Bowel Obstruction

Bowel Obstruction
Tad Kim, M.D. Connie Lee, M.D.

Bowel Obstruction

Definitions
Ileus = obstruction 2/2 dysfunctional motility of bowel Mechanical obstruction = 85% SB, 15% large bowel Simple obstruction Closed loop obstruction Strangulation

Bowel Obstruction

SBO: Etiology
Adhesion #1 (80-90% of SBO in pts w/prior abdominal surgery) Hernia #2 overall - #1 cause of SBO in pts w/o prior abdominal surgery Tumor Abscess Hematoma Annular pancreas SMA syndrome Congenital lesions Gallstone ileus Intussusception Foreign body (bezoars, worms, etc) Meconium ileus Malrotation

Bowel Obstruction

Colonic Obstruction: Etiology

Cancer #1 (60%) Volvulus (sigmoid > cecum) Adhesions Hernia UC Diverticulitis Congenital lesions Fecal impaction Adynamic ileus Hirschsprungs Meconium ileus Foreign body

Bowel Obstruction

Age & DDx

Age matters!
Neonate: meconium ileus, Hirschsprungs, malrotation, atresia Child: intussusception, Hirschsprungs Adult: hernia, IBD, CA, diverticular disease Elderly: CA, diverticular disease, Ogilvies

Bowel Obstruction

History & DDx

Proximal obstruction: early bilious vomiting, +flatus/BM Distal obstruction: obstipation, distension, vomiting feculent material (2/2 bacterial overgrowth of SB contents) Pain w/obstruction: begins as cramping pain, changes to continuous severe pain w/strangulation & peritonitis PMHx: remember to ask about cardiac history (arrhythmias, prior MI, Afib - think about intestinal ischemia), IBD, gallstones, cancer PSHx: remember to ask about ostomy output Meds: narcotics (ileus), antipsychotics (ileus), diuretics (hypoK a/w ileus) ROS: recent weight loss (CA, SMA syndrome)

Bowel Obstruction

PE
Start with ABCs Look for surgical scars Bowel sounds Distention: distal obstruction >> proximal Localized tenderness: think peritonitis Look for hernias/masses Do a rectal exam

Bowel Obstruction

Labs
WBC (nml in uncomplicated SBO) CBC (anemia w/CA) BMP (hypoK) Alkalosis (a/w proximal obstruction) Acidosis (a/w bowel infarction) Amylase (may be elevated in SBO)

Bowel Obstruction

Studies
Upright CXR: look for free air Flat and upright/left lateral decubitus: look for dilated bowel loops, air-fluid levels Note: if cecal diameter >12cm, there is a risk of perforation. At 12-14cm, the wall tension > perfusion pressure, increasing risk of necrosis Barium enema UGI series w/SB follow-through CT scan

Bowel Obstruction

SBO: Management
NPO, NGT, Foley, IVF Electrolyte replacement Many partial obstructions will resolve Dont let the sun set on a (complete) SBO Complete bowel obstruction w/concern for strangulation/perforation requires immediate operative intervention (resuscitate first)

Bowel Obstruction

A 72-year-old woman presented with a 2-day history of abdominal pain associated with nausea and vomiting

Dedouit F and Otal P. N Engl J Med 2008;358:1381

Bowel Obstruction

A 48-year-old healthy woman presented with anorexia of 2 days' duration and abdominal pain in the right lower quadrant

Liu K and Lin B. N Engl J Med 2007;356:1152

Bowel Obstruction

A 60-year-old woman presented to the outpatient clinic with vague abdominal discomfort that had developed over the previous several weeks

Jang M and Lee K. N Engl J Med 2008;358:e16

Bowel Obstruction

A 68-year-old man with alcoholic cirrhosis, portal hypertension, ascites, and an umbilical hernia presented to the emergency department after an episode of coughing that was followed by a rush of fluid and fat from the umbilicus

Miryala R and Neilan R. N Engl J Med 2009;360:e32

Bowel Obstruction

Ingested magnets

Avolio L and Martucciello G. N Engl J Med 2009;360:2770

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A 68-year-old man with chronic dysuria and increased urinary frequency presented with three weeks of weakness and fever

Rosmarin D and Tan C. N Engl J Med 2006;355:601

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Radiographic Findings in Body Packers

Traub S et al. N Engl J Med 2003;349:2519-2526

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An 83-year-old woman was hospitalized with nausea, vomiting, and obstipation

Graham J and Rothwell B. N Engl J Med 2004;351:1119

Bowel Obstruction

A previously healthy 102-year-old woman was admitted with abdominal pain and a 3-day history of vomiting

Chan D. N Engl J Med 2006;355:1714

Bowel Obstruction

A 64-year-old woman with ulcerative colitis presented with abdominal pain

Kurer M and Chintapatla S. N Engl J Med 2007;356:1656

Bowel Obstruction

Always start with ABC, resuscitation

Take Home Points

Includes 2 large bore IV, Foley, NGT, monitor

DDX is simple:
SBO: Adhesions, Bulges, Cancer, Crohns LBO: CANCER, Volvulus, Diverticulitis

Labs to assess dehydration & leukocytosis Imaging to assess obstruction & etiology If hypoTN/shock, toxic, or signs of strangulation or ischemia, resusc & OR stat Otherwise, for SBO, NGT & treat etiology LBO is different: really must rule out cancer, colonoscopy plays a larger role than w SBO