Distal small bowel obstruction

Plain film shows numerous dilated loops of bowel occupying the entire abdominal cavity, including the pelvic portion, and multiple air-fluid levels in upright film (Fig. 1.19). With this degree of distension the mucosal pattern of the small bowel is effaced and it is impossible to differentiate the small bowel from the colon (Winters et al. 1992). Examination of the colon is then warranted to disclose the presence or absence of a colonic lesion. In ileal atresia, the colon is normally placed but has an abnormally small caliber, the so-called functional microcolon typical of distal small bowel obstruction (Dalla Vecchia et al. 1998) (Fig. 1.19d,e). The presence of pneumoperitoneum indicates that perforation has occurred and a colon examination is contraindicated. Intraperitoneal calcifications, indicative of meconium peritonitis, are not uncommon in ileal atresia. 

Lees NP, Reid F, Lee SH et al. (2003) Distal small bowel obstruction caused by a migrated self expanding metal oesophageal stent. Eur J Surg [Suppl] 66-68 Lyon SM, Haslam PJ, Duke DM et al. (2003) De novo placement of button gastrostomy catheters in an adult population experience in 53 patients. J Vase Interv Radiol 14 1283-1289... 

Gastrointestinal involvement may present initially as small bowel obstruction shortly after birth (known as meconium ileus) due to abnormally thick meconium that cannot be passed. Older CF patients may develop distal intestinal obstruction syndrome (DIOS), formerly called meconium ileus equivalent, which occurs due to fecal impaction in the terminal ileum and cecum. 

Coverage against obligate anaerobic bacilli should be provided for distal small-bowel and colon-derived infections and for more-proximal gastrointestinal perforations when obstruction is present. 

Fig. 1.23a,b. Meconium ileus. a,b Intraoperative views illustrating the tenacious nature of the meconium impacted within the distal small bowel loops (arrows) in a patient in which contrast enema failed to solve the obstruction... 

In paralytic ileus supine radiographs of the abdomen will show both dilated small bowel loops and colon, whereas in obstructive ileus usually only the loops proximal to the obstruction are dilated and those distal have a reduced caliber. The closer to the obstruction, the more the loops are dilated. Air-... 

Before stent placement an accurate diagnosis is paramount for choosing between curative and palUative treatment. CT, upper GI series and endoscopy with biopsy should be performed to evaluate length, location and nature of the stenosis (Fig. 3.5a). In addition, distal obstruction in the small bowel which could compromise passage of intestinal contents should also be excluded (De Baere et al. 1997 Soetikno et al. 1998). Insertion of stents via gastrostomy... 

Kawamura, H., Yokota, R., Yokota, K., Watarai, H., Tsunoda, Y., Yamagami, H., Hata, T, Tanaka, K., Masuko, H., Ishizu, H., Okada, K., Adachi, T., Kondo, Y. A sodium hyaluronate carboxymethylcellulose bioresorbable membrane prevents postoperative small-bowel adhesive obstruction after distal gastrectomy. Surg. Today 40, 223-227 (2010)... 

These include ulcers in the distal duodenum, the presence of a double pyloric canal (Fig. 5.8b,c), or multiple recurrent anastomotic ulcers. Other findings include a non-dilated non-obstructed stomach filled with diluted barium due to hypersecretion, dilatation of the duodenum and proximal small bowel, sluggish gastric peristalsis, and thickening of gastric and duodenal folds (Berg and Wolfe 1991 Hirschowitz 1997). 

Fig. 1.14a,b. Jejunal atresia, a Supine radiograph shows a few dilated, air-filled intestinal loops, about four bubbles , which indicates a high obstruction, b Surgical image demonstrates the location of the atresia (arrow), the dilated proximal jejunum, and the small caliber of the bowel distal to the atresia... 

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