İnce Bağırsak Mekanik Obstrüksiyonları
Özet
İnce bağırsak obstrüksiyonu (İBO), ince bağırsak içeriğinin mekanik veya fonksiyonel nedenlerle ilerleyememesi durumu olup, tüm gastrointestinal tıkanıklıkların %80’ini oluşturur ve en sık intraabdominal adezyonlar, tümörler ve fıtıklardan kaynaklanır. Hastalığın fizyopatolojisinde, tıkanıklığın proksimalinde sıvı ve gaz birikimiyle artan lümen içi basınç, bağırsak duvarında ödeme ve ilerleyen evrelerde iskemi, nekroz ile perforasyona yol açabilir. Tanı sürecinde anamnez, fizik muayene, laboratuvar tetkikleri (lökositoz, laktat seviyesi) ve radyolojik görüntülemeler (direkt batın grafisi, bilgisayarlı tomografi, ultrasonografi, MR) kritik rol oynar. Tedavi yaklaşımı hastanın klinik durumuna göre belirlenir; iskemi, nekroz veya perforasyon gibi komplikasyon varlığında acil cerrahi müdahale gerekirken, komplike olmamış adheziv İBO olgularında nazogastrik dekompresyon, sıvı replasmanı ve suda çözünür kontrast madde (Gastrografin) uygulamalarını içeren non-operatif destek tedavisi %65-80 oranında başarı sağlar. Erken postoperatif dönem, virgin abdomen, yaşlılar, hamileler ve bariatrik cerrahi geçmişi olan hastalar ise yönetimde özel uzmanlık gerektirir.
Small bowel obstruction (SBO) is a condition where the passage of intestinal contents is interrupted due to mechanical or functional disorders, accounting for 80% of all gastrointestinal obstructions, primarily caused by intra-abdominal adhesions, tumors, and complicated hernias. In its pathophysiology, accumulation of fluid and gas proximal to the obstruction increases intraluminal pressure, leading to bowel wall edema, and can progress to ischemia, necrosis, and perforation as pressure rises. Diagnosis relies on anamnesis, physical examination, laboratory tests (leukocytosis, lactate levels), and radiological imaging, including plain abdominal X-ray, computed tomography (CT), ultrasound, and MRI. Treatment planning is guided by clinical findings; immediate emergency surgery is mandatory in the presence of complications like ischemia, necrosis, or perforation, whereas non-operative management—consisting of nasogastric decompression, fluid resuscitation, and water-soluble contrast medium (Gastrografin) administration—achieves a 65-80% success rate in uncomplicated adhesive SBO cases. Furthermore, early postoperative SBO, virgin abdomen, elderly, pregnant, and bariatric patients represent special cases that require distinct clinical management and close monitoring.
Referanslar
Kozol R. Mechanical bowel obstruction: A tale of 2 eras. The Archives of Surgery, 2012; 147:180.
Drożdż W, Budzyński P. Change in mechanical bowel obstruction demographic and etiological patterns during the past century: observations from one health care institution. The Archives of Surgery, 2012; 147:175.
Miller G, Boman J, Shrier I, et al. Etiology of small bowel obstruction. The American Journal of Surgery. 2000; 180:33.
Gore RM, Silvers RI, Thakrar KH, et al. Bowel Obstruction. Radiologic Clinics, 2015; 53:1225.
Ganong WF. Regulation of gastrointestinal function. Review of medical physiology, edn 21. McGeaw-Hill, 2003:471-483.
Long B, Robertson J, Koyfman A. Emergency Medicine Evaluation and Management of Small Bowel Obstruction: Evidence-Based Recommendations. The Journal of emergency medicine, 2019 Feb;56(2):166-176. doi: 10.1016/j.jemermed. 2018.10.024.
Markogiannakis H, Messaris E, Dardamanis D, et al. Acute mechanical bowel obstruction: clinical presentation, etiology, management and outcome. World journal of gastroenterology, 2007; 13:432.
Bordeianou L, Yeh DD. Etiologies, clinical manifestations, and diagnosis of mechanical small bowel obstruction in adults. In: Up To Date[online]. Available at: www.UpToDateInc.com/card. Accessed : April 15, 2022.
Hernandez MC, Haddad NN, Cullinane DC, et al. The American Association for the Surgery of Trauma Severity Grade is valid and generalizable in adhesive small bowel obstruction. Journal of Trauma and Acute Care Surgery, 2018; 84:372. DOI: 10.1097/TA.0000000000001736.
