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Large Bowel Obstruction

Katherine Jahnes MD Colorectal Conference St Lukes Roosevelt Hospital Center November 10, 2005

Case A


83 yo male presents with increasing abdominal distention s/p failed sigmoidoscopy/ colonoscopy PMH: Alzheimers Disease, HTN, COPD, glaucoma PSH: pacemaker placement (2001 for bradycardia) and left hip repair (2001) PE: Lungs clear, Abdomen distended but soft with hyperactive BS, TTP diffusely, LLQ>LUQ, no rebound

Case A
 

20 year history of sigmoid volvulus Managed by sigmoidoscopy reduction as outpatient three time a week On day of admission attempts at reduction where unsuccessful Films were obtained

Case A
 

Pt underwent a sigmoid resection Findings:

Sigmoid volvulus with

360 degree turns

around mesentery No sigmoid ischemia Rectum, descending colon healthy and viable Sigmoid resected with primary anastomosis of descending colon to rectum

Case B


  

71 year old female with 2 week history of increasing abdominal distention and no bowel movements PMH: HTN, DM, CVA- residual aphasia, hemiparesis PSH: none PE: Abdomen:

(? Rectal- gas in vault?) NT, Bowel sounds present, tympanitic

Case B


Radiology:

Case B


Operative findings:

Large Bowel Obstruction: Causes




Obstruction- mechanical interruption of the flow of intestinal contents

Volvulus Intussuception Neoplasia (60% of cases) Diverticular Strictures/ IBD




Colorectal CLL

Pseudo-obstruction- dilation of the bowel in the absence of a causative anatomic lesion

PseudoobstructionOgilvies syndrome
 

Distention of colon with signs and symptoms of colonic obstruction without a mechanical cause for the obstruction May be acute or chronic

Acute: usually involves only colon, and more commonly effects patients with chronic renal, respiratory, cerebral or cardiovascular disease Chronic: can effect other parts of the GI tract and tends to recur familial visceral myopathy Diffuse disorder involving autonomic innervation of intestinal wall Associated with: neuroleptics, opiates, metabolic illness, myxedema, DM, uremia, hyperPTH, lupus, scleroderma, Parkinsons, traumatic retroperitoneal hematomas

Primary pseudoobstruction- a motility disorder

Secondary more common.

Associated with sympathetic overactivity suppressing parasympathetics

PseudoobstructionOgilvies syndrome


Diagnosis

Water soluable contrast enema


pseudoobstruction

Can differentiate between mechanical and Can also be used for treatment

Colonoscopy


Initial treatment

NGT Resuscitation Neostigmine (parasympathomimetic)

2.5 mg IV over 3 minutes, with resolution in 10 minutes


Bradycardia is a side effect- atropine must be available

Volvulus


 

Bowel is twisted on mesenteric axis resulting in complete or partial obstruction of the bowel lumen as well as possible vascular impairment Represents about 5% of large bowel obstructions Associated factors-

chronic constipation Aging institutionalization (neuropyschiatric conditions treated with pyschotrophic drugs) in the developing world- possible association with high fiber diets

Characteristically affected bowel is attached to long floppy mesentery fixed to retroperitoneum with a narrow base

Volvulus


Most commonly sigmoid, also right colon and terminal ileum (cecal volvulus), cecum alone (due to a highly mobile cecum called a cecal basculemobile in caudad to cephalad direction), and rarely transverse colon
(photo: barium enema of cecal volvulus, contrast stops at hepatic flexure (arrowhead) and air filled cecum crosses midline of abdomen in LUQ)

Volvulus


Presentation: may be acute or subacute

Sudden onset of severe abdominal pain, vomiting, obstipation Abdomen is distended and tympanitic, often dramatically AXR: markedly dilated colon with an air-fluid level, no gas in rectum CT: mesenteric whirl (at right) Contrast enema: birds beak

Radiographic findings-

Volvulus


Treatment:

Decompression with rectal tube placed via


proctoscope or colonoscopy, with rectal tube left in place for 1-2 days. Often a sudden gush of gas and fluid is released upon decompression Detorsion with colonoscope Sigmoid resection

Hartmanns procedure- emergent if decompression not


successful If decompression is successful; redundant bowel may be removed laparoscopically with primary anastomosis electively (perform colonoscopy first to r/o neoplasm)

Neoplasm


Presentation, treatment, and multivariate anaysis of risk factors for obstructive and perforative colorectal carcinoma

Alvarez et al, American Journal of Surgery


190(3): Sept 2005


A high proportion of colon cancers present as surgical emergencies

Acute obstruction, perforation or both Associated with high morbidity and mortality

Retrospective study

936 consecutive pts underwent surgery for


primary colorectal carcinoma 107 (11.4%) underwent emergency surgery

Indications:

history and physical consistent with peritonitis Intrabdominal abscess with systemic signs of sepsis Clinical signs of obstruction and radiographic evidence thereof not responding to conservative measures within 4 days of hospitalization Study excluded pts with crohns, UC, other types of neoplasm, FAP, h/o operations at outside hospitals, and those not requiring surgery

Of 107 pts, 83 (78%) had complete obstruction and 24 (22%) had perforation

Sigmoid was most common location Comorbid conditions were present in 70% of pts- HTN, CV, COPD, DM. Males predominated in the obstruction group Advance tumor stage was seen in 70% of the obstructing pts and in 54% of the perforated pts Overall/ curative resection rate for obstructed pts was 85/ 83% respectively Mean OR time was 145.7 minutes (SD 57.1) 37% required a blood transfusion

Major postop complications in 33%most frequently GI and pulmonary Factors associated with major complications or mortality included:

Older age, female sex, perioperative blood


transfusion, high ASA or APACHE II score Not associated: location of lesion

Diverticular Strictures/ IBD




Crohns disease

Obstruction most commonly in terminal ileum

Intussusception


 

A segment of bowel and its associated mesentery (intussusceptum) invaginates into the lumen of an adjacent bowel segment (intussuscipiens) Leading cause of bowel obstruction in children May be caused by intramural, mural, or extramural process-

intraluminal mass pulled forward by peristalsis and drags bowel wall with it

Ie pedunculated tumors, inverted meckels diverticulum or appendix

Segment of bowel wall that does not contract normally and the opposite wall rotates the abnormal segment inward causing a kink that acts as a lead point

Ie sessile malignancies, local inflammation, suture lines, lymphoid hyperplasia

Adhesion causes focal area of abnormal peristalsis and kinking

Intussusception
  

In the colon, most frequently are colocolic or sigmoidrectal, and comprise 38% of adult intussusceptions Neoplasia causes 2/3 of cases in adults

Adenocarcinoma, leiomyosarcoma, reticular cell sarcoma, mets

 

Association with AIDS- secondary to lymphoma, Kaposis sarcoma, reative lymphoid hyperplasia, atypical mycobacteria infection, CMV, Camphylobacter enteritis Childhood presenting symptoms: acute presentation with episodic crampy abdominal pain and bloody currant jelly stool Adult presentation: often nonspecific chronic or subacute symptoms- crampy abdominal pain, nausea and vomiting, constipation or diarrhea, rarely bleeding or presence of a palpable mass

Intussusception


Radiology: Abdominal plain film Air crescent sign- intraluminal air between the walls of the the intussusceptum and the intussuscipiens Barium enema Coiled spring appearance (fig 12)- a thin central barium stream with or without a leading mass US More useful in childhood intussusceptions Target or doughnut mass with outer hypoechoic rim Ct Target lesion, whirling pattern of mesenteric vessels May see air bubble between opposed layers of bowel Underlying etiology may be difficult to determine Treatment Surgery Reduce or not?