Follow-up
Further Inpatient Care
- Resuscitation
- Anatomic and, if possible, pathological characterization of the cause of the obstruction
- Bowel cleansing if the obstruction is incomplete
- Surgical relief of the obstruction
- Dictated by the demands of postoperative convalescence
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
- Pain medicines generally should be avoided preoperatively. If the pain is sufficiently severe to merit use of significant analgesics, peritonitis, rather than large bowel obstruction, should be considered as the first diagnosis.
- Oral laxatives are contraindicated in patients with complete large bowel obstruction.
- A slow preoperative mechanical bowel preparation is indicated for patients who have incomplete obstruction, provided the patient can tolerate it.
- The author's preference is for polyethylene glycol solutions, such as GO-LYTELY, because they avoid issues of fluid and electrolyte imbalance. The fluid should be administered slowly (rather than given in the standard manner of 1 gal over 4 h), and the patient should be observed for abdominal cramping and intolerance.
Transfer
- Transfer to another facility is indicated if adequate surgical management or backup is not available.
- Prior to transfer, the patient should be adequately hydrated and resuscitated.
Deterrence/Prevention
- Patients with an endoscopically reduced sigmoid volvulus should be offered elective surgical procedures, including sigmoid resection or fixation, because of the high risk of recurrence.
- Aggressive screening for colorectal cancer in individuals who are older than 50 years or who have a strong family history of colorectal cancer, as indicated by current guidelines, should reduce the future incidence of malignant colonic obstruction.
- See related CME at Guidelines Issued for Early Detection of Colorectal Cancer.
Complications
- Peritonitis from bowel perforation secondary to overstrenuous attempts at reduction of volvulus or intussusception or injudicious attempts to dilate or stent an unsuitable colonic obstruction
- Misdiagnosis of an ileus secondary to intra-abdominal infection as large bowel obstruction, with consequent delay in treatment
- Intra-abdominal abscess from anastomotic leakage
- Pneumonia from aspiration during emesis
- Dehydration
- Electrolyte disturbance
Prognosis
- Prior to surgical decompression, the patient's overall medical condition and presence of any comorbidities that define surgical risk determine the prognosis.
- After surgical decompression, prognosis is determined by the underlying disease.
Patient Education
- For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education article Constipation in Adults.
Miscellaneous
Medicolegal Pitfalls
- Failure to recognize an incarcerated hernia as the cause of obstruction
- Confusing large bowel obstruction with obstipation and managing it nonoperatively for a prolonged period
- Confusing peritonitis and ileus with large bowel obstruction, resulting in delayed surgery
More on Colonic Obstruction |
| Overview: Colonic Obstruction |
| Differential Diagnoses & Workup: Colonic Obstruction |
| Treatment & Medication: Colonic Obstruction |
 Follow-up: Colonic Obstruction |
| References |
| « Previous Page |
References
Nagata K, Ota Y, Okawa T, et al. PET/CT colonography for the preoperative evaluation of the colon proximal to the obstructive colorectal cancer. Dis Colon Rectum. Jun 2008;51(6):882-90. [Medline].
Small AJ, Baron TH. Comparison of Wallstent and Ultraflex stents for palliation of malignant left-sided colon obstruction: a retrospective, case-matched analysis. Gastrointest Endosc. Mar 2008;67(3):478-88. [Medline].
van Hooft JE, Fockens P, Marinelli AW, et al. Early closure of a multicenter randomized clinical trial of endoscopic stenting versus surgery for stage IV left-sided colorectal cancer. Endoscopy. Mar 2008;40(3):184-91. [Medline].
Ripamonti CI, Easson AM, Gerdes H. Management of malignant bowel obstruction. Eur J Cancer. May 2008;44(8):1105-15. [Medline].
Mukai M, Tanaka A, Tajima T, et al. Two-port hand-assisted laparoscopic surgery for the 2-stage treatment of a complete bowel obstruction by left colon cancer: a case report. Oncol Rep. Apr 2008;19(4):875-9. [Medline].
