Large-Bowel Obstruction Clinical Presentation
- Author: Christy Hopkins, MD, MPH; Chief Editor: Steven C Dronen, MD, FAAEM more...
Obtain the patient's history of bowel movements, flatus, obstipation (ie, no gas or bowel movement), and associated symptoms. Attempt to distinguish complete bowel obstruction from partial obstruction, which is associated with passage of some gas or stool. Also inquire about the patient's current and past history in an attempt to determine the most likely cause.
Major complaints in patients with large-bowel obstruction (LBO) include abdominal distention, nausea, vomiting, and crampy abdominal pain. An abrupt onset of symptoms makes an acute obstructive event (eg, cecal or sigmoid volvulus) a more likely diagnosis. A history of chronic constipation, long-term cathartic use, and straining at stools implies diverticulitis or carcinoma.
Changes in the patient's caliber of stools strongly suggest carcinoma. When associated with weight loss, the likelihood of neoplastic obstruction increases.
When giving a history of obstipation, patients may state that pants or belts are not fitting properly.
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.
Complete vs partial obstruction vs ileus
Complete obstruction is characterized by the failure to pass either stool or flatus with an empty rectal vault (unless the obstruction is in the rectum). If the patient has a partial obstruction, the patient appears obstipated but continues to pass some gas or stools. Partial obstructions are a less urgent condition.
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.Pneumaturia, mucinuria, or fecaluria may occur if fistulization of the sigmoid colon to the bladder occurs. This is most often seen in the setting of diverticulitis or cancer.
Large-bowel obstruction is typically characterized by a slow onset of symptoms and may not cause vomiting despite a markedly distended bowel.
Paralytic ileus can be seen in the setting of peritonitis or traumatic injury. Bowel sounds are diminished, and abdominal cramping is less common.
Colonic lesion development history
Right-sided colonic lesions can grow quite large before obstruction occurs because of the large capacity of the right colon and soft stool consistency.
Sigmoid colon and rectal tumors cause colonic obstruction much earlier in their development, because the colon is narrower and the stool is harder in that area.
Obstruction secondary to intussusception
Patients may describe intermittent, crampy abdominal pain that is colicky and relieved by assuming fetal position. Weight loss and fatigue are common.
Obstruction secondary to ACPO
Symptoms of acute colonic pseudo-obstruction (ACPO), or Ogilvie syndrome, are similar to large-bowel obstruction and usually develop over 3-7 days, or less commonly, over 24-48 hours. Abdominal distention is the earliest sign. Late symptoms are similar to those seen with large-bowel obstruction.
Nausea and vomiting are not predominate complaints, but fever may be present in the setting of colonic ischemia or perforation.
Although a complete physical examination is necessary, key elements of the physical examination should focus on a thorough examination of the abdomen, groin, and rectum.
Perform the examination in standard fashion, that is, inspection, auscultation, percussion, and palpation.
Abdominal distention may be significant in patients with a large-bowel obstruction (LBO). The bowel sounds may be normal early on but usually become quiet, and the abdomen is hyperresonant to percussion.
Palpation of the abdomen may reveal tenderness. Fever, severe tenderness, and abdominal rigidity are ominous signs that suggest peritonitis secondary to perforation. The cecum is the area most likely to perforate (following the Laplace law that states, in a long pliable tube, the site of largest diameter requires the least pressure to distend ; thus, in a distal large-bowel obstruction, with a competent ileocecal valve, the cecum is the most common site of perforation. ).
The presence of true involuntary guarding or peritoneal signs may be indicative of another intra-abdominal process, such as an abscess. Rebound tenderness is best elicited by having the patient cough or by shaking the bed.
Sigmoid diverticulitis and a perforated sigmoid secondary to carcinoma are clinically difficult to differentiate. Guaiac-positive stool may be seen with carcinoma or diverticulitis.
A rectal or lower sigmoidal mass may be palpated on rectal examination. An abdominal mass or fullness may be palpated if a tumor is present in the cecum.
Examination of inguinal and femoral regions
Evaluation of the inguinal and femoral regions should be an integral part of the examination in a patient with suspected large-bowel obstruction.
Incarcerated hernias represent a frequently missed cause of bowel obstruction. In particular, colonic obstruction is often caused by a left-sided inguinal hernia with the sigmoid colon incarcerated in the hernia. Any old surgical scar should also be examined for the possibility of an incarcerated incisional hernia.
Digital rectal examination
Perform a digital rectal examination (DRE) 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 (FOBT) should be performed. A positive result may suggest the possibility of a more proximal neoplasm.
Kahi CJ, Rex DK. Bowel obstruction and pseudo-obstruction. Gastroenterol Clin North Am. 2003 Dec. 32(4):1229-47. [Medline].
