INTESTINAL OBSTRUCTION

Clinical Features

In infants, suspect bowel obstruction if:

  • No meconium is evacuated within the first 24 hours of birth.
  • There is green or bilious vomiting.
  • There is abdominal distension.

In older children and adults, suspect bowel obstruction if:

  • There is constipation.
  • There is abdominal distension.
  • There is fever (if advanced obstruction is present).
  • There are features of dehydration.
  • There are altered bowel sounds.
  • There is abdominal pain with vomiting.

If there is gross abdominal distension with no pain, suspect sigmoid volvulus.

Investigations

  • Haemoglobin, white blood count, packed cell volume
  • Urinalysis
  • Urea and electrolytes
  • Radiograph of abdomen (erect AP and dorsal decubitus)
    • Multiple air-fluid levels, gaseous distension of gut, double bubble sign in children, etc.
    • Volvulus

Management

  • Initiate resuscitation with nasogastric suction, intravenous fluids and nil orally.
  • Monitor vital signs.
  • Take radiographs (if available). If not able refer to facility with ability to manage condition.
  • Perform definitive management be it surgery or conservative management.
  • Correct fluid and electrolyte imbalance.
    • Group and cross match blood
    • Deflate the distended stomach with nasogastric suction. This is more effective for small bowel than in large bowel obstruction.
    • Give prophylactic antibiotic at induction: metronidazole 500mg IV stat and cefuroxime 1.5g STAT.
    • Note that high enema may be effective for faecal impaction only.
    • Remove the cause of the obstruction by surgery or conservative treatment.
  • NB. Obstruction due to adhesions from previous surgery may open under conservative treatment.
  • Emergency large bowel surgical resection usually involves creation of a defunctioning
    colostomy rather than performing primary resection and anastomosis if strangulation has taken place (Hartmann’s procedure).