Zamary K, Spain DA. Small Bowel Obstruction: the Sun Also Rises? Journal of Gastrointestinal Surgery, 2020 Aug;24(8):1922-1928. doi: 10.1007/s11605-019-04351-5.
Eskelinen M, Ikonen J, Lipponen P. Contributions of history-taking, physical examination, and computer assistance to diagnosis of acute small-bowel obstruction.Aprospective study of 1333 patients with acute abdominal pain. Scandinavian journal of gastroenterology, 1994;29(8):715–721.
Catena F, De Simone B, Coccolini F, et al. Bowel obstruction: a narrative review for all physicians. World Journal of Emergency Surgery, 2019;14(1):20. doi:10.1186/s13017-019-0240-7.
Azagury D, Liu RC, Morgan A, et al. Small bowel obstruction: a practical stepby-step evidence-based approach to evaluation, decision making, and management.. Journal of Trauma and Acute Care Surgery,2015;79(4):661–8.
Ferris B, Bastian-Jordan M, Fenwick J, et al. Vascular assessment in small bowel obstruction: can CT predict requirement for surgical intervention?Abdominal Radiology(NY), 2021 Feb;46(2):517-525. doi: 10.1007/s00261-020-02698-x.
Suri S, Gupta S, Sudhakar PJ, et al. Comparative evaluation of plain films, ultrasound and CT in the diagnosis of intestinal obstruction. Acta Radiologica, 1999; 40:422.
Chang KJ, Marin D, Kim DH, et al. ACR Appropriateness Criteria® Suspected Small-Bowel Obstruction. Journal of the American College of Radiology, 2020 May;17(5S):S305-S314. doi: 10.1016/j.jacr.2020.01.025.
Kohli MD, Maglinte DD. CT enteroclysis in incomplete small bowel obstruction. Abdominal imaging, 2009; 34:321.
Paulsen SR, Huprich JE, Fletcher JG, et al. CT enterography as a diagnostic tool in evaluating small bowel disorders: review of clinical experience with over 700 cases. Radiographic, 2006; 26:641.
Frager D, Medwid SW, Baer JW, et al. CT of small-bowel obstruction: value in establishing the diagnosis and determining the degree and cause. American journal of roentgenology,1994; 162:37.
Verheyden C, Orliac C, Millet I, et al. Large-bowel obstruction: CT findings, pitfalls, tips and tricks. European Journal of Radiology, 2020 Sep;130:109155. doi: 10.1016/j.ejrad.2020.109155.
De Giorgio R, Cogliandro RF, Barbara G, et al. Chronic intestinal pseudo-obstruction: clinical features, diagnosis, and therapy. Gastroenterology Clinics, 2011;40:787.
Choi J, Fisher AT, Mulaney B, et al. Safety of Foregoing Operation for Small Bowel Obstruction in the Virgin Abdomen: Systematic Review and Meta-Analysis. Journal of the American College of Surgeons, 2020; 231:368.
Tavangari FR, Batech M, Collins JC, et al T. Small Bowel Obstructions in a Virgin Abdomen: Is an Operation Mandatory? The American Surgeon, 2016; 82:1038.
Barmparas G, Branco BC, Schnüriger B, et al. In-hospital small bowel obstruction after exploratory laparotomy for trauma. Journal of Trauma and Acute Care Surgery, 2011; 71:486.
Beltran MA, Cruces KS. Primary tumors of jejunum and ileum as a cause of intestinal obstruction: a case control study. International Journal of Surgery, 2007; 5:183.
Ripamonti C, De Conno F, Ventafridda V, et al. Management of bowel obstruction in advanced and terminal cancer patients. Annals of oncology, 1993; 4:15.
Hayden GE, Sprouse KL. Bowel obstruction and hernia. Emergency Medicine Clinics, 2011; 29:319.
Yeo A, Htun NN, Lim YT, et al. Perforated Appendicitis Presenting as Mechanical Small Bowel Obstruction. The American Journal of Medicine, 2021 Mar;134(3):e213-e214. doi:10.1016/j.amjmed.2020.07.034.
Northcutt A, Hamidian Jahromi A, Johnson L, et al. Unusual late occurrence of bowel obstruction following blunt abdominal trauma. The Journal of the Louisiana State Medical Society, 2011; 163:305.
Ruiz-Tovar J, Morales V, Sanjuanbenito A, et al. Volvulus of the small bowel in adults. The American Surgeon, 2009; 75:1179.
