Colonic Obstruction

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Background

Large bowel obstruction may be caused by neoplasms or anatomic abnormalities, such as volvulus, incarcerated hernia, stricture, or obstipation. The challenges in managing this condition are distinguishing colonic obstruction from ileus, ruling out nonsurgical causes, and determining the best surgical management.

Pathophysiology

Large bowel obstruction from an anatomic abnormality leads to colonic distention, abdominal pain, anorexia, and, late in the course, feculent vomiting. Persistent vomiting may result in dehydration and electrolyte disturbances.

Epidemiology

Mortality/Morbidity

Age

History

History focuses initially on the failure to pass stools or gas. One should attempt to distinguish complete bowel obstruction from partial obstruction, which is associated with passage of some gas or stools, and from ileus.

Further historical questioning may be directed at the patient's current and past history in an attempt to determine the most likely cause.

Complete obstruction is characterized by the failure to pass either stools or flatus and the presence of an empty rectal vault upon rectal examination, unless the obstruction is in the rectum.

Partial obstruction, in which the patient appears obstipated but continues to pass some gas or stools, is a less urgent condition.

Distinguishing colonic ileus from organic obstruction is important.

Ileus may be suggested by abdominal pain as a dominant feature of the clinical presentation, by peritoneal signs, or by the presence of pronounced fever and leukocytosis.

Large bowel obstruction, or even constipation, may be accompanied by some degree of fever or leukocytosis. Similarly, based on peritoneal signs, distinguishing the tender gas-filled and stool-filled colon observed in organic obstruction from a tender abdomen due to peritonitis is difficult.

Obtaining a thorough history of previous bowel function, abdominal pain, and general systemic issues is important.

History of chronic weight loss and passage of melanotic bloody stools suggest neoplastic obstruction.

Conversely, a history of recurrent left lower quadrant abdominal pain over several years is more consistent with diverticulitis, a diverticular stricture, or similar problems.

A history of aortic surgery suggests the possibility of an ischemic stricture.

Physical

Although a complete physical examination is necessary, key elements of the physical examination should focus on thorough examination of the abdomen, groin, and rectum.

Abdominal examination

Perform the examination in standard fashion, that is, inspection, auscultation, percussion, and palpation.

Large bowel obstruction may be characterized by diminished or, in later stages, absent bowel sounds.

The abdomen is distended and may be tender.

The presence of true involuntary guarding or peritoneal signs should raise the specter of another intra-abdominal process, such as an abscess.

The practice of seeking rebound tenderness is misleading and potentially cruel. Many patients without peritoneal signs complain vigorously after an aggressive rebound maneuver. Seeking tenderness and pain by having the patient cough or by shaking the bed probably is more useful.

Examination of inguinal and femoral regions

This should be an integral part of the examination.

Incarcerated hernias represent a frequently missed cause of bowel obstruction.

In particular, colonic obstruction often is caused by a left-sided inguinal hernia with the sigmoid colon incarcerated in the hernia.

Digital rectal examination

Perform this to verify the patency of the anus in a neonate.

The examination focuses on identifying rectal pathology that may be causing the obstruction and determining the contents of the rectal vault.

Hard stools suggest impaction.

Soft stools suggest obstipation.

An empty vault suggests obstruction proximal to the level that the examining finger can reach.

Fecal occult blood testing should be performed, and a positive result may suggest the possibility of a more proximal neoplasm.

Causes

Causes of adult large bowel obstruction include the following:

Laboratory Studies

Imaging Studies

Other Tests

Procedures

Endoscopic reduction of volvulus

This procedure is indicated for sigmoid volvulus when peritoneal signs are absent, which would imply dead bowel or perforation. It also is indicated when evidence of mucosal ischemia is not present upon endoscopy.

This procedure is not indicated for the less common cecal or transverse colon volvulus.

An experienced person should perform the procedure.

A rigid sigmoidoscope may be used if a flexible instrument is not available. The endoscopist must have sufficient experience with this technique.

Reduction of a volvulus does not imply cure. The sigmoid usually revolvulizes if definitive treatment is not carried out.

These patients generally are admitted, subjected to mechanical bowel preparation, and managed surgically by sigmoid resection, unless contraindications are present.

Barium enema for reduction of intussusception

This is useful and often successful in children in whom a pathological leading point for the intussusception is unlikely.

