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Large-Bowel Obstruction Treatment & Management

  • Author: Christy Hopkins, MD, MPH; Chief Editor: Steven C Dronen, MD, FAAEM  more...
 
Updated: Dec 09, 2015
 

Approach Considerations

Initial therapy in patients with suspected large-bowel obstruction (LBO) includes volume resuscitation, appropriate preoperative broad-spectrum antibiotics, and timely surgical consultation.

A nasogastric tube should be considered for patients with severe colonic distention and vomiting. The patient's intravascular volume is usually depleted, and early intravenous fluid (IVF) resuscitation with isotonic saline or Ringer lactate solution is necessary.

Surgical intervention is frequently indicated, depending on the cause of the obstruction. Closed loop obstructions, bowel ischemia, and volvulus are surgical emergencies.

Transfer to another facility is indicated if adequate surgical management or backup is not available.

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Ileus

Adynamic ileus is treated with conservative measures. This involves correction of fluid and electrolyte imbalances, and treatment of the underlying disorder. Nasogastric decompression may be helpful if the patient is vomiting. Medications that slow colonic motility should be stopped, if possible.

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Acute Colonic Pseudo-Obstruction

If no perforation is present, pseudo-obstruction is treated with conservative management for the first 24 hours. This includes bowel rest, hydration, and management of underlying disorders.

Pharmacologic treatment of acute colonic pseudo-obstruction with neostigmine or colonoscopic decompression may be effective in cases that do not resolve with conservative management.[13] Colonoscopic decompression may be successful in as many as 80% of patients with acute colonic pseudo-obstruction.[8]

Surgical intervention for acute colonic pseudo-obstruction is associated with a high mortality and morbidity. This treatment is reserved for refractory cases or cases complicated by perforation.[8]

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Volvulus

Endoscopic reduction and decompression of a sigmoid volvulus can be performed in the absence of peritoneal signs. This procedure is also contraindicated when evidence of mucosal ischemia is present on endoscopy. An experienced person should perform the procedure.

Recurrence after decompression is as high as 50%; thus, surgical resection is indicated. In healthy patients who have undergone successful decompression, an elective resection should follow. Emergency surgery is indicated in patients with evidence of perforated or ischemic bowel, or if attempts at endoscopic reduction and decompression are not successful.

The preferred treatment for cecal or transverse colon volvulus is surgical resection and anastomosis. Endoscopic detorsion and decompression is an option when the patient is a poor surgical candidate.

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Intussusception

A contrast enema (barium or air) can successfully reduce 60-80% of intussusceptions. It is often successful in children in whom a pathologic leading point for the intussusception is unlikely. This procedure should be performed by an experienced radiologist, because the risk of perforation is significant.

In adults, a pathologic leading point for the intussusception is usually present. Reduction with a contrast enema is far less likely, and patients are more likely to require surgery.

Surgery is indicated if there are signs of peritonitis or bowel perforation, or if attempts at reduction by contrast enema are unsuccessful.

Intussusception may recur in approximately 3% of patients after contrast enema reduction and 1% of patients after operative repair.

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Colonic Masses and Strictures

Endoscopic dilation and stenting of colonic obstruction is helpful in selected cases and may be an alternative to multistage surgery.[14] The procedure may be palliative in a high-risk patient with an unresectable malignancy, or it may be preparatory to surgical resection.[14, 15]

In cases in which the stent is deployed before surgery, this procedure permits relief of the acute obstruction, resuscitation of the patient, and allows for a mechanical bowel preparation before colonic resection and reanastomosis, thus avoiding temporary or permanent colostomy.

