intestinal obstruction


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intestinal

 [in-tes´tĭ-nal]
pertaining to the intestine.
intestinal bypass a surgical procedure in which all but a short section of the proximal jejunum and terminal ileum is bypassed in order to bring about malabsorption of digested food. The procedure is done for the purpose of correcting obesity. Patients having this type of surgery must be meticulously managed so that severe nutritional cirrhosis and serious loss of water and electrolytes are avoided. Called also jejunoileal bypass and jejunoileal shunt.
intestinal flu a popular term for what may be any of several disorders of the stomach and intestinal tract. The symptoms are nausea, diarrhea, abdominal cramps, and fever. During the acute stage all foods should be avoided. Carbonated soft drinks such as ginger ale or cola can be taken in moderation to relieve the nausea. When the symptoms subside, the diet should at first be confined to liquids and soft, bland foods. Milk and dairy products, butter and fats generally, fruits, and greens should be avoided completely until the patient is free of all symptoms.
intestinal obstruction any hindrance to the passage of the intestinal contents. Causes may be mechanical or neural or both. Some of the more common mechanical causes are hernia, adhesions of the peritoneum, volvulus, intussusception, malignant or benign tumor, congenital defect, and local inflammation, as in diverticulitis. Failure of peristalsis (adynamic ileus) is frequently associated with peritonitis; it also may occur with gallstones, uremia, heavy metal poisoning, infection, and spinal injury.
Symptoms. The most characteristic symptoms are abdominal pain, vomiting, and distention. The symptoms may be mild at first and in its early stages the condition can be confused with less serious disorders of the intestinal tract. Under no circumstances should the patient be given a cathartic or other laxative, because that will aggravate the situation. If the obstruction continues the patient suffers from dehydration and shock because of inadequate absorption of fluids, electrolytes, and nutrients from the intestinal tract. If the bowel becomes strangulated and circulation to the bowel wall is obstructed, the patient shows signs of peritonitis with extreme tenderness and rigidity of the abdomen.
Diagnosis. The diagnosis of obstruction can usually, but not always, be made from plain abdominal radiographs. If there is a question, a gastrointestinal series with barium will usually resolve the issue quickly.
Treatment. The basic steps of treatment are decompression of the intestine, replacement of fluids and electrolytes, and removal of the cause of the obstruction. Decompression is accomplished by intubation with a special tube (usually the miller-abbott tube) designed to reach past the pyloric sphincter and into the intestine. Constant suction is then applied to remove accumulations of gas and liquids. Fluids, sodium chloride, and glucose are administered intravenously at a specific rate as prescribed. Transfusions of whole blood plasma may be given as necessary to restore normal blood values.

Surgical removal of the cause of obstruction is necessary in cases of complete obstruction. If there is no evidence of strangulation of the bowel, the surgeon may choose to postpone surgery until dehydration and shock have been overcome and a normal electrolyte balance is restored. The type of surgical procedure performed depends on the cause of the obstruction and whether or not the intestine is gangrenous. In some cases a colostomy may be necessary along with removal of the damaged portion of the bowel. A surgical incision into the cecum with insertion of a drainage tube (cecostomy) may be done when intestinal intubation is not successful in relieving distention.
Patient Care. Assessment of the patient with intestinal obstruction includes noting the location and character of abdominal pain, degree of distention, character of the bowel sounds, and occurrence or absence of bowel movements or passing of flatus. Should defecation occur, a specimen is saved for examination and laboratory analysis. If there is vomiting, the amount and special characteristics of the vomitus should be noted and recorded. In severe cases of obstruction of the small bowel the vomitus may contain fecal material because of the reversal of peristalsis and forcing of the intestinal contents backward into the stomach. Foods and fluids by mouth are restricted. Frequent mouth care is necessary to relieve the dryness and foul taste that accompanies intestinal obstruction and vomiting. Urinary output is measured and recorded because of the possibility of decreased urinary output related to dehydration.
Preoperative Care. If conservative measures fail to relieve the obstruction, or if the bowel has become strangulated, surgery is indicated. Suction siphonage, once initiated, is continued and the intestinal tube is left in place when the patient goes to the operating room.
Postoperative Care. Routine postoperative care of the patient with abdominal surgery is indicated. Specific measures depend on the type of surgical procedure done. Suction siphonage is usually continued until peristalsis resumes. Results of the assessment of bowel sounds and the passing of flatus or feces should be noted on the patient's chart because they indicate a return of normal peristaltic movements of the bowel. In some cases a cecostomy tube or rectal tube is inserted during surgery; the tube is attached to a drainage system and the amount and type of material collected in the system are recorded. If there is evidence that the tube has become obstructed the surgeon should be notified. The skin around the site of insertion of a cecostomy tube should be protected with a skin barrier. The area must be washed frequently to avoid erosion of the skin by intestinal contents leaking around the tube. (See colostomy for patient care after that procedure.)
intestinal tract the small and large intestines in continuity; this long, coiled tube is the part of the digestive system where most of the digestion of food takes place. (See color plates.) The small intestine has three parts: the duodenum (connected to the stomach), the jejunum, and the ileum. The small intestine is small in diameter but very long (about 6.1 m). The large intestine, which starts just below the ileum, is about 1.5 m long. It is made up of the cecum (to which the appendix is attached), the colon (comprising the ascending, transverse, and descending colon and the sigmoid), and the rectum.

