Bowel obstruction

Small Bowel

Small Bowel Gas Pattern

Centrally located
Soft tissue across entire lumen
Colon Gas Pattern
Peripheral Located
Mostly not overlapping
Haustra markings

Normal fluid levels

Stomach
Always (upright, decub)

Small bowel
Two or three levels
acceptable (upright, decub)

Large bowel
None normally
(functions to remove fluid)

Large vs small bowel

Large bowel
Peripheral (except RUQ occupied by liver)
Haustral markings dont extend from wall
to wall

Small bowel
Central
Valvulae conniventes extend across lumen
and are spaced closer together

Symptoms:
Colicky abdominal pain, nausea, vomiting, and obstipation.
Continued passage of gas and/or stool beyond 12 hours after onset
of symptoms is characteristic of partial rather than complete
obstruction.
Signs:
Abdominal Distention (Greater the farther distal the obstruction) and
hyperactive, high pitched bowel sounds.
Laboratory Findings: Intravascular volume depletion (consist of
hemoconcentration and electrolyte abnormalities) Mild leukocytosis.
Features of Strangulated Obstruction (Bowel Infarction):
Acute Abdomen,Tachycardia, localized abdominal tenderness, fever,
marked leukocytosis, and acidosis. Serum levels of amylase, lipase,
lactate dehydrogenase, phosphate, and potassium may be elevated.

Abdominal series
1. Radiograph of the abdomen in a supine position
2. Radiograph of the abdomen in an upright position
3. Radiograph of the abdomen in an left lateral decubitus position
4. Radiograph of the chest in an upright position.
Most Specific Finding: The Triad
1. Dilated small-bowel loops (>3 cm in diameter), coiled spring ,
herring bone sign (+)
2. Air-Fluid levels on upright films
3. Paucity of air in the colon.
Sensitivity is 70 to 80%.
Specificity is low, because ileus and colonic obstruction have similar
appearing findings.
Despite some limitations, Plain films remain an important study
because of their widespread availability and low cost.

Flat Abdominal Film

Dilated Loops of Small Bowel

No Air in Colon or Rectum

Upright Abdominal Film

Air - Fluid Levels

Dilated Small Bowel

Computed Tomographic (CT) scanning

Study preformed with oral and IV contrast.
Findings:
1. Discrete transition zone with dilation of bowel proximally and
decompressed distally
2. Intraluminal contrast that does not pass beyond the transition zone
3. Colon containing little gas or fluid.
Strangulation:
Suggested by thickening of the bowel wall, pneumatosis intestinalis (air in
the bowel wall), portal venous gas, mesenteric haziness, and poor uptake
of intravenous contrast into the wall of the affected bowel.
Offers a global evaluation of the abdomen.
Important when intestinal obstruction represents only one possible diagnosis
in all acute abdominal conditions.
Sensitivity 80 to 90% (More sensitive the higher grade obstruction)
Specificity 70 to 90%

 Dilated Loops of Small Bowel with Air-Fluid levels

Area of non-dilated small bowel.
Absence of Air in the Colon.

Pneumatosis Intestinalis
Dilated Loops of SB
Air in Wall of SB
No Air in Colon

SBO or Illeus?

Colonic obstruction may result from

Infectious/inflammatory
Neoplastic
Mechanical pathology
Volvulus
Incarcerated hernia
Stricture
Obstipation
Etiology
Age dependent
Serosa can expand to only a variable but
limited diameter
Rupture and fecal soilage of the
peritoneal cavity can occur

Large Bowel Obstruction

Obstructions caused by:
Tumors
Gradual onset
Normally result from tumor ingrowth into the colonic lumen
Diverticulitis
Muscular hypertrophy of the colonic wall
Repetitive episodes of inflammation
Lumen becomes narrow as the colonic wall becomes fibrotic and
thickened
Intussusception
Commonly involves a tumor
Volvulus
Incarcerated hernia
Ogilvie syndrome
Symptoms and definition
May occur in elderly individuals who abuse cathartics or have
diabetes
Loss of peristalsis.
No obstruction is evident
Colon becomes significantly and dangerously dilated.
Once a contrast evaluation demonstrates nonobstructive colonic
dilation
Management should be pharmacologic
Stimulation of colonic contractions
Intravenous neostigmine has been therapeutic in these
situations

