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Little Black Book of Gastroenterology

4.14 Bowel Obstruction


Lancet 1999;353:1476; Adv Surg 1997;31:1
Pathophys: Most episodes of bowel obstruction occur in the small intestine, and most of those
are due to adhesions. While adhesions can be inflammatory, most of them are postoperative.
Nearly a third of pts undergoing laparotomy are readmitted over the following 10 years with
adhesion-related complications (Lancet 1999;353:1476). Pts having colonic resections and pelvic
surgery are at higher risk. Other causes of obstruction include herniae, malignancy, Crohn's,
radiation, bezoars, intussusception, gallstone ileus (obstruction by a gallstone), and volvulus. In
the colon, malignancy is the most common cause of obstruction.
Obstruction results in distension of bowel loops, edema of the bowel wall, and third spacing of
intravascular volume. The distended, edematous bowel is more likely to twist, creating a closed-
loop obstruction. This twist occludes the arterial blood supply and causes gangrene of the bowel
(strangulation).
Sx: Colicky abdominal pain is the typical presenting sx (70%), though pain may become more
steady in nature as obstruction persists (Scand J Gastroenterol 1994;29:715). Anorexia and
nausea are frequently seen. Vomiting is common, especially in high-grade or proximal
obstructions. Diarrhea may result transiently as the downstream bowel is emptied.
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Si: Abnormal sounds and distension are the best physical exam evidence of obstruction (Scand J
Gastroenterol 1994;29:715). Usually bowel sounds are high pitched, but if seen late in the illness
or if strangulation has occurred, bowel sounds may be diminished or absent. Distension may be
absent if the obstruction is proximal. Peritoneal signs (percussion and rebound tenderness,
involuntary guarding) suggest the possibility of strangulation. Inguinal and femoral hernias
should be excluded by exam.
Crs: A large proportion of pts with partial obstruction resolve nonoperatively. Of those with
complete obstruction 8-23% will have strangulation at surgery. Recurrence rates are high (34%
at 4 years, 42% at 10 years) except if obstruction is due to hernia. Recurrence rates are lower in
pts treated operatively (29% vs 53%) and mortality rates range from 2-12% (Arch Surg
1993;128:765).
Cmplc: Strangulation with subsequent perforation, and intra-abdominal sepsis.
Diff Dx: Gastroenteritis (pain, nausea, vomiting), ileus, and pseudo-obstruction (p 210).
Lab: Leukocytosis is usually mild, and wbc >15,000/mm
3
should raise the question of ischemia.
Electrolyte abnormalities and azotemia should be sought and corrected.
X-ray: (AJR Am J Roentgenol 1997; 168:1171) Plain films of the abdomen are routine in
suspected bowel obstruction. Air fluid levels in dilated small bowel are diagnostic but are seen in
only 50-60% of cases. About 20-30% of films are equivocal, and 10-20% are normal and
misleading. The x-ray can be normal if loops are all fluid filled or if the obstruction is proximal.
An upright chest film centered on the diaphragm may show free air due to perforation.
CT scan is very helpful in diagnosing obstruction (AJR Am J Roentgenol 1994;162:255). It can
be used to visualize air or
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fluid-filled loops without aid of oral contrast, which can be difficult to give due to vomiting. Iv
contrast should be used. Sometimes the point of obstruction can be seen. If the obstruction is
caused by an extrinsic process such as mass or inflammation, CT can identify it. CT signs have
also been identified for evidence of strangulation that may prompt earlier surgery.
Other radiographic studies may be needed. An unprepped gastrograffin enema is an efficient way
to evaluate suspected large bowel obstruction and may be therapeutic if the obstruction is due to
fecal impaction. In the acute setting, barium studies (SBFT or enteroclysis) are of limited value
but may be of use after an episode of obstruction has spontaneously resolved. Ultrasound may be
of some value in determining that obstruction exists (seeing dilated loops) but usually does not
reveal the cause (Radiology 1993;188:649). It may be of most value in pregnant pts.