The digestion of food is completed in the small intestine. The digested food is absorbed through the walls of the small intestine into the blood. Indigestible parts of the food pass into the large intestine. Here the liquid from the wastes is gradually absorbed back into the body through the intestinal walls. The waste itself is formed into fairly solid feces and pushed down into the rectum for evacuation.

Among the disorders of the intestinal tract are the disturbances of function, such as diarrhea, constipation, and irritable bowel syndrome; the organic diseases, ulcerative colitis, appendicitis, and ileitis; and communicable diseases, such as dysentery. Irritable bowel syndrome is characterized by constipation, sometimes alternating with diarrhea. Ulcerative colitis is a disorder in which ulcers may appear in the wall of the large intestine. Ileitis is a disorder of the ileum, or lower portion of the small intestine. A symptom of both is diarrhea. Dysentery, which is characterized by diarrhea, is the result of infection by bacteria, viruses, or various parasites.

obstruction

 [ob-struk´shun]
1. the act of blocking or clogging.
2. the state or condition of being clogged; see also atresia. Called also blockade, closure, and occlusion.
chronic airflow obstruction (chronic airway obstruction) name given to a group of disorders in which the upper or lower airways are chronically obstructed; it includes chronic bronchitis, asthma, emphysema, pneumoconiosis, and any other type of chronic obstructive pulmonary disease.
intestinal obstruction see intestinal obstruction.

intestinal obstruction

Bowel obstruction Surgery Obstruction of the intestine due to either mechanical causes–eg, volvulus, fecal impaction or nonmechanical causes–eg, paralytic ileus, see there.

intestinal obstruction

Blockage of the inner bore of the INTESTINE so that forward movement of the contents is prevented. This may occur as a congenital condition, as a result of twisting of the bowel (VOLVULUS), from STRANGULATION by swelling in a HERNIA, by a sleeve-like ‘telescoping’ into itself (INTUSSUSCEPTION), by impaction of hard faeces, by an internal or encircling tumour, or by a failure of the normal mechanism of PERISTALSIS by which the contents are moved along. See also ILEUS. Obstruction causes severe colicky abdominal pain, distention, constipation and often vomiting. Treatment is urgent.

Intestinal Obstruction

DRG Category:329
Mean LOS:14.9 days
Description:SURGICAL: Major Small and Large Bowel Procedures With Major CC
DRG Category:389
Mean LOS:4.6 days
Description:MEDICAL: Gastrointestinal Obstruction With CC

Intestinal obstruction occurs when a blockage obstructs the normal flow of contents through the intestinal tract. Obstruction of the intestine causes the bowel to become vulnerable to ischemia. The intestinal mucosal barrier can be damaged, allowing intestinal bacteria to invade the intestinal wall and causing fluid exudation, which leads to hypovolemia and dehydration. About 7 L of fluid per day is secreted into the small intestine and stomach and is usually reabsorbed. During obstruction, however, fluid accumulates, causing abdominal distention and pressure on the mucosal wall, which can lead to peritonitis and perforation. Obstructions can be partial or complete. The most common type of intestinal obstruction is one of the small intestine from fibrous adhesions.

