eMedicine Specialties > Emergency Medicine > Gastrointestinal

Obstruction, Large Bowel

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

Introduction

Background

Large-bowel obstruction (LBO) is an emergency condition that requires early identification and intervention. The etiology of LBO is age dependent.

LBO can result from either mechanical interruption of the flow of intestinal contents or by the dilation of the colon in the absence of an anatomic lesion (pseudo-obstruction).

Distinguishing between a true mechanical obstruction and a pseudo-obstruction is important, as the treatment differs.1

Pathophysiology

The prevalence of mechanical large-bowel obstruction (LBO) increases with age as does it main causes, colon cancer and diverticulitis. Sigmoid volvulus and cecal volvulus are also potential causes of this disorder.2

Large-bowel obstruction. Abdominal (KUB) radiogra...

Large-bowel obstruction. Abdominal (KUB) radiograph depicting massive dilation of the colon due to a cecal volvulus. Radiograph courtesy of Charles McCabe, MD.

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Large-bowel obstruction. Abdominal (KUB) radiogra...

Large-bowel obstruction. Abdominal (KUB) radiograph depicting massive dilation of the colon due to a cecal volvulus. Radiograph courtesy of Charles McCabe, MD.

 

Mechanical obstruction of the large bowel causes bowel dilation above the obstruction. This causes mucosal edema and impaired venous and arterial blood flow to the bowel. Bowel edema and ischemia increase the mucosal permeability of the bowel, which can lead to bacterial translocation, systemic toxicity, dehydration, and electrolyte abnormalities. Bowel ischemia can lead to perforation and fecal soilage of the peritoneal cavity.

The pathophysiology of acute colonic pseudo-obstruction (ACPO) is not clear, but it is thought to result from an autonomic imbalance, which results from decreased parasympathetic tone or excessive sympathetic output.1

ACPO usually occurs in the setting of a wide range of medical or surgical illnesses. If untreated, colonic ischemia or perforation can occur. This syndrome is characterized by a loss of peristalsis and results in the accumulation of gas and fluid in the colon. The right colon and cecum are most commonly involved. The risk of perforation for ACPO ranges from 3-15%. The mortality rate is 15% with early care; this increases to 36% if colonic ischemia or perforation develops.3

Clinical

History

  • Obtain history of bowel movements, flatus, obstipation (ie, no gas or bowel movement), and symptoms.
    • Major complaints include abdominal distention, nausea, vomiting, and crampy abdominal pain.
    • Abrupt onset of symptoms makes an acute obstructive event (eg, cecal or sigmoid volvulus) a more likely diagnosis.
    • History of chronic constipation, long-term cathartic use, and straining at stools implies diverticulitis or carcinoma.
    • Change in caliber of stools strongly suggests carcinoma. When associated with weight loss, likelihood of carcinoma increases.
  • 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.
  • Large-bowel obstruction prior to perforation
    • Obstruction that dilates the colon causes vague, visceral abdominal cramps. Pain receptors sense distention or vigorous contraction.
    • Peritonitis may ensue.
    • When giving a history of obstipation, patients may state that pants or belts are not fitting properly.
    • Intervention is necessary to prevent perforation.
  • 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 are similar to LBO and usually develop over 3-7 days, or less commonly, over 24-48 hours.
    • Eighty-three percent of patients complain of mild/moderate pain, which is typically diffuse and colicky in nature.
    • Nausea and vomiting are not predominate complaints.
    • Fever may be present in the setting of colonic ischemia or perforation.
  • Pneumaturia, mucinuria, or fecaluria may occur when fistulization of the sigmoid colon to the bladder occurs secondary to diverticulitis or cancer.

Physical

  • Abdominal distention may be significant in patients with a large-bowel obstruction.

    • Bowel sounds may be normal early on but usually become quiet.
    • Abdomen is hyperresonant to percussion.
  • Palpation of the abdomen reveals 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). Sigmoid diverticulitis and a perforated sigmoid secondary to carcinoma are clinically difficult to differentiate.
  • Guaiac-positive stool may be seen with carcinoma or diverticulitis.
  • 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.

Causes

  • Approximately 60% of mechanical large-bowel obstructions (LBOs) are caused by malignancies, 20% are caused by diverticular disease, and 5% are the result of colonic volvulus.4,1,5
    • Obstructions caused by tumors tend to have a gradual onset and result from tumor growth narrowing the colonic lumen.


Large-bowel obstruction. Contrast study demonstra...

Large-bowel obstruction. Contrast study demonstrates colonic obstruction at the level of the splenic flexure, in this case due to carcinoma. Radiograph courtesy of Charles McCabe, MD.

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Large-bowel obstruction. Contrast study demonstra...

Large-bowel obstruction. Contrast study demonstrates colonic obstruction at the level of the splenic flexure, in this case due to carcinoma. Radiograph courtesy of Charles McCabe, MD.

    • Diverticulitis is associated with muscular hypertrophy of the colonic wall. Repetitive episodes of inflammation cause the colonic wall to become fibrotic and thickened, leading to luminal narrowing.
    • Colonic volvulus results when the colon twists on its mesentery. This impairs the venous drainage and arterial inflow. Symptoms are usually abrupt.
      • Sigmoid volvulus typically occurs in older, debilitated individuals with a history of chronic constipation, or those living in an institutionalized setting.


Large-bowel obstruction. Massive dilation of the ...

Large-bowel obstruction. Massive dilation of the colon due to a sigmoid volvulus. Radiograph courtesy of Charles McCabe, MD.

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Large-bowel obstruction. Massive dilation of the ...

Large-bowel obstruction. Massive dilation of the colon due to a sigmoid volvulus. Radiograph courtesy of Charles McCabe, MD.

      • Cecal volvulus is caused by a congenital defect in the peritoneum, which results in inadequate fixation of the cecum, and increased cecal mobility.1 Patients usually present with this disorder in the sixth decade of life.6
    • Intussusception is primarily a pediatric disease. It is estimated that between 5% and 16% of all intussusceptions in the western world occur in adults. Approximately two thirds of adult intussusception cases are caused by tumors. Two main types of intussusception affect the large bowel.
      • Enterocolic intussusceptions involve both the small bowel and the large bowel. These are composed of either ileocolic intussusceptions or ileocecal intussusceptions, depending on where the lead point is located.
      • Colocolic intussusceptions involve only the colon. They are classified as either colocolic or sigmoidorectal intussusceptions.
  • Acute colonic pseudo-obstruction (ACPO), or Ogilvie syndrome, has many etiologies. This disorder is typically seen in elderly patients who are hospitalized with a severe illness. In a retrospective review of more than 1400 cases of ACPO, the most common predisposing conditions were operative and nonoperative trauma (11%), infections (10%), and cardiac disease (10-18%).7,8

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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