Bowel Obstruction

Bowel Obstruction

• Timothy M. Farrell

• Department of Surgery

• UNC-Chapel Hill

Small Bowel Obstruction

Small Bowel Obstruction Signs & Symptoms

• Intermittent, Crampy Abdominal Pain

• Nausea / Emesis

• Distension

• Obstipation

• Peristaltic Rushes on Auscultation

• Focal Tenderness

• Diffuse Peritonitis

Small Bowel Obstruction Etiologies

• Adhesions

• Malignancy

• External or Internal Hernia

• Volvulus

• Crohn’s Disease

• Intra-abdominal Abscess

Small Bowel Obstruction Etiologies (Cont.)

• Radiation Stricture

• Foreign Body

• Gallstone Ileus

• Meckel’s Diverticulum

• Intramural Hematoma

• Mesenteric Ischemia

• Intussusception

Intestinal Ileus Etiologies

• Postoperative State

• Sepsis

• Electrolyte Imbalance

• Drugs

• Ureteral and Biliary Colic

• Retroperitoneal Hemorrhage

• Spinal Cord Injury

• Myocardial Infarction

• Pneumonia

Small Bowel Obstruction Partial vs. Total

• Why Not Just Wait??

• Potential for Closed Loop Obstruction
• Risk of Ischemia / Perforation (4-6 hrs)

Small Bowel Obstruction Radiologic Evaluation

• Xrays: ? AFLs, ? Free Air, ? Distal Gas

• UGI / SBFT: Identify mechanical obstruction

• Enteroclysis: Independent of gastric emptying

• CT Scan: ? Free Air, ? Pneumatosis, ? Tumor

Small Bowel Obstruction Laboratory Evaluation

• May see hypochloremic, hypokalemic metabolic alkalosis if having frequent emesis (proximal obstruction).

• May see evidence of contraction alkalosis

• Increased H/H, BUN.

• WBC usually normal early.

Small Bowel Obstruction Treatment

• Correct intravascular volume deficit

• NGT vs. Miller-Abbott or Cantor Tubes

• Serial Exams

• Operation if no improvement or if signs of complete (closed loop) obstruction or incarceration.

• Evaluation of Bowel Viability

Small Bowel Obstruction Special Cases

• Early Postoperative SBO

• <1% risk in first month
• Must be considered after 7 days of “ileus” since adhesions become dense in 2-3 weeks.

• Recurrent SBO (5-15%)

• Malignant Obstruction

• Radiation Fibrosis

Large Bowel Obstruction

Large Bowel Obstruction Etiologies

• Colon Cancer

• Diverticulitis

• Extrinsic Cancer

• Fecal Impaction

• Intussusception

• Volvulus

• Incarcerated Hernias

Large Bowel Obstruction Colon Cancer

• 20% of colon cancers present with obstruction

• Left-sided lesions are more prone to obstruct (more narrow lumen, more solid fecal stream)

Large Bowel Obstruction Diagnosis

• Crampy Pain

• Onset may be acute or insidious

• Distension (50-60% have competent ileo-cecal valve and develop severe distension)

• Xrays: 12-14 cm cecum, perforation risk

• Contrast enema: Obstruction vs Oglive’s

• Consider rigid sigmoidoscopy to r/o and treat sigmoid volvulus

Large Bowel Obstruction Treatment

• IVF

• NGT

• Operation

• Emergently if signs of peritonitis / perforation
• Prep bowel if possible

• Is an ostomy necessary?

• Right vs. Left-sided Lesions
• Traditional vs. Newer Attitudes

Oglive’s Syndrome (Colonic Pseudo-Obstruction)

• May mimic mechanical obstruction

• Associated Conditions

• Treatment:

• Rectal tube / enemas /exams (work in most)
• Colonoscopic decompression (80-90% eff.)
• Surgery (Cecostomy vs. Resection) - cecum >12 cm or peritoneal signs