It should be performed by an experienced radiologist because the risk of perforation is significant.

In adults, typically a pathologic leading point for the intussusception is present. Success is far less likely, and patients still require surgery to deal with their pathology.

Cleansing enemas

Perform these if obstipation is suspected rather than true large bowel obstruction.

Also perform them to prepare the distal colon for endoscopic evaluation.

Endoscopic dilation and stenting of colonic obstruction

This procedure is indicated for colonic near total obstruction through which some small amount of lumen remains.

The procedure may be palliative in a high-risk patient with an unresectable malignancy, accepting a risk of reobstruction of the stent, or preparatory to surgical resection.

In cases in which the stent is deployed prior to surgery, it permits relief of the acute obstruction, resuscitation of the patient, and mechanical bowel preparation prior to a one-stage colonic resection and reanastomosis, thus avoiding temporary or permanent colostomy.

The procedure should be performed only by an endoscopist experienced in such procedures.

Surgical consultation and backup should be available, as the risk of perforation is increased during attempts at such procedures, with a potentially catastrophic result.

Although some experience with stenting has been positive,[2] with some retrospective preference for the Ultraflex stent over the Wallstent because of ease of placement, a recent multicenter trial of endoscopic stenting using the Wallstent versus surgery for stage IV left-sided colorectal cancer was terminated early because of an unacceptably high incidence of perforation.[3] Whether this reflects the technical aspects of the procedure in that study, the particular stent used, or a truly unacceptable incidence of this dangerous complication awaits further study.

Histologic Findings

Histology is of minimal relevance to the acute management of a large bowel obstruction because the obstruction must be relieved regardless of the pathology. However, the histological distinction between malignant and benign causes of obstruction obviously is important for subsequent patient management.

Medical Care

Surgical Care

Consultations

Diet

Medication Summary

Oral laxatives are contraindicated if large bowel obstruction is suspected. If any evidence suggests simple constipation, patients should be managed with transrectal enemas. Tap water, isotonic sodium chloride solution, and a variety of other fluids may be used. In patients with renal insufficiency, the physician should be sensitive to the electrolyte content of the fluid.

Further Inpatient Care

Further Outpatient Care

Care after discharge focuses on surgical convalescence and, if relevant, the need to care for the disease that caused the obstruction. An obstructing colon cancer may require postoperative chemotherapy, depending on the stage of the disease. The patient who is chronically obstipated may need stool softeners.

If the patient has received a colostomy or ileostomy, a decision regarding whether it is temporary or permanent may have been made at the time of discharge, depending on the patient's diagnosis, comorbidity, and postoperative convalescence.

Most patients who retain a rectum are, at least in principle, candidates for reanastomosis at a subsequent stage. Generally, it is performed 2-3 months after the initial operation. Careful counseling and assessment are required before proceeding with the second procedure.

Counseling is directed at the risks of the second procedure because the patient must understand that this surgery is elective and that a colostomy or ileostomy is compatible with a reasonable lifestyle. Often, local ostomy support groups and meeting with other patients with ostomies are helpful at this time.

Patients who had stool incontinence before their first operation, those with substantial surgical risks, and patients with decreased mental status who are cared for in nursing homes may potentially be better off without a reanastomosis.

In addition, the remaining colon, both proximally and distally, must be evaluated radiographically or endoscopically to rule out synchronous colonic lesions, such as neoplasms, because the presence of the large bowel obstruction prevented this from being performed before the first procedure.

Inpatient & Outpatient Medications

Transfer

Deterrence/Prevention

Complications

Prognosis

Author

Marc D Basson, MD, PhD, MBA, FACS, Professor, Chair, Department of Surgery, Assistant Dean for Faculty Development in Research, Michigan State University College of Human Medicine

Disclosure: Nothing to disclose.

Specialty Editors

Juan B Ochoa, MD, Assistant Professor, Department of Surgery, University of Pittsburgh; Medical and Scientific Director, HCN, Nestle Healthcare Nutrition

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

BS Anand, MD, Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

Disclosure: Nothing to disclose.

Alex J Mechaber, MD, FACP, Senior Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine

Disclosure: Nothing to disclose.

Chief Editor

Julian Katz, MD, Clinical Professor of Medicine, Drexel University College of Medicine

Disclosure: Nothing to disclose.

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