PK jw\_rels/PK jw\ docProps/PK jw\ppt/PK jw\ ppt/_rels/PK jw\ ppt/charts/PK jw\ppt/charts/_rels/PK jw\ppt/embeddings/PK jw\ ppt/media/PK jw\ppt/slideLayouts/PK jw\ppt/slideLayouts/_rels/PK jw\ppt/slideMasters/PK jw\ppt/slideMasters/_rels/PK jw\ ppt/slides/PK jw\ppt/slides/_rels/PK jw\ ppt/theme/PK jw\ppt/notesMasters/PK jw\ppt/notesMasters/_rels/PK jw\ppt/notesSlides/PK jw\ppt/notesSlides/_rels/PK jw\.tw1w1[Content_Types].xml PK jw\]] _rels/.rels PK jw\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 jw\docProps/core.xml Intestinal Obstruction - Bailey & Love PptxGenJS Presentation PptxGenJS PptxGenJS 1 2026-03-23T13:22:02Z 2026-03-23T13:22:02Z PK jw\rKppt/_rels/presentation.xml.rels PK jw\Oݨ ppt/theme/theme1.xmlPK jw\ppt/presentation.xml PK jw\Xppt/presProps.xml PK jw\ppt/tableStyles.xml PK jw\D >00ppt/viewProps.xml PK jw\H7t!ppt/slideLayouts/slideLayout1.xml PK jw\ђ77,ppt/slideLayouts/_rels/slideLayout1.xml.rels PK jw\mfppt/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 jw\3 ppt/slides/_rels/slide1.xml.rels PK jw\.ppt/notesSlides/notesSlide1.xml 1PK jw\:A*ppt/notesSlides/_rels/notesSlide1.xml.rels PK jw\J#J#ppt/slides/slide2.xml ⚡ CLINICAL SCENARIOThe Surgical Emergency60-year-old male, post-appendicectomy scarColicky central pain since early morningProfuse vomiting; has not passed flatusAXR: central dilated small bowel loopsWhat is your diagnosis and management??Most common causeof small bowel obstruction?Answer: ADHESIONS (40%)PK jw\2- ppt/slides/_rels/slide2.xml.rels PK jw\ppt/notesSlides/notesSlide2.xml 2PK jw\xշ*ppt/notesSlides/_rels/notesSlide2.xml.rels PK jw\Od--ppt/slides/slide3.xml DEFINITION & CLASSIFICATION DYNAMIC (MECHANICAL)Peristalsis works against obstructionAcute or chronic presentation possibleIntraluminal / intramural / extramuralProximal bowel dilates; distal collapsesAdhesions = 40% of all SBO cases ADYNAMIC (FUNCTIONAL)No mechanical obstruction presentPeristalsis absent or inadequateParalytic ileus: most common typePseudo-obstruction (Ogilvie's syndrome)No surgery unless complications arisePK jw\W/ ppt/slides/_rels/slide3.xml.rels PK jw\K |Őppt/notesSlides/notesSlide3.xml 3PK jw\9 Y*ppt/notesSlides/_rels/notesSlide3.xml.rels PK jw\uJ3ppt/slides/slide4.xml AETIOLOGY — CAUSES AT A GLANCE 📊SMALL BOWEL OBSTRUCTION CAUSE FREQ Adhesions & Bands 40% External Hernia 12% Inflammatory (Crohn's) 15% Carcinoma 15% Pseudo-obstruction 5% Miscellaneous 5% Faecal Impaction 8% LARGE BOWEL OBSTRUCTION CAUSE NOTES Carcinoma (most common) ~60% Diverticular Disease Stricture Sigmoid Volvulus Elderly Pseudo-obstruction Ogilvie's Faecal Impaction Elderly Hernia / Other Rare ⭐ EXAM PEARL: Adhesions = #1 (SBO) | Carcinoma = #1 (LBO) | Both carry risk of strangulationPK jw\` ppt/slides/_rels/slide4.xml.rels PK jw\vsppt/notesSlides/notesSlide4.xml 4PK jw\J *ppt/notesSlides/_rels/notesSlide4.xml.rels PK jw\qr}x}xppt/slides/slide5.xml PATHOPHYSIOLOGY — MECHANICAL OBSTRUCTIONProximal bowel dilates; distal collapses normallyGas (90% N₂) and H₂S