Colonic Obstruction Follow-up

• 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

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.

• 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 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.

• 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.

• 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

• 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.

• For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education article Constipation in Adults.