The patient’s mortality depends on the type of lesion causing the small bowel obstruction (closed-loop or strangulated) and the time until diagnosis and treatment; when an early diagnosis is made, mortality is low, but if more than 75% of the small bowel is necrotic at the time of surgery, the mortality rate is 65%. Complications of intestinal obstruction include bacteremia, secondary infection, or metabolic alkalosis or acidosis. If it is left untreated, a complete intestinal obstruction can cause death within a few hours from hypovolemic or septic shock and vascular collapse.

Causes

The two major types of intestinal obstruction are mechanical and neurogenic (or nonmechanical). Neurogenic obstruction occurs primarily after manipulation of the bowel during surgery or with peritoneal irritation, pain of thoracolumbar origin, or intestinal ischemia. It is also caused by the effect of trauma or toxins on the nerves that regulate peristalsis, electrolyte imbalances, and neurogenic abnormalities such as spinal cord lesions. Mechanical obstruction of the bowel is caused by physical blockage of the intestine. Examples of mechanical obstruction include adhesions and strangulated hernias (usually associated with the small intestine), volvulus (twisting of the intestine) of the cecum or sigmoid, intussusception (telescoping of the bowel), strictures, fecal or barium impaction, carcinomas (usually associated with the large intestine), or foreign bodies such as gallstones and fruit pits.

Genetic considerations

No clear genetic contributions to susceptibility have been defined.

Gender, ethnic/racial, and life span considerations

Intestinal obstructions can occur at any age, in all races and ethnicities, and in both sexes, but they are more common in patients who have undergone major abdominal surgery or have congenital abnormalities of the bowel. When it occurs in a child, the obstruction is most likely to be an intussusception. Although small bowel obstructions in children are uncommon, the diagnosis should be considered for any child with persistent vomiting, abdominal distention, and abdominal pain; early diagnosis is critical because delayed diagnosis and treatment are associated with significant complications.

Global health considerations

No data are available.

Assessment

History

Establish any predisposing factors: surgery, especially abdominal surgery; radiation therapy; gallstones; Crohn’s disease; diverticular disease; ulcerative colitis; or a family history of colorectal cancer. Ask if the patient has had hiccups, which is often a symptom of intestinal obstruction.

To establish the diagnosis of small bowel obstruction, ask about vomiting fecal contents, wavelike abdominal pain, or abdominal distention. Elicit a history of intense thirst, generalized malaise, or aching. A paralytic ileus usually causes a distended abdomen, with or without pain, but usually without cramping. To establish the diagnosis of large bowel obstruction, which has a slower onset of symptoms, ask about recent constipation with a history of spasmodic abdominal pain several days afterward. Establish a history of hypogastric pain and nausea. Ask if the patient has been vomiting. To establish neurogenic obstruction, ask about abdominal pain. Neurogenic obstruction characteristically produces diffuse abdominal discomfort rather than colicky pain. Establish a history of vomiting; ask the patient to describe the vomitus, which may consist of gastric and bile contents but rarely fecal contents.

Physical examination

The most common symptoms are abdominal pain and distention and vomiting. Inspect the patient’s abdomen for distention. Observe the patient’s abdomen for signs of visible peristalsis or loops of large bowel. Measure the patient’s abdominal girth every 4 hours to observe the progress of an obstruction. Auscultate the patient’s abdomen for bowel sounds in all four quadrants; you may hear rushes or borborygmus (rumbling noises in the bowels). Always auscultate the abdomen for up to 5 minutes for bowel sounds before palpation. Lack of bowel sounds can indicate a paralytic ileus. High-pitched tingling sounds with rushes can indicate a mechanical obstruction. Palpate all four quadrants of the abdomen to determine areas of localized tenderness, guarding, and rebound tenderness.

