Page 16 - 69 stomac-duodenum-&-small-intestine66-72_opt

CHAPTER 69

Miscellaneous Causes of

Intestinal Obstruction

Lohfa B. Chirdan
Sanjay Krishnaswami

Introduction Table 69.1: Summary of features of intestinal obstruction from various causes.
Various causes of mechanical bowel obstruction, such as intestinal Aetiology Important features Important Treatment
atresias, intussusception, meconium ileus, external herniations, and investigations
midgut volvulus, have been covered elsewhere in this book. This
chapter is concerned with the various other causes of obstruction that Peritoneal Abdominal scars or Multiple air- Nasogastric
adhesions
decompression,
history of surgeries,
fluid levels
could be encountered in children in Africa. These conditions include trauma, or acute on plain x-ray intravenous
peritoneal adhesions, parasites, foreign bodies, sigmoid volvulus and abdomen in the past of abdomen; fluids and
ileosigmoid knotting, internal herniations, external compression from contrast study antibiotics for
24–48 hours;
of GI tract in
abdominal masses, faecal impaction, and paralytic ileus. A summary of doubtful cases exploratory
the important features and investigations of these conditions is outlined laparotomy
in Table 69.1. if child is not
improving
Peritoneal Adhesions Bezoars/foreign History of ingestion Plain abdominal Endoscopic
Adhesions are internal fibrous, band-like scars occurring after injury to bodies of foreign bodies films and removal; use
the peritoneum and are the result of biochemical and cellular responses or psychological contrast of pancreatic
condition; vomiting,
studies;
enzymes;
attempting to repair the peritoneum. Although this process is beneficial, failure to thrive; computed laparotomy
it could also have detrimental effects, one of which is small bowel abdominal mass tomography
obstruction (SBO). The most common cause of adhesions is iatrogenic, that may be (CT) scan if
secondary to previous abdominal operations. The data on postopera- palpable available
tive adhesions in children are sparse, and most of what we know about Faecal impaction History of Plain x-ray of Repeated rectal
adhesions is extrapolated from adult series. An estimated 93% of adults constipation or abdomen washout; manual
evacuation
motility disorder
undergoing laparotomy eventually develop adhesions, although only
1
a fraction of these will become symptomatic. Grant et al. reported Parasites Endemic area, Stool Antihelminthic;
that 1.1% of children younger than 16 years of age undergoing lower passage of worms examination, laparotomy
plain x-ray of
per rectum or
abdominal surgery would be admitted as a direct consequence of adhe- vomiting of worms abdomen
sions and 8.3% would have a readmission that may be related to adhe-
sions four or more years from the time of initial surgery. 2 Sigmoid volvulus Rapid onset of Plain x-ray Laparotomy and
In developed countries, strategies to reduce postoperative adhesions, and ileosigmoid abdominal distention of abdomen; sigmoidectomy
knotting
contrast
such as the use of talc-free gloves, improved suture and prosthetic enema, lower
materials, and especially minimal access surgery, are commonly endoscopy in
utilized. Many of these resources are not available in developing doubtful cases
countries, however. Therefore, it appears that the burden of morbidity Pseudo- History of chronic Plain x-ray Neostigmine
3
due to adhesions may gradually shift to developing countries where obstruction constipation; sickle
(Ogilvie’s
cell disease
open laparotomies are still the norm in children. syndrome)
4–6
Apart from postoperative adhesions, inflammatory diseases and Internal herniation Recurrent Plain x-ray; Laparotomy
trauma can cause peritoneal adhesions, leading to bowel obstruction in abdominal pains contrast study
children. SBO from inflammatory adhesions may sometimes be seen or CT scan in
soon after operation for such suppurative conditions of the abdomen some cases
as ruptured appendix and typhoid intestinal perforations or in patients External Abdominal mass Plain x-ray; CT Laparotomy and
with solid organ injury due to trauma who were managed either compression scan removal of mass
operatively or nonoperatively. Note that other causes of postoperative Paralytic ileus Usually Urea and Nasogastric
4–7
bowel obstruction, such as intussusception (classically seen after large postoperative, electrolyte decompression;
retroperitoneal operations), can exist, and the treatment of these may sepsis or severe estimation; intravenous
plain x-ray
fluids; electrolyte
hypokalaemia/
differ from adhesion-related SBO. hypomagnesaemia of abdomen, replenishment
Clinical Features presence of
rectal gas
The clinical features of bowel obstruction from peritoneal adhesions
could include vomiting, abdominal distention, abdominal pain, consti-
pation, and fever. While the other signs may be seen even early in the
disease course, fever usually occurs in children with bowel gangrene
or perforated bowel and should therefore be taken seriously if pres-