Rx: Third space fluid losses and electrolyte abnormalities must be rapidly corrected. Pts with a
specific cause of obstruction (such as mass or hernia) and those with no prior surgery that might
have led to adhesions should undergo laparotomy. Prompt surgery is needed if there is evidence
of compromised bowel (peritoneal signs, toxicity, evidence of perforation). In obstruction due to
suspected adhesions, an attempt should be made to avoid operation. A nasogastric tube should be
placed to decompress the stomach and small bowel. Longer tubes are of no proven additional
value (Am J Surg 1995;170:366). Most pts who resolve without operation begin to do so within
24-48 hours, though some experts wait as long as 5 days before giving up and proceeding with
laparotomy (Am J Surg 1993;165:121). Those with partial obstructions are at low risk for
strangulation. Pts are monitored frequently with physical exam for signs of compromised bowel
and undergo laparotomy urgently if they develop. The role of laparoscopy is not yet defined
(Surg Endosc 2000;14:154). Intraperitoneal
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bioresorbable membranes have been used to prevent recurrent adhesions (J Am Coll Surg
1996;183:297).

4.15 Colonic Volvulus
Adv Surg 1996;29:131
Epidem: Incidence is lowest in Western nations (1-3/100,000/yr) and higher in developing
nations (12/100,000/yr in Ghana). The mean age of presentation is 60-70 in the West and 40-60
in developing nations. Institutionalized pts with chronic constipation are at high risk.
Pathophys: A volvulus is an axial twist of part of the gi tract around the mesentery, resulting in a
complete or partial obstruction. Most volvulus occur in the sigmoid or the cecum. A redundant
sigmoid colon contributes to sigmoid volvulus. A cecal mesentery that is not well attached to the
posterior abdominal wall predisposes to cecal volvulus. Volvulus in other segments of colon is
rare.
Sx: The presentation is that of bowel obstruction with distension, pain, and constipation. Since
the condition may spontaneously revert, pts may have a hx of prior similar episodes.
Si: Distension is striking and is often asymmetric. Peritoneal signs are absent unless ischemia has
complicated the volvulus.
Crs: Mortality is high in Western countries (14%) (where volvulus occurs in the medically unfit)
and is higher in those needing emergency operations (25%) (Dis Colon Rectum 2000;43:414).
Cmplc: Intestinal gangrene from loss of vascular supply carries a 50% mortality (Dis Colon
Rectum 1982;25:494).
Diff Dx: The differential includes mechanical obstruction from malignancy or diverticular
disease and pseudo-obstruction (J Am Coll Surg 1996;183:297).
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X-ray: Plain films are diagnostic in 80% of sigmoid volvulus, with findings of a distended
sigmoid, two air fluid levels, and a bird beak deformity. Cecal volvulus can be more difficult to
identify. Contrast studies can identify the bird beak deformity and may be therapeutic by
decompressing the volvulus.
Rx: In sigmoid volvulus without clinical evidence of perforation or ischemia, sigmoidoscopy is
the initial therapeutic approach. As the scope passes by the twist, there is a large and sometimes
spectacular rush of gas as decompression occurs. The mucosa is then inspected for evidence of
ischemia. A decompression tube is left behind, which may help splint the bowel in place.
Surgery is indicated in fit pts because the risk of recurrence is high. Operations that tack bowel
down (sigmoidopexy, suturing the sigmoid serosa to the posterior abdominal wall) are associated
with higher recurrence rates (30-80%) than those that involve a bowel resection (Dis Colon
Rectum 2000;43:414). However, resection carries greater operative risk. Extraperitonealization
of the sigmoid without resection has been described as an alternative, with acceptable mortality
and low recurrence rate (Dis Colon Rectum 1998;41:381). Cecal volvulus usually requires
surgical rx.
4.16 Acute Colonic Pseudo-Obstruction
Gastro Endosc 2002;56:789; Annu Rev Med 1999;50:37
Epidem: This disorder (aka Ogilvie's syndrome) has been associated with a long list of
conditions, notably orthopedic surgery, narcotics, anticholinergics, and chemotherapy. Many
neurologic, renal, cardiac, obstetrical, and lung disorders have been described in association with
this disorder. Malignancy, metabolic, and endocrine disorders may be present.
Pathophys: In pseudo-obstruction, the radiographs suggest mechanical obstruction, but no
mechanical obstruction is present. The
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pathogenesis of acute colonic pseudo-obstruction is unknown. It is thought to represent an
imbalance of sympathetic and parasympathetic stimulation.