Assess the patient for tachycardia, a narrowed pulse pressure, urine output less than 30 mL/hr, and delayed capillary blanching—all indicators of severe hypovolemia and impending shock. Assess for fever, which may indicate peritonitis. Inspect the patient’s skin for loss of turgor and mucous membranes for dryness.

Psychosocial

The patient with an intestinal obstruction is acutely ill and may need emergency intervention. Assess the patient’s level of anxiety and fear. Assess the patient’s coping skills, support system, and the significant other's response to the illness.

Diagnostic highlights

TestNormal ResultAbnormality With ConditionExplanation
Chest and abdominal x-rayNormal abdominal structuresDistended loops of bowel; may have a ladderlike pattern with air-fluid levelsIdentifies free air under the diaphragm if perforation has occurred or blockage of lumen of bowel with distal passage of fluid and air (partial) or complete obstruction
Water-soluble contrast enemaNormal abdominal structuresBlockage of lumen of bowelIdentifies site and severity of colonic obstruction

Other Tests: Complete blood count, serum electrolytes, blood urea nitrogen, colonoscopy, sigmoidoscopy, abdominal computed tomography scan with contrast, abdominal ultrasound

Primary nursing diagnosis

Diagnosis

Fluid volume deficit related to abnormal loss of gastrointestinal fluids

Outcomes

Fluid balance; Hydration; Nutritional status: Food and fluid intake; Bowel elimination; Knowledge: Disease process

Interventions

Fluid management; Intravenous insertion and therapy; Surveillance; Venous access devices maintenance; Vital signs monitoring

Planning and implementation

Collaborative

surgical.
Surgery is often indicated for a complete mechanical obstruction. The operative procedure varies with the location and type of obstruction. A strangulated bowel constitutes a surgical emergency. A bowel resection may be necessary in some obstructions.

Postoperative care includes monitoring the patient’s cardiopulmonary response and identifying surgical complications. The highest priority is maintaining airway, breathing, and circulation. The patient may require temporary endotracheal intubation and mechanical ventilation to manage airway and breathing. The circulation may need support from parenteral fluids, and total parenteral nutrition may be prescribed if the patient has protein deficits. Care for the surgical site and notify the physician if you observe any signs of poor wound healing, bleeding, or infection.

medical.
Medical management with intravenous fluids, electrolytes, and administration of blood or plasma may be required for patients whose obstruction is caused by infection or inflammation or by a partial obstruction. Insertion of a nasogastric (NG) tube, often ordered by the physician to rest and decompress the bowel, greatly decreases abdominal distention and patient discomfort.

Analgesic medication may be ordered after the cause of the obstruction is known, but it may be withheld until the diagnosis of intestinal obstruction is confirmed so as to not mask pain, which is an important clinical indicator. Explore nonpharmacologic methods of pain relief. The physician may order oxygen. Usually, until the patient is stabilized, her or his condition precludes any oral intake.

Pharmacologic highlights

Medication or Drug ClassDosageDescriptionRationale
AntibioticsVaries with drugBroad-spectrum antibiotic coverageMay be prescribed when the obstruction is caused by an infectious process

Other Drugs: Analgesics

Independent

Focus on increasing the patient’s comfort and monitoring for complications. Elevate the head of the bed to assist with patient ventilation. Position the patient in the Fowler or semi-Fowler position to ease respiratory discomfort from a distended abdomen. Reposition the patient frequently.

Instruct the patient about the need to take nothing by mouth. Frequent mouth care and lubrication of the mucous membranes can assist with patient comfort. Patient teaching should include the indications and function of the NG tube. Discuss care planning with the patient and the family.

Teach the causes, types, signs, and symptoms of intestinal obstruction. Explain the diagnostic tests and treatments, preparing the patient for the possibility of surgery. Explain surgical and postoperative procedures. Note the patient’s and significant others’ responses to emergency surgery if needed and provide additional support if the family or patient copes ineffectively.

