Don't forget constipation as a cause of intestinal obstruction in elderly sedentary people, especially if they are taking codeine derivatives for arthritis. It is less common in communities of the developing world with their soft bulky stools from high fibre diets. Here are some more causes of obstruction. Most of them are rare.
OTHER PROBLEMS WITH INTESTINAL OBSTRUCTION CONSTIPATION [s7]CAUSING INTESTINAL OBSTRUCTION If a patient's COLON IS OBSTRUCTED BY A MASS OF FAECES, try a soap suds enema. If this fails, try an oil retention enema left in for an hour, and washed out by a soap suds enema. If this too fails, remove his faeces manually.
INTERNAL HERNIAS [s7]CAUSING INTESTINAL OBSTRUCTION If an INTERNAL HERNIA is obstructing his gut (rare), it will probably be of the closed loop variety. You can usually divide the obstructing structure quite safely, but be careful with a hernia into the recess formed by the paraduodenal fold at his duodenojejunal flexure, because you can easily cut his inferior mesenteric vein.
If gut is STRANGULATING THROUGH A HOLE IN THE MESENTERY, don't cut the neck of the constricting ring, or it will probably bleed severely. Instead, decompress the distended loop (10-9), withdraw it, and suture the hole in the mesentery, carefully avoiding its blood vessels.
FOREIGN BODIES [s7]CAUSING INTESTINAL OBSTRUCTION If you feel a SOLID OBJECT at the point where the distended loops join the collapsed ones, decompress his obstructed gut proximally and apply noncrushing clamps to the empty segment. If you can easily move the solid object to another site in the gut where the mucosa will not have been ulcerated, do so. Isolate the segment with packs and make a longitudinal incision in its antemesenteric border. Remove the foreign body and repair the gut transversely.
If a FOOD BOLUS has impacted in his small gut, try to break it up and massage down into his caecum. If you fail, do an enterotomy as above.
STRICTURES [s7]CAUSING INTESTINAL OBSTRUCTION If he has a TIGHT STRICTURE of his small gut, consider the possibility of tuberculosis (29.7). Resect it and do an end[nd]to[nd]end anastomosis.
TUMOURS [s7]CAUSING INTESTINAL OBSTRUCTION If he has a localized CARCINOMA of his sigmoid colon (rare in the developing world), see section 32.27.
If he has a TUMOUR OF HIS SMALL GUT (carcinoma, carcinoid, or a benign mesenchymal tumour), resect it if you can, and do an end[nd]to[nd]end anastomosis. If this is impossible (unusual), make a bypass (29-8) to relieve the obstruction.
If he has CARCINOMATOSIS of his peritoneum, don't do a colostomy, or an ileostomy. If his gut is obstructed, do a bypass procedure, because intestinal obstruction is one of the most horrible ways to die. For further management, see Chapter 33.