accumulate in lumen~7 litres of fluid secreted daily; reabsorption failsDehydration: vomiting, sequestration, ↓ oral intakeUntreated → flaccidity, paralysis, strangulation FLUID SOURCE VOL/24h Saliva 500 mL Bile 500 mL Pancreatic juice 500 mL Gastric secretion 1000 mL Intestinal secretion ~4500 mL TOTAL ~7 Litres CAUSES OF DEHYDRATION:↓ Oral intake • Defective intestinal absorption • Vomiting lossesSequestration in bowel lumen • Peritoneal transudationPK jw\5 ppt/slides/_rels/slide5.xml.rels PK jw\W8ppt/notesSlides/notesSlide5.xml 5PK jw\Qe*ppt/notesSlides/_rels/notesSlide5.xml.rels PK jw\kqPPppt/slides/slide6.xml PATHOPHYSIOLOGY — PROGRESSION FLOWCHART 🔄 Mechanical Obstruction Proximal Dilation + Gas Accumulation Fluid Sequestration + Bacterial Overgrowth Dehydration + Electrolyte Imbalance Increased Intraluminal Pressure Strangulation → Gangrene → PeritonitisCONSEQUENCES• Dehydration & shock• Electrolyte imbalance• Bowel ischaemia• Bacterial translocation• Systemic sepsis• Multi-organ failureKEY FACTS• N₂ = 90% of bowel gas• Venous before arterial• Caecum: highest risk• Closed-loop = danger• Reperfusion injury risk• No colicky pain in ileusPK jw\ج+ ppt/slides/_rels/slide6.xml.rels PK jw\zppt/notesSlides/notesSlide6.xml 6PK jw\=|*ppt/notesSlides/_rels/notesSlide6.xml.rels PK jw\u-5-5ppt/slides/slide7.xml STRANGULATION — SURGICAL EMERGENCY ⚠️ CAUSES OF STRANGULATION1. Hernial orifices (direct pressure)2. Adhesions/bands (constriction)3. Volvulus (mesenteric occlusion)4. Intussusception (invagination)5. Closed-loop (raised intraluminal pressure) CLINICAL FEATURES:• Constant, severe, unrelenting pain• Tenderness + rigidity + peritonism• Shock (tachycardia, hypotension)• Pyrexia, leukocytosis, raised LDH SEQUENCE OF EVENTS:Venous obstruction → ↑ capillary pressure→ Impaired perfusion → Arterial supply lost→ Haemorrhagic infarction → Gangrene→ Bacterial translocation → Sepsis/deathPK jw\F ppt/slides/_rels/slide7.xml.rels PK jw\)lppt/notesSlides/notesSlide7.xml 7PK jw\|g*ppt/notesSlides/_rels/notesSlide7.xml.rels PK jw\ 8=FFppt/slides/slide8.xml SPECIAL TYPES OF MECHANICAL OBSTRUCTION 📋 ADHESIONSPost-op bands; 40% SBO; divide only causative band HERNIAExternal orifice; strangulates; Richter's = partial wall VOLVULUSAxial rotation; sigmoid most common adult type INTUSSUSCEPTIONProximal into distal; ileocolic 77%; redcurrant jelly stool GALLSTONE ILEUSElderly; Rigler's triad; impacted 60cm from ICV CLOSED LOOPObstructed proximally + distally; caecum perforatesPK jw\6 ppt/slides/_rels/slide8.xml.rels PK jw\iސppt/notesSlides/notesSlide8.xml 8PK jw\pO*ppt/notesSlides/_rels/notesSlide8.xml.rels PK jw\$ ffppt/slides/slide9.xml INTUSSUSCEPTIONProximal gut invaginates into adjacent distal segmentPeak incidence: infants 5–10 months of ageChildren 90% idiopathic; adults always pathologicalIleocolic = 77%; colocolic more common in adultsAdult lead points: polyp, Meckel's, lipoma🖼 [Insert Diagram: Intussusception anatomy — intussusceptum (inner/entering), middle