Evidence-Based Practice and Health Policy

Malik, A.M., Shah, M., Pathan, R., & Sufi, K. (2010). Pattern of acute intestinal obstruction: Is there a change in the underlying etiology? Saudi Journal of Gastroenterology, 16(4), 272–274.

  • A prospective study among 229 patients over age 10 who presented with acute intestinal obstruction revealed an overall mortality rate of 3.49% and complete recovery in 87.3% of patients. Mortality was highest among patients with a symptom duration of 1 week or more (p < 0.001).
  • In this sample, 87% of patients presented with abdominal distention, 73% presented with vomiting, 88% presented with complete constipation, 67% were dehydrated, and 75% reported abdominal pain.
  • The small bowel was the site of 85% of the obstructions, with the other 15% occurring in the large bowel. Postoperative adhesions accounted for 41% of obstructions, followed by abdominal tuberculosis (25%) and obstructed/strangulated hernias (18%).

Documentation guidelines

  • Physical findings: Vital signs, abdominal assessments, pulmonary assessment, fluid volume status
  • Response to pain medications, antibiotics, NG intubation, and suctioning
  • Presence of complications (preoperative): Peritonitis, sepsis, respiratory insufficiency, hypovolemia, shock
  • Presence of complications (postoperative): Poor wound healing, hemorrhage, or infection

Discharge and home healthcare guidelines

Teach postoperative care to patients who have had surgery. Teach the patient how to plan a paced progression of activities. Teach the patient the dosages, routes, and side effects for all medications. Review drug and food interactions with the patient. Instruct the patient to report bowel elimination problems to the physician. Emphasize that in the case of recurrent abdominal pain, fever, or vomiting, the patient should go to the emergency department for evaluation.

Patient discussion about intestinal obstruction

Q. I recently had my surgery for bowel obstruction? I recently had my surgery for bowel obstruction? None of the diet was restricted for me by doctor but should I go for any special diet.

A. I had surgery in 08/08 during having a c-section and hernia repair, and I'm having diarrhea all the time. I don't know what to eat nor what medicines to take. Only Immodium AD helps temporary. If I have an appointment, I don't eat breakfast or lunch. I come home and eat dinner. About 30 minutes after eating, I'm in the bathroom. Can someone help me please? I have to return back to work next month, and I don't want to be in the bathroom more than I am at my desk.

More discussions about intestinal obstruction
References in periodicals archive ?
Results showed the same material in the ventriculus of most birds, but no intestinal obstructions were identified.
Aetiology, clinical pattern and outcome of adult intestinal obstruction in JOS, north central Nigeria.
Intestinal obstruction for malrotation in an adult patient.
All patients older than 14 years with clinical and radiological evidence of intestinal obstruction were included in the study.
Rare cause of intestinal obstruction, Ascaris lumbricoides infestation: two case reports.
Ileosigmoidal knotting, an unusual form of acute intestinal obstruction. Acute Med Surg.
In present study, number of bacterial biomass isolated from peritoneal fluid in cattle suffering from intestinal obstruction at twenty four hours after surgery was[10.sup.4-4.5] CFU/ml of peritoneal fluid.
Furthermore, the effect of the water retention capacity of the beads, which is swallowed by chewing, on the intestinal obstruction requires a separate study.
Intestinal obstruction causes failure of the intestine functions, leading to an increase of intestinal toxins, high intestinal pressure, bacterial translocation and malnutrition (1).
Conclusion: From this study it is concluded that postoperative adhesions and bands are commo-nest cause of intestinal obstruction followed by TB abdomen, external hernias, colonic tumors, volvulus, paralytic ileus, internal hernias and intussusceptions and that pattern of intestinal obstruction depends upon geographical factors.
Patient was then referred for surgical treatment for intestinal obstruction. Soon after laparotomy and resolution of obstruction, the dramatic ECG changes disappeared (Figure 4) while the cardiac biomarkers remained negative making an acute coronary event unlikely.
died after consuming a large quantity of bananas which resulted in an intestinal obstruction, causing a severe infection that spread in his intestines and later killed him.

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