Obstructed hernia

Any cause of small bowel obstruction (adhesions, hernia) Vascular causes... 

Contraindications Glaucoma, obstructive uropathy, obstructive disease of Gl-anti-cholinergic tract, paralytic ileus, intestinal atony of the elderly or debilitated patient, unstable cardiovascular status in acute hemorrhage, severe ulcerative colitis especially if complicated by toxic megacolon, myasthenia gravis, hiatal hernia associated with reflux esophagitis, hypersensitivity to any component of f he formulaf ion, acuf e infermiffenf porphyria. 

Caution Prostatic hypertrophy, history of urinary retention or obstruction, glaucoma, diabetes mellitus, history of seizures, hyperthyroidism, cardiac/hepatic/renal disease, schizophrenia, increased intraocular pressure, hiatal hernia... 

Indications Shao yin disease, four counterflows patterns (i.e., cold extremities due to the liver failing to course and discharge heat). Gastritis, peptic ulcer, cholecystitis, gallstones, hepatitis, intercostal neuralgia, biliary ascariasis, hernia, acute appendicitis, pancreatitis, intestinal obstruction, allergic colitis, neurotic diarrhea, pleurisy, rhinitis, tubercular peritonitis, neurosis, epilepsy, mastitis, and fibrocystic breasts... 

Besides perforated appendicitis and intussusception, the most common causes of small howel obstruction are incarcerated hernias and adhesions. Other causes of small bowel obstruction comprise a miscellaneous group of rare conditions, such as midgut volvulus, Meckel s diverticulum, advanced stages of Crohn s disease, and bezoars. Adhesions usually result from prior surgery and are often multiple. There is an increasing tendency for initial conservative management rather than immediate operative intervention, as a proportion of cases will resolve spontaneously. 

The diagnosis of bowel obstruction is established on clinical grounds and usually confirmed with plain abdominal radiographs. Plain radiographs usually show distended bowel loops with air-fluid levels (Fig. 1.66). In inguinal incarcerated hernia, plain film will also show thickening of the... 

Paralytic ileus, due to intrinsic abnormalities of the bowel wall, can be caused for example by drugs, after laparotomy, sepsis or peritonitis. Obstructive ileus is most often due to extrinsic causes, for example adhesions (in 70% of cases), incarcerated hernia, small bowel wall hematoma posttraumatic, neoplasms, Crohn disease and intussusception (Parker 2003 Devos and Meradji 2003). Clinically the child has a distended and tender abdomen with failure to pass stools or no defecation and possibly (bilious) vomiting. 

Sonography may show dilated fluid-filled bowel loops. The obstructing cause can occasionally be visualized if it is a tumor or hernia. Absence of peristaltic movements, bowel wall thickening without perfusion on color Doppler imaging and dilated small bowel containing fluid can all indicate infarction in the appropriate clinical setting. 

Intestinal adhesion, the most frequent cause of bowel obstruction, cannot be demonstrated on sonography. Likewise, internal hernia and congenital fibrotic band can rarely be identified at sonography. Previous history of abdominal operation in patients without a sonographically visible cause of obstruction can lead to a diagnosis of adhesive ileus. 

The pattern of complications is common for all types of hernia. The complications are irreducibility, obstruction and strangulation. Irreducible (incarcerated) hernia may be due to a narrow neck or adhesion of contents to the sac wall. In obstruction, the intestine in the hernia gets obstructed due to a narrow neck, adhesion or volvulus, but it is viable. Strangulation results when there is compromise to venous drainage and later arterial supply of the contents. In obstructed hernia there is colicky pain, abdominal distension and vomiting. Incarcerated hernia is present at rest it is irreducible and usually contains some fluid in the sac that can be seen on sonography (Fig. 5.2b Rettenbacher et al. 2001). In obstructed hernia the patient has symptoms of intestinal obstruction. There are dilated bowel loops... 

Fig.5.4a-d. Complicatedhernia.aAfferentloop obstruction shows the transition between the dilated intraabdominal loop (BO) and collapsed loop in inguinal hernia (arrow), b Efferent loop obstruction shows dilated bowels in ventral hernia (BO) with transition between the dilated loop in hernia and collapsed intraabdominal loop at the neck of the sac (arrow), c Tensely distended loop is devoid of air in a ventral hernia due to closed loop obstruction, d Strangulated loop of bowel (BO) in a ventral hernia shows thick walls... 

DISORDERS WHICH ARE OFTEN AGGRAVATED BY OBESITY. Statistics from the Metropolitan Life Insurance Company show that obese people (those who are more than 20% overweight) have significantly higher death rates than the nonobese from such conditions as appendicitis, cancers of the gallbladder and liver, cirrhosis of the liver, diabetes, gallstones, heart disease, hernia and intestinal obstruction, kidney disease, stroke, and toxemia of pregnancy. 

Breakdown of suture lines and leakage are a common complication of the early postoperative phase. Afferent loop syndrome is a specific problem of Billroth II procedures and is caused by mechanical obstruction usually from adhesions. Internal hernias, extrinsic compression, bowel stenosis may also occur. Bezoar formation in the gastric remnant, anastomotic ulcers, incisional hernia of the abdominal wall and hiatal hernia are all also potential complications. Stenosis of the gastrojejunostomy after Billroth II procedures leads to obstruction (Fig. 13.14). Fistula after Billroth II is rare (Fig. 13.15). Tumour of the gastric renmant can be due to recurrence or present as a primary carcinoma of the stump (Fig. 13.16). 

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