Diaz JJ Jr, Bokhari F, Mowery NT, et al. Guidelines for management of small bowel obstruction. Journal of Trauma and Acute Care Surgery, 2008; 64:1651.
Takeuchi K, Tsuzuki Y, Ando T, et al. Clinical studies of strangulating small bowel obstruction. The American Surgeon, 2004; 70:40.
Kim JH, Ha HK, Kim JK, et al. Usefulness of known computed tomography and clinical criteria for diagnosing strangulation in small-bowel obstruction: analysis of true and false interpretation groups in computed tomography. World journal of surgery, 2004; 28:63.
Di Saverio S, Catena F, Ansaloni L, et al. Water-soluble contrast medium (gastrografin) value in adhesive small intestine obstruction (ASIO): a prospective, randomized, controlled, clinical trial. World journal of surgery, 2008; 32:2293.
Kumar P, Kaman L, Singh G, et al. Therapeutic role of oral water soluble iodinated contrast agent in postoperative small bowel obstruction. Singapore medical journal, 2009; 50:360.
Ceresoli M, Coccolini F, Catena F, et al. Water-soluble contrast agent in adhesive small bowel obstruction: a systematic review and meta-analysis of diagnostic and therapeutic value. The American Journal of Surgery, 2016; 211:1114.
Fevang BT, Jensen D, Svanes K, et al. Early operation or conservative management of patients with small bowel obstruction? European Journal of Surgery, 2002; 168:475.
Cosse C, Regimbeau JM, Fuks D, et al. Serum procalcitonin for predicting the failure of conservative management and the need for bowel resection in patients with small bowel obstruction. Journal of the American College of Surgeons, 2013; 216:997.
Onoue S, Katoh T, Shibata Y, et al. The value of contrast radiology for postoperative adhesive small bowel obstruction. Hepatogastroenterology, 2002; 49:1576.
Ten Broek RPG, Krielen P, Di Saverio S, et al. Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2017 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group. World Journal of Emergency Surgery, 2018 Jun 19;13:24. doi: 10.1186/s13017-018-0185-2.
Maung AA, Johnson DC, Piper GL, et al. Eastern Association for the Surgery of Trauma. Evaluation and management of small-bowel obstruction: an Eastern Association for the Surgery of Trauma practice management guideline. Journal of Trauma and Acute Care Surgery, 2012, 73.5 Suppl 4: S362-S369..doi: 10.1097/TA.0b013e31827019de.
Schwenter F, Poletti PA, Platon A, et al. Clinicoradiological score for predicting the risk of strangulated small bowel obstruction. Journal of British Surgery, 2010; 97:1119.
Richards WO, Williams LF Jr. Obstruction of the large and small intestine. Surgical Clinics of North America, 1988; 68:355.
Bordeianou L, Yeh DD. Management of small bowel obstruction in adults. In: Up To Date[online]. Available at: www.UpToDateInc.com/card. Accessed : April 15, 2022.
Nauta RJ. Advanced abdominal imaging is not required to exclude strangulation if complete small bowel obstructions undergo prompt laparotomy. Journal of the American College of Surgeons, 2005; 200:904.
Biondo S, Miquel J, Espin-Basany E, et al. A Double-Blinded Randomized Clinical Study on the Therapeutic Effect of Gastrografin in Prolonged Postoperative Ileus After Elective Colorectal Surgery. World journal of surgery, 2016; 40:206.
Catena F, Di Saverio S, Kelly MD, et al. Bologna Guidelines for Diagnosis and Management of Adhesive Small Bowel Obstruction (ASBO): 2010 Evidence-Based Guidelines of the World Society of Emergency Surgery. World Journal of Emergency Surgery, 2011; 6:5.
Ozturk E, van Iersel M, Stommel MM, et al. Small bowel obstruction in the elderly: a plea for comprehensive acute geriatric care. World Journal of Emergency Surgery, 2018; 13:48.
Webster PJ, Bailey MA, Wilson J, et al. Small bowel obstruction in pregnancy is a complex surgical problem with a high risk of fetal loss. The Annals of The Royal College of Surgeons of England, 2015;97(5):339-344. doi:10.1308/003588415X14181254789844.
Shimizu H, Maia M, Kroh M, et al. Surgical management of early small bowel obstruction after laparoscopic Roux-en-Y gastric bypass. Surgery for obesity and related diseases, 2013; 9:718.