Use of a decompression tube may be a feasible, safe, and effective bridge to surgery for acute malignant left-sided colonic obstruction.[16] Surgical treatment of left colon carcinoma includes resection without primary anastomosis or resection with primary anastomosis and intraoperative lavage.[17, 18] Endoscopically placed self-expandable metal stents (SEMS) can be used to relieve the large-bowel obstruction, thus allowing for a primary colorectal anastomosis.[19]

Right colonic obstructions are treated with a right colectomy and a primary anastomosis between the ileum and the transverse colon. Patients with high-risk features for surgery (advanced age, complete obstruction, or severe comorbidities) may benefit from stent placement until the patient can be optimized for a surgical procedure.[20, 21] Palliative colorectal stents are an option in patients who are poor surgical candidates or have advanced cancer.

Endoscopic dilation and stenting of colonic obstruction should be performed only by an endoscopist experienced in such procedures. Surgical consultation and backup should be available, as the risk of perforation is increased during attempts at such procedures, with a potentially catastrophic result. Studies in recent years have identified the following as predictive factors for outcomes after SEMS for large-bowel obstruction:

  • Good prognostic factors: Experienced operators (>10 procedures) using through-the-scope (TTS) endoscopy technique (90.3%) versus use of radiologic placement alone (74.8%) [15] ; the presence of short, malignant strictures with less angulation distal to the obstruction [22]
  • Poor prognostic factors: Older patients with American Society of Anaesthesiologists (ASA) grade of 3 or more for physical status (ie, more ill); the presence of extracolonic and benign strictures [15, 22] (which may have an increased risk of perforation [22]

In addition, SEMS appears to significantly improve histopathologic edema as compared with transanal drainage tube and emergency surgery after failure of decompression for malignant colorectal obstruction.[23]

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Diverticulitis

Patients with persistent obstruction secondary to diverticular disease despite appropriate medical management are treated surgically. Surgical resection follows the same principles as the treatment of carcinomas. Elective colonic resection is offered to patients with recurrent disease.

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Obstructed Defecation Syndrome

For obstructed defecation syndrome (ODS) with rectocele, surgery is a last resort. In a study of 90 rectocele patients with functional constipation, 64 responded to treatment with fiber supplements and biofeedback training with significant improvements in ODS symptoms, including 15 of the 17 patients with rectocele and concomitant intussusception[24, 25] ; the remaining 26 required surgical intervention.

In this study, median cumulative ODS scores improved from 15.0 before treatment to 10.5 after treatment in the medical management group (P < .001) and from 13.5 before surgery to 10.5 after surgery in the surgical intervention group (P < .001).[25]

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Long-Term Monitoring and Prevention

Care after discharge following surgical management of large-bowel obstruction (LBO) focuses on surgical convalescence and, if relevant, the need to care for the disease that caused the obstruction.

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.

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.

In addition, the remaining colon, both proximally and distally, must be evaluated radiographically or endoscopically to rule out synchronous colonic lesions, such as neoplasms.

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Contributor Information and Disclosures
Author

Christy Hopkins, MD, MPH Associate Professor, Department of Surgery, University of Utah School of Medicine; Medical Director, Division of Emergency Medicine, University Health Care

Christy Hopkins, MD, MPH is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Chief Editor

Steven C Dronen, MD, FAAEM Chair, Department of Emergency Medicine, LeConte Medical Center

Steven C Dronen, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Acknowledgements

BS Anand, MD Professor, Department of Internal Medicine, Division of Gastroenterology, Baylor College of Medicine

BS Anand, MD is a member of the following medical societies: American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association, and American Society for Gastrointestinal Endoscopy

Disclosure: Nothing to disclose.

Marc D Basson, MD, PhD, MBA, FACS Professor, Chair, Department of Surgery, Assistant Dean for Faculty Development in Research, Michigan State University College of Human Medicine

Marc D Basson, MD, PhD, MBA, FACS is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Gastroenterological Association, Phi Beta Kappa, and Sigma Xi

Disclosure: Nothing to disclose.

Julian Katz, MD Clinical Professor of Medicine, Drexel University College of Medicine

Julian Katz, MD is a member of the following medical societies: American College of Gastroenterology, American College of Physicians, American Gastroenterological Association, American Geriatrics Society, American Medical Association, American Society for Gastrointestinal Endoscopy, American Society of Law, Medicine & Ethics, American Trauma Society, Association of American Medical Colleges, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Juan B Ochoa, MD Assistant Professor, Department of Surgery, University of Pittsburgh; Medical and Scientific Director, HCN, Nestle Healthcare Nutrition

Disclosure: Nothing to disclose.