Yeh EL, McNamara RM. Abdominal pain. Clin Geriatr Med. 2007 May. 23(2):255-70, v. [Medline].
Saunders MD. Acute colonic pseudoobstruction. Curr Gastroenterol Rep. 2004 Oct. 6(5):410-6. [Medline].
Fazel A, Verne GN. New solutions to an old problem: acute colonic pseudo-obstruction. J Clin Gastroenterol. 2005 Jan. 39(1):17-20. [Medline].
Dite P, Lata J, Novotny I. Intestinal obstruction and perforation--the role of the gastroenterologist. Dig Dis. 2003. 21(1):63-7. [Medline].
Flasar MH, Goldberg E. Acute abdominal pain. Med Clin North Am. 2006 May. 90(3):481-503. [Medline].
Rabinovici R, Simansky DA, Kaplan O, Mavor E, Manny J. Cecal volvulus. Dis Colon Rectum. 1990 Sep. 33(9):765-9. [Medline].
De Giorgio R, Knowles CH. Acute colonic pseudo-obstruction. Br J Surg. 2009 Mar. 96(3):229-39. [Medline].
Batke M, Cappell MS. Adynamic ileus and acute colonic pseudo-obstruction. Med Clin North Am. 2008 May. 92(3):649-70, ix. [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). 2008 Jan. 17(1):72-3. [Medline].
Jaffe T, Thompson WM. Large-bowel obstruction in the adult: classic radiographic and CT findings, etiology, and mimics. Radiology. 2015 Jun. 275(3):651-63. [Medline].
Saunders MD, Kimmey MB. Systematic review: acute colonic pseudo-obstruction. Aliment Pharmacol Ther. 2005 Nov 15. 22(10):917-25. [Medline].
Atukorale YN, Church JL, Hoggan BL, et al. Self-expanding metallic stents for the management of emergency malignant large bowel obstruction: a systematic review. J Gastrointest Surg. 2015 Oct 26. [Medline].
Geraghty J, Sarkar S, Cox T, et al. Management of large bowel obstruction with self-expanding metal stents. A multicentre retrospective study of factors determining outcome. Colorectal Dis. 2014 Jun. 16 (6):476-83. [Medline].
Xu YS, Song T, Guo YT, et al. Placement of the decompression tube as a bridge to surgery for acute malignant left-sided colonic obstruction. J Gastrointest Surg. 2015 Dec. 19 (12):2243-8. [Medline].
Deen KI, Madoff RD, Goldberg SM, Rothenberger DA. Surgical management of left colon obstruction: the University of Minnesota experience. J Am Coll Surg. 1998 Dec. 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. 2006 Feb 7. 12(5):755-9. [Medline].
Repici A, Adler DG, Gibbs CM, Malesci A, Preatoni P, Baron TH. Stenting of the proximal colon in patients with malignant large bowel obstruction: techniques and outcomes. Gastrointest Endosc. 2007 Nov. 66(5):940-4. [Medline].
Ptok H, Meyer F, Marusch F, et al. Palliative stent implantation in the treatment of malignant colorectal obstruction. Surg Endosc. 2006 Jun. 20(6):909-14. [Medline].
Boyle DJ, Thorn C, Saini A, et al. Predictive factors for successful colonic stenting in acute large-bowel obstruction: a 15-year cohort analysis. Dis Colon Rectum. 2015 Mar. 58 (3):358-62. [Medline].
Takeyama H, Kitani K, Wakasa T, et al. Self-expanding metallic stent improves histopathologic edema compared with transanal drainage tube for malignant colorectal obstruction. Dig Endosc. 2015 Dec 3. [Medline].
Boggs W. Surgery should be last resort for obstructed defecation with rectocele. Medscape Medical News. January 6, 2014. Available at http://www.medscape.com/viewarticle/818698. Accessed: January 13, 2014.
Hicks CW, Weinstein M, Wakamatsu M, Savitt L, Pulliam S, Bordeianou L. In patients with rectoceles and obstructed defecation syndrome, surgery should be the option of last resort. Surgery. 2014 Apr. 155(4):659-67. [Medline].
Douglas D. Palliative surgery for malignant bowel obstruction problematic. Medscape Medical News. February 13, 2014. [Full Text].
Paul Olson TJ, Pinkerton C, Brasel KJ, Schwarze ML. Palliative surgery for malignant bowel obstruction from carcinomatosis: a systematic review. JAMA Surg. 2014 Apr. 149(4):383-92. [Medline].
Frago R, Ramirez E, Millan M, Kreisler E, del Valle E, Biondo S. Current management of acute malignant large bowel obstruction: a systematic review. Am J Surg. 2014 Jan. 207 (1):127-38. [Medline].