Caceres A, Zhou Q, Iasonos A, et al. Colorectal stents for palliation of large-bowel obstructions in recurrent gynecologic cancer: an updated series. Gynecol Oncol. Mar 2008;108(3):482-5. [Medline].
De Giorgio R, Stanghellini V, Barbara G, et al. Prokinetics in the treatment of acute intestinal pseudo-obstruction. IDrugs. 2004/02;7(2):160-5.
de Gregorio MA, Mainar A, Tejero E, et al. Acute colorectal obstruction: stent placement for palliative treatment--results of a multicenter study. Radiology. Oct 1998;209(1):117-20. [Medline].
Deen KI, Madoff RD, Goldberg SM, et al. Surgical management of left colon obstruction: the University of Minnesota experience. J Am Coll Surg. Dec 1998;187(6):573-6. [Medline].
Fan YB, Cheng YS, Chen NW, et al. Clinical application of self-expanding metallic stent in the management of acute left-sided colorectal malignant obstruction. World J Gastroenterol. Feb 7 2006;12(5):755-9. [Medline].
Forloni B, Reduzzi R, Paludetti A, et al. Intraoperative colonic lavage in emergency surgical treatment of left-sided colonic obstruction. Dis Colon Rectum. Jan 1998;41(1):23-7. [Medline].
Isbister WH, Prasad J. Emergency large bowel surgery: a 15-year audit. Int J Colorectal Dis. 1997;12(5):285-90. [Medline].
Lopez-Kostner F, Hool GR, Lavery IC. Management and causes of acute large-bowel obstruction. Surg Clin North Am. Dec 1997;77(6):1265-90. [Medline].
Losanoff JE, Basson MD. Amyand hernia: what lies beneath--a proposed classification scheme to determine management. Am Surg. Dec 2007;73(12):1288-90. [Medline].
Reemst PH, Kuijpers HC, Wobbes T. Management of left-sided colonic obstruction by subtotal colectomy and ileocolic anastomosis. Eur J Surg. Jul 1998;164(7):537-40; discussion 541-2. [Medline].
Sakorafas GH, Peros G. Obstructing sigmoid cancer in a patient with a large, tender, non-reducible inguinal hernia: the obvious diagnosis is not always the correct one. Eur J Cancer Care (Engl). Jan 2008;17(1):72-3. [Medline].
Schermer CR, Hanosh JJ, Davis M, et al. Ogilvie's syndrome in the surgical patient: a new therapeutic modality. J Gastrointest Surg. Mar-Apr 1999;3(2):173-7. [Medline].
[Best Evidence] Sgouros SN, Vlachogiannakos J, Vassiliadis K, et al. Effect of polyethylene glycol electrolyte balanced solution on patients with acute colonic pseudo obstruction after resolution of colonic dilation: a prospective, randomised, placebo controlled trial. Gut. May 2006;55(5):638-42. [Medline].
Stefanidis D, Brown K, Nazario H, et al. Safety and efficacy of metallic stents in the management of colorectal obstruction. JSLS. Oct-Dec 2005;9(4):454-9. [Medline].
Suri S, Gupta S, Sudhakar PJ, et al. Comparative evaluation of plain films, ultrasound and CT in the diagnosis of intestinal obstruction. Acta Radiol. Jul 1999;40(4):422-8. [Medline].
Turegano-Fuentes F, Echenagusia-Belda A, Simo-Muerza G, et al. Transanal self-expanding metal stents as an alternative to palliative colostomy in selected patients with malignant obstruction of the left colon. Br J Surg. Feb 1998;85(2):232-5. [Medline].
Turegano-Fuentes F, Munoz-Jimenez F, Del Valle-Hernandez E, et al. Early resolution of Ogilvie's syndrome with intravenous neostigmine: a simple, effective treatment. Dis Colon Rectum. Nov 1997;40(11):1353-7. [Medline].
Further Reading
Keywords
colonic obstruction, colon obstruction, large bowel obstruction, bowel obstruction, obstructed bowels, volvulus, incarcerated hernia, stricture, obstipation, complete bowel obstruction, partial bowel obstruction, constipation, colostomy, ileostomy