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.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

References
  1. Kahi CJ, Rex DK. Bowel obstruction and pseudo-obstruction. Gastroenterol Clin North Am. 2003 Dec. 32(4):1229-47. [Medline].

  2. Yeh EL, McNamara RM. Abdominal pain. Clin Geriatr Med. 2007 May. 23(2):255-70, v. [Medline].

  3. Saunders MD. Acute colonic pseudoobstruction. Curr Gastroenterol Rep. 2004 Oct. 6(5):410-6. [Medline].

  4. Fazel A, Verne GN. New solutions to an old problem: acute colonic pseudo-obstruction. J Clin Gastroenterol. 2005 Jan. 39(1):17-20. [Medline].

  5. Dite P, Lata J, Novotny I. Intestinal obstruction and perforation--the role of the gastroenterologist. Dig Dis. 2003. 21(1):63-7. [Medline].

  6. Flasar MH, Goldberg E. Acute abdominal pain. Med Clin North Am. 2006 May. 90(3):481-503. [Medline].

  7. Rabinovici R, Simansky DA, Kaplan O, Mavor E, Manny J. Cecal volvulus. Dis Colon Rectum. 1990 Sep. 33(9):765-9. [Medline].

  8. De Giorgio R, Knowles CH. Acute colonic pseudo-obstruction. Br J Surg. 2009 Mar. 96(3):229-39. [Medline].

  9. Batke M, Cappell MS. Adynamic ileus and acute colonic pseudo-obstruction. Med Clin North Am. 2008 May. 92(3):649-70, ix. [Medline].

  10. Slam KD, Calkins S, Cason FD. LaPlace's law revisited: cecal perforation as an unusual presentation of pancreatic carcinoma. World J Surg Oncol. 2007 Feb 2. 5:14. [Medline]. [Full Text].

  11. 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].

  12. 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].

  13. Saunders MD, Kimmey MB. Systematic review: acute colonic pseudo-obstruction. Aliment Pharmacol Ther. 2005 Nov 15. 22(10):917-25. [Medline].

  14. 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].

  15. 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].

  16. 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].

  17. Trompetas V. Emergency management of malignant acute left-sided colonic obstruction. Ann R Coll Surg Engl. 2008 Apr. 90(3):181-6. [Medline]. [Full Text].

  18. 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].

  19. 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].

  20. 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].

  21. 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].

  22. 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].

  23. 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].

  24. 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.

  25. 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].

  26. Douglas D. Palliative surgery for malignant bowel obstruction problematic. Medscape Medical News. February 13, 2014. [Full Text].

  27. 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].

  28. 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].

 
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This chest radiograph demonstrates free air under the diaphragm, indicating bowel perforation in a patient with large-bowel obstruction. Radiograph courtesy of Charles J McCabe, MD†.
Abdominal (kidney-ureter-bladder [KUB]) film of a patient with obstipation. Dilatation of the colon is associated with large-bowel obstruction. Radiograph courtesy of Charles J McCabe, MD†.
Gastrografin study in a patient with obstipation reveals colonic obstruction at the rectosigmoid level. Radiograph courtesy of Charles J McCabe, MD†.
Contrast study demonstrates colonic obstruction at the level of the splenic flexure, in this case due to carcinoma. Radiograph courtesy of Charles J McCabe, MD†.
Abdominal (kidney-ureter-bladder [KUB]) radiograph depicting massive dilatation of the colon due to a cecal volvulus. Radiograph courtesy of Charles J McCabe, MD†.
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 J McCabe, MD†.
Massive dilatation of the colon due to a sigmoid volvulus. Radiograph courtesy of Charles J McCabe, MD†.
 
 
 
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