tube, intussuscipiens (sheath/outer), lead point, apex and neck labelled] CLASSIC PAEDIATRIC PRESENTATION Symptom Description Episodic pain Screaming + drawing up of legs Pallor During attacks; listless between Vomiting Becomes bile-stained later Stool 'Redcurrant jelly' — blood + mucus Lump Sausage-shaped, right abdomen Sign of Dance Emptiness in right iliac fossa TREATMENT:• Air/barium enema: >70% success• Contraindicated: peritonitis, shock• Surgery if radiological reduction fails• Recurrence: up to 10% post-reductionPK jw\>$ ppt/slides/_rels/slide9.xml.rels PK jw\qppt/notesSlides/notesSlide9.xml 9PK jw\1*ppt/notesSlides/_rels/notesSlide9.xml.rels PK jw\!zzppt/slides/slide10.xml VOLVULUS — AXIAL ROTATIONAxial twisting of bowel around mesentery>180°: luminal obstruction; >360°: vascularSigmoid: most common adult spontaneous typePredisposed: elderly, high-residue diet, megacolonSigmoid: flexible sigmoidoscopy + flatus tube first🖼 [Insert Image: Supine AXR showing sigmoid volvulus — coffee bean/omega loop sign; two limbs running right-to-left] TYPE AGE GROUP TREATMENT Volvulus Neonatorum Neonates Emergency surgery (malrotation) Sigmoid Volvulus Elderly Sigmoidoscopy → elective resection Caecal Volvulus 4th–5th decade Resection or caecopexy Small Bowel Volvulus Any Adhesiolysis / resection PK jw\Ѳ!ppt/slides/_rels/slide10.xml.rels PK jw\O ppt/notesSlides/notesSlide10.xml 10PK jw\T+ppt/notesSlides/_rels/notesSlide10.xml.rels PK jw\MXCXCppt/slides/slide11.xml CLINICAL FEATURES — THE CARDINAL QUARTET 1. PAINSudden onset; colicky; severe initiallyCentral (SBO) or lower abdomen (LBO)Colicky → constant if strangulation occurs 2. VOMITINGMore distal = longer delay in vomitingHigh SBO: early, profuse, rapid dehydrationLate: faeculent material (bacterial overgrowth) 3. DISTENSIONGreater the more distal the obstructionVisible peristalsis in thin patients possibleLate feature in large bowel obstruction 4. ABSOLUTE CONSTIPATIONNeither faeces nor flatus passedCardinal sign of complete obstructionNot present in Richter's / gallstone ileusPK jw\;!ppt/slides/_rels/slide11.xml.rels PK jw\s6ӑ ppt/notesSlides/notesSlide11.xml 11PK jw\O+ppt/notesSlides/_rels/notesSlide11.xml.rels PK jw\tppt/slides/slide12.xml HIGH SBO vs LOW SBO vs LARGE BOWEL — COMPARISON 📊 FEATURE HIGH SBO LOW SBO LARGE BOWEL Pain Epigastric; early Central; colicky Lower abdomen; mild Vomiting Early & profuse Moderate; later Late feature Distension Minimal Central; prominent Peripheral; marked Constipation Late Present Early; absolute Dehydration Rapid; severe Moderate Less severe X-Ray (AXR) Few dilated loops Multiple + ladders Peripheral colon gas No. of fluid levels Few Many Depends on ICV PK jw\c!ppt/slides/_rels/slide12.xml.rels PK jw\*)@ ppt/notesSlides/notesSlide12.xml 12PK jw\Fb+ppt/notesSlides/_rels/notesSlide12.xml.rels PK jw\@M$$ppt/slides/slide13.xml CLINICAL FEATURES OF STRANGULATIONPain constant, severe, uncontrolled by IV opiatesTenderness → rigidity → peritonism (infarction)Shock: tachycardia, hypotension, cold peripheriesExternal hernia: tense, tender, irreducible lumpSkin erythema / discolouration → necrosis beneath🖼 [Insert Image: Skin discolouration (purplish/erythema) over strangulated incisional hernia — indicates underlying ischaemia] ⭐ EXAM PEARLS — STRANGULATION:• Diagnosis is primarily CLINICAL; CT scan should NOT delay surgical intervention• Venous obstruction occurs BEFORE arterial; ↑K⁺, ↑amylase, ↑LDH + leukocytosis suggestive• Even in absence of signs: persistent pain despite conservative management = presume strangulationPK jw\x!ppt/slides/_rels/slide13.xml.rels PK jw\Ї ppt/notesSlides/notesSlide13.xml 13PK jw\yv+ppt/notesSlides/_rels/notesSlide13.xml.rels PK jw\9--ppt/slides/slide14.xml INVESTIGATIONS BLOOD INVESTIGATIONSFBC: leukocytosis (strangulation/sepsis)U&E: raised urea, electrolyte imbalance↑ Serum amylase + LDH → strangulationHaematocrit ↑ → secondary polycythaemiaABG / Serum lactate: ischaemia marker IMAGING INVESTIGATIONSPlain AXR (supine): first-line alwaysErect AXR: air-fluid levels if neededCT abdomen: gold standard; shows causeUSG: doughnut sign in intussusception⚠️ Barium follow-through CONTRAINDICATEDPK jw\O!ppt/slides/_rels/slide14.xml.rels PK jw\0 ppt/notesSlides/notesSlide14.xml 14PK jw\?ݤ+ppt/notesSlides/_rels/notesSlide14.xml.rels PK jw\e(\u\uppt/slides/slide15.xml RADIOLOGICAL FEATURES — PLAIN X-RAY 🔬🖼 [Insert Image: Supine AXR showing central dilated small bowel loops with valvulae conniventes — 'concertina/ladder' pattern; fluid levels on erect film] STRUCTURE X-RAY APPEARANCE Jejunum Valvulae conniventes; full-width; 'concertina' Ileum Featureless; central; transverse loops 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 Fluid Levels Air-fluid on erect AXR; number ∝ obstruction level PK jw\*R!ppt/slides/_rels/slide15.xml.rels PK jw\Qz ppt/notesSlides/notesSlide15.xml 15PK jw\$Q+ppt/notesSlides/_rels/notesSlide15.xml.rels PK jw\ph=V`V`ppt/slides/slide16.xml CT ABDOMEN — GOLD STANDARD INVESTIGATIONIdentifies site, level and cause of obstructionReduced bowel wall enhancement → strangulationAbsence of mesenteric oedema → strangulationTarget sign = pathognomonic of intussusceptionSensitivity 96%; specificity 98% for SBO resolution🖼 [Insert Image: CT abdomen showing 'target sign' of ileocolic intussusception — concentric rings on cross-section] CT SIGN INTERPRETATION ↓ Bowel wall enhancement ↑ Probability of strangulation Absent mesenteric fluid ↓ Probability of strangulation Mesenteric vascular engorgement Suggests ischaemia Pneumatosis intestinalis Advanced ischaemia / necrosis ⚠️ Strangulation diagnosis remains primarily CLINICAL — never delay surgery awaiting imagingPK jw\ !ppt/slides/_rels/slide16.xml.rels PK jw\  ppt/notesSlides/notesSlide16.xml 16PK jw\ y+ppt/notesSlides/_rels/notesSlide16.xml.rels PK jw\ "8P:P:ppt/slides/slide17.xml MANAGEMENT — THREE PILLARS 1. RESUSCITATEIV Hartmann's / Normal SalineCorrect electrolytes (K⁺, Na⁺)Urinary catheter; monitor UOIV access; analgesia; O₂ 