.xml.rels PK "x\T==ppt/slides/slide18.xml MANAGEMENT ALGORITHM 🔄 SUSPECTED INTESTINAL OBSTRUCTION Resuscitate: IV fluids + NGT + catheter + O₂ Imaging: AXR first → CT Abdomen STRANGULATION / HERNIA / CLOSED LOOP?YES ↓ EMERGENCYSURGERYNO ↓ CONSERVATIVEmax 72 hoursAssess viability: colour • sheen • peristalsis • mesenteric pulsation | Resect non-viable bowelPK "x\Yh!ppt/slides/_rels/slide18.xml.rels PK "x\ ppt/notesSlides/notesSlide18.xml 18PK "x\N+ppt/notesSlides/_rels/notesSlide18.xml.rels PK "x\~oppt/slides/slide19.xml TREATMENT OF ADHESIVE SBOIV fluids + NGT; conservative max 72hWater-soluble contrast: Rx + diagnosticDivide only the causative adhesion🖼 [Insert: Intraoperative — band adhesion causing closed-loop; proximal dilated (a) vs. collapsed distal segment (b)] PREVENTION: Good surgical technique • Saline peritoneal lavage • Minimise gauze contact • Cover raw surfaces • Laparoscopic surgery reduces adhesion riskPK "x\~!ppt/slides/_rels/slide19.xml.rels PK "x\0[ ppt/notesSlides/notesSlide19.xml 19PK "x\i+ppt/notesSlides/_rels/notesSlide19.xml.rels PK "x\ȗ*^V^Vppt/slides/slide20.xml TREATMENT OF LARGE BOWEL OBSTRUCTIONRight colon → emergency hemicolectomyLeft colon → Hartmann's procedureMetal stent: palliation / bridge🖼 [Insert: Radiograph — self-expanding metal stent for malignant left colonic obstruction (80–90% success)] SITE OF LESION RECOMMENDED TREATMENT Caecum / Ascending Emergency right hemicolectomy + anastomosis Splenic flexure Extended right hemicolectomy + anastomosis Left colon / Rectosigmoid Resection ± Hartmann's procedure Palliative / Unfit Self-expanding metal stent (80–90%) PK "x\g_!ppt/slides/_rels/slide20.xml.rels PK "x\7 ppt/notesSlides/notesSlide20.xml 20PK "x\SB+ppt/notesSlides/_rels/notesSlide20.xml.rels PK "x\г>rrppt/slides/slide21.xml SURGICAL ASSESSMENT — BOWEL VIABILITY 📋Assess viability AFTER relieving obstructionDoubtful: hot packs × 10 min; reassessUncertain → resect (unless short bowel risk)Second-look laparotomy at 24–48h if needed PARAMETER VIABLE BOWEL ✅ NON-VIABLE BOWEL ❌ Colour Pink — lightens on compression Dark — remains unchanged Appearance Shiny and glistening Dull and lustreless Wall tone Firm; intact muscle Flabby, thin, friable Peristalsis Present; stimulable Absent — no movement PK "x\z!ppt/slides/_rels/slide21.xml.rels PK "x\89| ppt/notesSlides/notesSlide21.xml 21PK "x\HΩ+ppt/notesSlides/_rels/notesSlide21.xml.rels PK "x\ %%ppt/slides/slide22.xml ADYNAMIC OBSTRUCTION PARALYTIC ILEUSCauses: post-op, sepsis, metabolic, reflexNormal if resolves within 72 h post-operativelySilent abdomen; no colic; NGT + IV fluids OGILVIE'S PSEUDO-OBSTRUCTIONAcute colonic dilation; no mechanical causeCaecal distension → risk of perforationColonoscopic decompression first-line RxPK "x\dV!ppt/slides/_rels/slide22.xml.rels PK "x\cQc ppt/notesSlides/notesSlide22.xml 22PK "x\aeZ+ppt/notesSlides/_rels/notesSlide22.xml.rels PK "x\dbbppt/slides/slide23.xml COMPLICATIONS DISEASE COMPLICATIONS TREATMENT / SURGICAL COMPLICATIONS Dehydration & electrolyte loss Wound infection / anastomotic leak Strangulation & bowel gangrene Short bowel syndrome Intestinal perforation & peritonitis Recurrent adhesive SBO Septicaemia & multi-organ failure Stoma complications Hypovolaemic shock Reperfusion injury post-ischaemia Respiratory embarrassment Port-site hernia (~2%) PK "x\A!ppt/slides/_rels/slide23.xml.rels PK "x\] ppt/notesSlides/notesSlide23.xml 23PK "x\ ~t+ppt/notesSlides/_rels/notesSlide23.xml.rels PK "x\|ZZppt/slides/slide24.xml ⭐ HIGH-YIELD EXAM PEARLS TOPIC KEY FACT / VIVA ANSWER Most common SBO cause Adhesions (40%) Most common LBO cause Carcinoma (~60%) Rigler's Triad SBO + Pneumobilia + Ectopic stone shadow Intussusception peak age 5–10 months; ileocolic = 77% Sigmoid volvulus Rx Sigmoidoscopy + flatus tube first Conservative SBO limit Maximum 72 hours Strangulation diagnosis Primarily CLINICAL — CT must not delay surgery Hartmann's procedure Resection + end colostomy + close rectal stump Water-soluble contrast Sensitivity 96% / Specificity 98% PK "x\Y!ppt/slides/_rels/slide24.xml.rels PK "x\`z ppt/notesSlides/notesSlide24.xml 24PK "x\8+ppt/notesSlides/_rels/notesSlide24.xml.rels PK "x\ݪOMMppt/slides/slide25.xml SUMMARYClassify: Dynamic (mechanical) vs AdynamicCardinal quartet: pain, distension, vomiting, constipationStrangulation = emergency; diagnose clinicallyCT abdomen = gold standard; never delay surgeryResuscitate; assess viability at operationSource: Bailey & Love's Short Practice of Surgery, 28th Edition — Chapter 78PK "x\̜|g!ppt/slides/_rels/slide25.xml.rels PK "x\Y ppt/notesSlides/notesSlide25.xml 25PK "x\#+ppt/notesSlides/_rels/notesSlide25.xml.rels PK "x\K 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