Bowel Obstruction



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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



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



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