Large Bowel Obstruction

Differential
Colorectal carcinoma
Cecal volvulus
Intussusception
Ogilvie syndrome
Sigmoid volvulus
Abdominal Hernias
Acute Mesenteric Ischemia
Appendicitis
Colon Cancer,
Adenocarcinoma
Colonic Polyps

Constipation
Diverticulitis
Intestinal Perforation
Intestinal Pseudoobstruction: Surgical
Perspective
Megacolon, Chronic
Megacolon, Toxic
Mesenteric Artery Ischemia
Pseudomembranous Colitis
Pseudomembranous Colitis
Rectal Cancer

Large Bowel Obstruction

Workup
Lab Studies:
Obtain blood for a
CBC
Electrolyte levels
PT
Type and crossmatch.
Imaging Studies:
Upright chest radiograph
Will demonstrate free air of perforated
Flat and upright abdominal radiographs
May be diagnostic of sigmoid or cecal volvulus
Kidney bean appearance on the radiograph
CT
Gastrografin
An enema with water-soluble contrast
CT with intravenous and rectal contrast.
Procedures:
Nasogastric tube
If the patient has been vomiting
Intravenous fluid resuscitation (intravascular depletion)
Isotonic saline or Ringer lactate solution

Large Bowel Obstruction

Workup
Lab Studies:
Chemistry
Evaluating the dehydration
Electrolyte imbalance
May occur as a consequence of large bowel obstruction
Ruling out ileus as a diagnosis.

Abnormail anion gap

Should prompt an arterial blood gas and/or a serum lactate level

Routine urine specific gravity should be evaluated.

A decreased hematocrit
With evidence of chronic iron-deficiency anemia
Suggests chronic lower gastrointestinal bleeding
Colon cancer?

Stool guaiac test

Colon cancer

Leukocytosis
Mild leukocytosis may be seen with obstruction or constipation
Severe leukocytosis should prompt reconsideration of the diagnosis
Ileus, secondary to an intra-abdominal or extra-abdominal infection or another
process, is a possibility.

Large Bowel Obstruction

Workup
Imaging Studies:
Upright chest radiograph
Will demonstrate free
air of perforated

Flat and upright

abdominal radiographs
May be diagnostic of
sigmoid or cecal volvulus
Kidney bean
appearance on the
radiograph

Demonstrates dilation of
the small and/or large
bowel and air fluid levels

Sigmoid volvulus

Large Bowel Obstruction

Workup
X-ray findings
Tracing colonic air around the colon, into the left gutter, and down into the rectum or demonstrating an
abrupt cut-off in colonic air suggests the anatomic location of the obstruction
A dilated colon without air in the rectum is more consistent with obstruction
Air in the rectum is consistent with
Obstipation
Iileus
Partial obstruction.
Rectal examinations may cause misleading results
The characteristic bird's beak of volvulus may be seen.
Radiopaque contrast
Imaging of the colon may be performed under the following circumstances.
Perform it if the diagnosis of large bowel obstruction is suspected but not proven.
If differentiation between obstipation and obstruction is required, imaging with contrast is
indicated.
If localization is required for surgical intervention, imaging with contrast is indicated.
Gastrografin (water soluble)
Advantages over barium (first line)
It usually does not cause chemical peritonitis if the patient has colonic perforation.
It has an osmotic laxative effect that may actually wash out an obstipated colon.
Barium enema
If large bowel perforation is ruled out using a Gastrografin study and
More detailed anatomic definition is required (particularly of the right colon)
CT scanning
Generally is not used initially in patients with large bowel obstruction unless a diagnosis has been made
CT scan, particularly with rectal contrast, may demonstrate a mass or evidence of metastatic
disease.
Generally, the findings do not alter management because these patients will be explored and
operatively decompressed, regardless of the CT scan findings.

