Introduction
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.
Mortality/Morbidity
- Large bowel obstruction is a surgical entity.
- The morbidity and mortality often are related to the surgical procedure used to relieve the colonic obstruction and, in the long term, to the underlying disease that caused the obstruction.
Age
- Colonic obstruction is most common in elderly individuals because the incidence of neoplasms and other causative diseases is higher in this population.
- In neonates, colonic obstruction may be caused by an imperforate anus or other anatomic abnormalities. Obstruction also may be secondary to meconium ileus.
- Hirschsprung disease resembles colonic obstruction in the pediatric population.
Clinical
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:
- Neoplasm (benign or malignant)
- Stricture (diverticular or ischemic)
- Incarcerated hernia
- Volvulus
- Intussusception, usually with an identifiable anatomic abnormality in adults but not in children
- Impaction or obstipation
- Gallstone ileus
More on Colonic Obstruction |
 Overview: Colonic Obstruction |
| Differential Diagnoses & Workup: Colonic Obstruction |
| Treatment & Medication: Colonic Obstruction |
| Follow-up: Colonic Obstruction |
| References |
| Next Page » |
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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
