eMedicine Specialties > Emergency Medicine > Gastrointestinal

Obstruction, Large Bowel: Treatment & Medication

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

Treatment

Emergency Department Care

Initial therapy includes volume resuscitation, appropriate preoperative antibiotics, gastric decompression, and timely surgical consultation.

Consultations

Obtain early consultation from a general surgeon. Surgical intervention is frequently indicated, depending on the cause of the obstruction.

  • Carcinoma
    • Left colon9
      • Surgical treatment includes resection without primary anastomosis or resection with primary anastomosis and intraoperative lavage.
      • Endoscopically placed expandable metal stents can be used to relieve the LBO, thus allowing for a primary colorectal anastomosis.
    • Right colon
      • Palliative colorectal stents are an option in patients who are poor surgical candidates or have advanced cancer.
      • 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 patient can be optimized for a surgical procedure.10
  • Diverticulitis
    • Patients with persistent obstruction 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.
  • Volvulus
    • Sigmoid volvulus1
      • First choice is sigmoidoscopy with volvulus reduction.
      • Second choice is sigmoid colectomy.
    • Cecal volvulus1
      • The primary treatment is surgical, often a cecopexy needs to be performed to prevent recurrence.
      • Second choice is colonoscopy, due to the high risk of colonic perforation.
  • Intussusception: Adult colonic intussusception is treated with primary colon resection without prior reduction.
  • Acute colonic pseudo-obstruction
    • Underlying precipitant factors must be identified and corrected. If no perforation, pseudo-obstruction is treated with conservative management for the first 24 hours. This includes bowel rest, hydration, and management of underlying disorders.
    • Electrolyte abnormalities should be corrected, and medications that slow colonic motility (eg, narcotics, anticholinergics) should be stopped, if possible.
    • Pharmacologic treatment with neostigmine or colonoscopic decompression may be effective in cases that do not resolve with conservative management. Colonoscopic decompression may be successful in as many as 80% of patients with ACPO.7
    • Surgical intervention is is associated with a high mortality and morbidity and is reserved for refractory cases or cases complicated by perforation.7

Medication

Bowel obstruction frequently necessitates surgical intervention. However, antibiotics should be started in the ED. Coverage must include gram-negative aerobic and gram-negative anaerobic organisms. The following antibiotics do not represent an all-inclusive list.

Antibiotics

Therapy must cover all likely pathogens in the context of this clinical setting.


Clindamycin (Cleocin)

A lincosamide useful to treat serious skin and soft-tissue infections caused by most staphylococcal strains. Also effective against aerobic and anaerobic streptococci, except enterococci.
Inhibits bacterial protein synthesis by inhibiting peptide chain initiation at bacterial ribosome, where it preferentially binds to 50S ribosomal subunit, inhibiting bacterial growth.

Adult

450-900 mg IV q8h

Pediatric

20-40 mg/kg/d IV divided tid/qid

Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects; antidiarrheals may delay absorption

Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibiotic-associated colitis

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis


Metronidazole (Flagyl)

Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Used in combination with other antimicrobial agents (used alone in Clostridium difficile enterocolitis).

Adult

1 g IV loading dose, followed by 0.5 g IV q6h or 1 g IV q12h

Pediatric

Not established

May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity; disulfiram reaction may occur with orally ingested ethanol

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy


Aztreonam (Azactam)

Monobactam that inhibits cell wall synthesis during bacterial growth. Active against gram-negative bacilli. Effective against aerobic gram-negative organisms.

Adult

2 g IV q8h

Pediatric

30 mg/kg IV q6h or q8h

Tetracyclines may reduce effects

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal insufficiency


Cefoxitin (Mefoxin)

Second-generation cephalosporin indicated for management of infections caused by susceptible gram-positive cocci and gram-negative rods.
Effective against aerobic and anaerobic gram-negative organisms.

Adult

2 g IV q8h

Pediatric

80-100 mg/kg/d IV divided tid/qid

Probenecid may increase effects; coadministration with aminoglycosides or furosemide may increase nephrotoxicity (closely monitor renal function)

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged use or repeated treatment; caution in patients with previously diagnosed colitis


Cefotetan (Cefotan)

Second-generation cephalosporin indicated for management of infections caused by susceptible gram-positive cocci and gram-negative rods.

Adult

2 g IV q12h

Pediatric

Not established

Consumption of alcohol within 72 h may produce disulfiramlike reactions; may increase hypoprothrombinemic effects of anticoagulants; coadministration with potent diuretics (eg, loop diuretics) or aminoglycosides may increase nephrotoxicity

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Reduce dosage by one half if CrCl is 10-30 mL/min and by three quarters if CrCl <10 mL/min; bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged or repeated therapy


Imipenem and cilastatin (Primaxin)

Effective against aerobic and anaerobic gram-negative organisms.

Adult

0.5 g IV q6h

Pediatric

<12 years: Not recommended
>12 years: Administer as in adults

Coadministration with cyclosporine may increase adverse CNS effects of both agents; coadministration with ganciclovir may result in generalized seizures

Documented hypersensitivity; children <12 y

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studies in humans; may use if benefits outweigh risk to fetus

Precautions

Adjust dose in renal insufficiency; avoid use in children <12 y


Meropenem (Merrem)

Bactericidal broad-spectrum carbapenem antibiotic that inhibits cell-wall synthesis. Effective against most gram-positive and gram-negative bacteria.

Adult

1 g IV q8h

Pediatric

40 mg/kg IV q8h

Probenecid may inhibit renal excretion of meropenem, increasing meropenem levels

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Pseudomembranous colitis and thrombocytopenia may occur, requiring immediate discontinuation of medication

More on Obstruction, Large Bowel

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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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