Sx: The usual presentation is progressive abdominal distension that occurs over days in a
hospitalized pt. Pain, nausea, and vomiting are variable features.
Si: Tympany to percussion and visible distension. Bowel sounds are present and may be high
pitched.
Crs: The course is largely dependent on the underlying illness.
Cmplc: Perforation rates of up to 3% have been reported, and perforation is associated with a
50% mortality.
Diff Dx: The major differential point is that of mechanical obstruction. In pts with a typical
clinical background, conservative measures can be employed without further evaluation. In those
pts who fail to improve within 24 hours, endoscopy or unprepped, water-soluble contrast enema
should be obtained to rule out mechanical obstruction.
Lab: Electrolytes, Ca
++
, Mg
++
, PO
4
, BUN/Cr, 02 saturation, and a CBC are routinely obtained.
Leukocytosis is a finding worrisome for perforation.
X-ray: KUB shows a distended colon. Cecal diameter should be measured, because the risk of
perforation becomes higher when cecal diameter reaches 10-12 cm. KUB is repeated daily until
the findings resolve. A water-soluble contrast enema should be considered in all pts prior to the
use of neostigmine to rule out a mechanical obstruction (Nejm 1999;341:1622; discussion 1623).
Endoscopy: See Rx.
Rx: (Nejm 1999;341:192) Metabolic abnormalities such as acidosis, hypokalemia, hypocalcemia,
hypomagnesemia, and volume depletion should be corrected. Drugs that inhibit motility (eg,
narcotics, anticholinergics) should be stopped. Frequent turning
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of pts (or log rolling, spending 15 minutes in each of decubitus, prone, and supine positions) can
be effective. An NGT and/or a rectal tube is inserted. If the pts fail to improve or worsen in the
first 24 hours and if there are no contraindications, neostigmine should be used. A dose of 2 mg
iv provides decompression within minutes (Nejm 1999;341:137). It should be given with the pt
supine, on the bedpan, and on a cardiac monitor because of the risk of bradycardia, which may
require atropine. Abdominal pain, salivation, and vomiting may occur. For pts who relapse or fail
to respond to this intervention, colonoscopic decompression with a tube placed in the right colon
is usually advocated (Gastrointest Endosc 1996;44:144). Surgery is indicated for those who have
clinical evidence of perforation, peritonitis, or who fail all other rx.
4.17 Chronic Intestinal Pseudo-Obstruction
Annu Rev Med 1999;50:37; Gut 1997;41:675
Epidem: Rare.
Pathophys: This disorder is defined by the radiographic picture of chronic obstruction in the
absence of a mechanical obstruction. A variety of underlying diseases may result in a chronic
defect in gut motility. In most pts, the disorder is secondary to diseases such as scleroderma,
amyloid, or a paraneoplastic syndrome associated with malignancy. In some pts, there is a defect
in enteric smooth muscle (hollow visceral myopathy), and in others there is a defect of the
enteric nervous system.
Sx: The predominant sx are pain, distension, vomiting, constipation, and diarrhea. A family
history may suggest one of the primary disorders.
Si: Distension or signs of an associated collagen-vascular, or neurologic disease.
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Crs: The course in pts with the secondary form depends on the associated disorder. The course in
those with primary gut myopathy or neuropathy is that of chronic illness, pain, and malnutrition.
Cmplc: Bacterial overgrowth, malnutrition.
Diff Dx: Mechanical obstruction and mucosal disease such as Crohn's must be excluded.
Lab: A CMP, thyroid studies, Mg
++
, and CBC are obtained. In specialty centers, motility and
transit studies may be performed. Fibrosis and other morphologic abnormalities are seen on full
thickness biopsies or resected specimens.
X-ray: Plain films show dilated bowel, giving a radiographic impression of obstruction though
no mechanical obstruction exists.
Rx: Promotility agents are usually ineffective. Therapy is supportive with nutrition and rx of
bacterial overgrowth. Surgery is indicated in severe, symptomatic distension in order to place a
decompressive tube enterostomy (Am J Gastro 1995;90:2147). When there is localized pseudo-
obstruction, resection or bypass can be performed.