eMedicine Specialties > Emergency Medicine > Gastrointestinal

Obstruction, Large Bowel: Differential Diagnoses & Workup

Author: Christy McCowan, MD, MPH, Assistant Professor, Department of Surgery, University of Utah School of Medicine; Clinical Operations Director, Division of Emergency Medicine, University Health Care; Medical Director, University Health Care Transfer Center
Contributor Information and Disclosures

Updated: Jul 16, 2009

Differential Diagnoses

Abdominal Pain in Elderly Persons
Constipation
Diverticular Disease
Obstruction, Small Bowel

Other Problems to Be Considered

Colorectal carcinoma
Cecal volvulus
Intussusception
Ogilvie syndrome
Sigmoid volvulus

Workup

Laboratory Studies

  • Obtain a blood sample for a CBC, electrolyte levels, lactate level, prothrombin time (PT), and type and crossmatch.

Imaging Studies

  • Obtain an upright chest radiograph and flat and upright abdominal radiographs. Chest radiographs demonstrate free air if perforation has occurred; abdominal radiographs may be diagnostic of sigmoid or cecal volvulus (ie, kidney bean appearance on the radiograph).


Large-bowel obstruction. This chest radiograph de...

Large-bowel obstruction. This chest radiograph demonstrates free air under the diaphragm, indicating bowel perforation. Radiograph courtesy of Charles McCabe, MD.

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Large-bowel obstruction. This chest radiograph de...

Large-bowel obstruction. This chest radiograph demonstrates free air under the diaphragm, indicating bowel perforation. Radiograph courtesy of Charles McCabe, MD.

  • Intramural air is an ominous sign that suggests colonic ischemia.
  • The absence of free air does not exclude perforation (this finding may be absent in half of all perforations).
  • Additional contrast studies include an enema with water-soluble contrast (ie, Gastrografin) or CT with intravenous and oral or rectal contrast.


Large-bowel obstruction. Gastrografin study in a ...

Large-bowel obstruction. Gastrografin study in a patient with obstipation reveals colonic obstruction at the rectosigmoid level. Radiograph courtesy of Charles McCabe, MD.

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Large-bowel obstruction. Gastrografin study in a ...

Large-bowel obstruction. Gastrografin study in a patient with obstipation reveals colonic obstruction at the rectosigmoid level. Radiograph courtesy of Charles McCabe, MD.

  • Contrast studies that reveal a column of contrast ending in a "bird's beak" are suggestive of colonic volvulus.


Large-bowel obstruction. Contrast study of patien...

Large-bowel obstruction. Contrast study of patient with cecal volvulus. The column of contrast ends in a "bird's beak" at the level of the volvulus. Radiograph courtesy of Charles McCabe, MD.

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Large-bowel obstruction. Contrast study of patien...

Large-bowel obstruction. Contrast study of patient with cecal volvulus. The column of contrast ends in a "bird's beak" at the level of the volvulus. Radiograph courtesy of Charles McCabe, MD.

Procedures

  • Insert a nasogastric tube if the patient has been vomiting. Intravascular volume usually is depleted, and early intravenous fluid resuscitation with isotonic saline or Ringer lactate solution is necessary.

More on Obstruction, Large Bowel

Overview: Obstruction, Large Bowel
Differential Diagnoses & Workup: Obstruction, Large Bowel
Treatment & Medication: Obstruction, Large Bowel
Follow-up: Obstruction, Large Bowel
Multimedia: Obstruction, Large Bowel
References
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References

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Further Reading

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Keywords

colonic obstruction, large bowel obstruction, obstruction of the large bowel, bowel obstruction causes, bowel obstruction treatment, sigmoid volvulus, straining at stool, cecal volvulus, congenital defect in peritoneum, closed loop obstruction, Gastrografin studies, bird's beak, obstipation, abdominal distention, crampy abdominal pain, rectal tumors, peritonitis, intussusception, pneumaturia, mucinuria, fecaluria, diverticulitis, sigmoid diverticulitis, guaiac-positive stool, rectalmass, lower sigmoidal mass, colon tumors, Ogilvie syndrome, cathartic abuse, diabetes, acute colonic pseudo-obstruction, ACPO

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Contributor Information and Disclosures

Author

Christy McCowan, MD, MPH, Assistant Professor, Department of Surgery, University of Utah School of Medicine; Clinical Operations Director, Division of Emergency Medicine, University Health Care; Medical Director, University Health Care Transfer Center
Christy McCowan, MD, MPH is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Medical Editor

Joseph J Sachter, MD, FACEP, Consulting Staff, Department of Emergency Medicine, Muhlenberg Regional Medical Center
Joseph J Sachter, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Medical Association, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Eugene Hardin, MD, FAAEM, FACEP, Former Chair and Associate Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science; Former Chair, Department of Emergency Medicine, Martin Luther King Jr/Drew Medical Center
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Steven C Dronen, MD, FAAEM, Director of Emergency Services, Director of Chest Pain Center, Department of Emergency Medicine, Ft Sanders Sevier Medical Center
Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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