2. DECOMPRESSNasogastric tube (Salem / Ryle's)Free drainage + 4-hourly aspirationReduces proximal distensionEssential before anaesthesia induction 3. RELIEVE CAUSEConservative if adhesive SBO (max 72h)Surgery if strangulation suspectedMidline laparotomy if cause unknownAssess viability; resect necrotic bowelPK jw\檋!ppt/slides/_rels/slide17.xml.rels PK jw\r. ppt/notesSlides/notesSlide17.xml 17PK jw\BI+ppt/notesSlides/_rels/notesSlide17.xml.rels PK jw\==ppt/slides/slide18.xml MANAGEMENT ALGORITHM 🔄 SUSPECTED INTESTINAL OBSTRUCTION Resuscitate: IV fluids, NGT, catheter, O₂ Imaging: AXR → CT Abdomen STRANGULATION / HERNIA / CLOSED LOOP?YES ↓ EMERGENCYSURGERYNO ↓ CONSERVATIVE(max 72 hours)Assess viability: colour • sheen • peristalsis • mesenteric pulsation | Resect non-viable bowel | Record residual lengthPK jw\Yh!ppt/slides/_rels/slide18.xml.rels PK jw\ ppt/notesSlides/notesSlide18.xml 18PK jw\N+ppt/notesSlides/_rels/notesSlide18.xml.rels PK jw\$$ppt/slides/slide19.xml TREATMENT OF ADHESIVE SMALL BOWEL OBSTRUCTIONInitial: IV fluids + NGT + nil by mouthConservative management: maximum 72 hoursWater-soluble contrast: diagnostic + therapeuticSurgery: divide only causative adhesion(s)Laparoscopic adhesiolysis: selected advanced cases🖼 [Insert Image: Intraoperative photograph — band adhesion causing closed-loop obstruction; dilated proximal and collapsed distal bowel] PREVENTION OF ADHESIONS:• Good surgical technique • Saline peritoneal lavage (removes clots)• Minimise gauze contact • Cover raw peritoneal surfaces and anastomoses• Laparoscopic approach reduces intra-abdominal adhesion incidencePK jw\~!ppt/slides/_rels/slide19.xml.rels PK jw\0[ ppt/notesSlides/notesSlide19.xml 19PK jw\i+ppt/notesSlides/_rels/notesSlide19.xml.rels PK jw\j[j[ppt/slides/slide20.xml TREATMENT OF LARGE BOWEL OBSTRUCTIONAlways exclude pseudo-obstruction before surgeryRight colon: emergency right hemicolectomyLeft colon: resection + Hartmann's procedureMetal stent: bridge to surgery or palliationSigmoid volvulus: sigmoidoscopy + flatus tube first🖼 [Insert Image: Radiograph showing self-expanding metal stent in situ for malignant left colonic obstruction] SITE OF LESION RECOMMENDED TREATMENT Caecum / Ascending colon Emergency right hemicolectomy + primary anastomosis Splenic flexure Extended right hemicolectomy + anastomosis Left colon / Rectosigmoid Resection ± Hartmann's procedure Palliative / Unfit patient Self-expanding metal stent (80–90% success) PK jw\g_!ppt/slides/_rels/slide20.xml.rels PK jw\7 ppt/notesSlides/notesSlide20.xml 20PK jw\SB+ppt/notesSlides/_rels/notesSlide20.xml.rels PK jw\(ffppt/slides/slide21.xml SURGICAL ASSESSMENT — BOWEL VIABILITY 📋Assess viability AFTER relieving obstructionIf doubtful: wrap in hot packs × 10 minutesInfarcted bowel = obvious; borderline = difficultCheck: colour, sheen, muscle tone, peristalsisDoubt persists → resect (unless short bowel risk) PARAMETER VIABLE BOWEL ✅ NON-VIABLE BOWEL ❌ Colour Pink (lightens on compression) Dark (remains