Large Bowel Obstruction

Pneumoperitoneum

Large Bowel Obstruction

Workup
Procedures:
Endoscopic reduction of volvulus
Indicated for sigmoid volvulus when
Peritoneal signs are absent
Dead bowel or perforation
Evidence of mucosal ischemia is not present upon endoscopy

Rigid sigmoidoscope
May be used if a flexible instrument is not available

Reduction of a volvulus does not imply cure

Sigmoid usually revolvulizes

Patients admitted, subjected to mechanical bowel

preparation, and managed surgically by sigmoid resection

Barium enema for reduction of intussusception

Children
Often successful

Adults
Success is far less likely, and patients still require surgery
to deal with their pathology.

Cleansing enemas
Used if obstipation is suspected rather than true large
bowel obstruction
Also perform them to prepare the distal colon for
endoscopic evaluation.

Large Bowel Obstruction

Treatment
Emergency Department Care
Initial therapy
Directed at patient comfort
Volume resuscitation
Ultimate goal to decompress the large intestine.

Medical Care:
Resuscitation
Correction of fluid and electrolyte imbalance
Nasogastric decompression
Treat temporarily
Obstruction and prevent vomiting and aspiration

Directed primarily at supporting the patient and

treating any comorbid illnesses

Large Bowel Obstruction

Treatment
Surgical Care:
Surgical care is directed at relieving the obstruction
Obstructed lesion is resected.(most cases)
Because the colon has not been cleansed, anastomosis often is risky.
After resection, most surgeons perform a proximal colostomy if the obstruction is on the left side or ileostomy if
it is on the right side.

Diverting proximal colostomy or ileostomy

Substantial comorbidity and surgical risk or in the presence of an unresectable tumor

Diverting transverse loop colostomy

Least invasive procedure for a very ill patient with a left colonic obstruction
Permits relief of the obstruction and further resuscitation without compromising chances for a subsequent
resection

Sigmoid colostomy without resection

Employed in patients with a rectal obstruction that cannot be managed without a combined abdominoperineal
approach.

Cecostomy should not be performed because the diversion is inadequate.

Youth
Some surgeons would consider primary anastomosis, rather than ileostomy, in the right colon,
assuming no intraoperative hypotension, blood loss, or other complications are present.

If nonsurgical therapy employed

i.e. decompressing a volvulus
Deferring surgery temporarily and supporting the patient while the large bowel is cleansed so
that primary anastomosis may be performed more safely is preferable

Large Bowel Obstruction

Treatment
Consultations
Obtain early consultation from a general surgeon
Surgical intervention frequently is indicated

Diet
Complete obstruction NPO
Partial obstruction Clear liquids

Specific cases
Sigmoid volvulus
First choice is sigmoidoscopy with volvulus reduction.
Second choice is sigmoid colectomy.

Cecal volvulus
First choice is hemicolectomy.
Second choice is colonoscopy.

Sigmoid obstruction secondary to diverticulitis or carcinoma

Procedure of choice is a sigmoid resection and Hartman procedure or a sigmoid resection.
Alternative is primary anastomosis.

Obstruction of splenic flexure

First choice is extended hemicolectomy.
Second choice is proximal colostomy with delayed resection.

Large Bowel Obstruction

Treatment
In/Out Patient Meds:
Pain medicines generally should be avoided
preoperatively
If the pain is sufficiently severe to merit use of
significant analgesics
Peritonitis, rather than large bowel obstruction, should
be considered as the first diagnosis.

Oral laxatives are contraindicated in patients

with complete large bowel obstruction.

Chemotherapy?
Temporary or permanent colostomy?

Large Bowel Obstruction

Follow up

Complications:
Perforation
Sepsis
Intra-abdominal abscess
Death

Prognosis:
If treated early, outcome is generally good.
If secondary to carcinoma
Outcome is dependent on the carcinoma
prognosis