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).