unchanged) General appearance Shiny, glistening Dull, lustreless Wall consistency Firm Flabby, thin, friable Peristalsis Present (stimulated) Absent Mesenteric pulsation Visible pulsation in arcades No detectable pulsation PK jw\z!ppt/slides/_rels/slide21.xml.rels PK jw\89| ppt/notesSlides/notesSlide21.xml 21PK jw\HΩ+ppt/notesSlides/_rels/notesSlide21.xml.rels PK jw\*n--ppt/slides/slide22.xml ADYNAMIC OBSTRUCTION PARALYTIC ILEUSCauses: post-op, sepsis, metabolic, reflexPost-op ileus: normal if <72 hoursFeatures: silent abdomen, NO colicky painManagement: NGT, IV fluids, electrolytesCT scan if >7 days to exclude mechanical OGILVIE'S PSEUDO-OBSTRUCTIONAcute colonic dilation WITHOUT mechanical causeMarked caecal distension; risk of perforationConfirm with CT or water-soluble enemaTreatment: colonoscopic decompressionNeostigmine: effective pharmacological optionPK jw\dV!ppt/slides/_rels/slide22.xml.rels PK jw\cQc ppt/notesSlides/notesSlide22.xml 22PK jw\aeZ+ppt/notesSlides/_rels/notesSlide22.xml.rels PK jw\o1ccppt/slides/slide23.xml COMPLICATIONS DISEASE COMPLICATIONS TREATMENT / SURGICAL COMPLICATIONS Dehydration & electrolyte loss Wound infection / anastomotic leak Strangulation & gangrene Short bowel syndrome (extensive resection) Intestinal perforation & peritonitis Recurrent adhesive small bowel obstruction Septicaemia & multi-organ failure Stoma complications (prolapse, stenosis) Hypovolaemic shock Reperfusion injury after ischaemia relief Respiratory embarrassment Port-site hernia (laparoscopic surgery) PK jw\A!ppt/slides/_rels/slide23.xml.rels PK jw\] ppt/notesSlides/notesSlide23.xml 23PK jw\ ~t+ppt/notesSlides/_rels/notesSlide23.xml.rels PK jw\lppt/slides/slide24.xml ⭐ HIGH-YIELD EXAM PEARLS TOPIC KEY FACT / 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 first-line Flexible sigmoidoscopy + flatus tube Water-soluble contrast Sensitivity 96% / Specificity 98% (SBO resolution) Conservative SBO limit Max 72 hours Strangulation diagnosis Primarily CLINICAL; CT aids but must not delay surgery Hartmann's procedure Resection + end colostomy + close rectal stump Port-site hernia rate ~2% (laparoscopic cholecystectomy) PK jw\Y!ppt/slides/_rels/slide24.xml.rels PK jw\`z ppt/notesSlides/notesSlide24.xml 24PK jw\8+ppt/notesSlides/_rels/notesSlide24.xml.rels PK jw\ppt/slides/slide25.xml SUMMARYClassify first: Dynamic (mechanical) vs AdynamicCardinal quartet: pain, distension, vomiting, constipationStrangulation = surgical emergency; diagnose clinicallyCT abdomen: gold standard; don't delay surgery for itResuscitate fully before operating; assess bowel viabilitySource: Bailey & Love's Short Practice of Surgery, 28th Edition — Chapter 78PK jw\̜|g!ppt/slides/_rels/slide25.xml.rels PK jw\Y ppt/notesSlides/notesSlide25.xml 25PK jw\#+ppt/notesSlides/_rels/notesSlide25.xml.rels PK jw\K !ppt/slideMasters/slideMaster1.xml PK jw\N),ppt/slideMasters/_rels/slideMaster1.xml.rels PK jw\6TT!ppt/notesMasters/notesMaster1.xml 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