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__NOTOC__ | __NOTOC__ | ||
{{Bowel obstruction}} | {{Bowel obstruction}} | ||
{{CMG}};{{AE}}{{HM}} | |||
==Overview== | |||
The mainstay of treatment for bowel obstruction is surgical. [[Surgery]] is specifically indicated for complicated bowel obstruction. Complications include: Complete obstruction, closed-loop obstruction, [[bowel ischemia]], [[necrosis]], and [[perforation]]. | |||
==Surgery== | |||
*Open [[abdominal surgery]] is commonly performed in small bowel obstruction.<ref name="pmid24649301">{{cite journal |vauthors=Chen JH, Huang TC, Chang PY, Dai MS, Ho CL, Chen YC, Chao TY, Kao WY |title=Malignant bowel obstruction: A retrospective clinical analysis |journal=Mol Clin Oncol |volume=2 |issue=1 |pages=13–18 |year=2014 |pmid=24649301 |pmc=3915666 |doi=10.3892/mco.2013.216 |url=}}</ref><ref name="pmid1727026">{{cite journal |vauthors=Butler JA, Cameron BL, Morrow M, Kahng K, Tom J |title=Small bowel obstruction in patients with a prior history of cancer |journal=Am. J. Surg. |volume=162 |issue=6 |pages=624–8 |year=1991 |pmid=1727026 |doi= |url=}}</ref><ref name="pmid7632142">{{cite journal |vauthors=Tang E, Davis J, Silberman H |title=Bowel obstruction in cancer patients |journal=Arch Surg |volume=130 |issue=8 |pages=832–6; discussion 836–7 |year=1995 |pmid=7632142 |doi= |url=}}</ref><ref name="pmid21595546">{{cite journal |vauthors=Dalal KM, Gollub MJ, Miner TJ, Wong WD, Gerdes H, Schattner MA, Jaques DP, Temple LK |title=Management of patients with malignant bowel obstruction and stage IV colorectal cancer |journal=J Palliat Med |volume=14 |issue=7 |pages=822–8 |year=2011 |pmid=21595546 |doi=10.1089/jpm.2010.0506 |url=}}</ref><ref name="pmid20698371">{{cite journal |vauthors=Oyasiji T, Angelo S, Kyriakides TC, Helton SW |title=Small bowel obstruction: outcome and cost implications of admitting service |journal=Am Surg |volume=76 |issue=7 |pages=687–91 |year=2010 |pmid=20698371 |doi= |url=}}</ref><ref name="pmid18545135">{{cite journal |vauthors=Diaz JJ, Bokhari F, Mowery NT, Acosta JA, Block EF, Bromberg WJ, Collier BR, Cullinane DC, Dwyer KM, Griffen MM, Mayberry JC, Jerome R |title=Guidelines for management of small bowel obstruction |journal=J Trauma |volume=64 |issue=6 |pages=1651–64 |year=2008 |pmid=18545135 |doi=10.1097/TA.0b013e31816f709e |url=}}</ref><ref name="pmid24477929">{{cite journal |vauthors=Paul Olson TJ, Pinkerton C, Brasel KJ, Schwarze ML |title=Palliative surgery for malignant bowel obstruction from carcinomatosis: a systematic review |journal=JAMA Surg |volume=149 |issue=4 |pages=383–92 |year=2014 |pmid=24477929 |pmc=4030748 |doi=10.1001/jamasurg.2013.4059 |url=}}</ref><ref name="pmid3279551">{{cite journal |vauthors=Richards WO, Williams LF |title=Obstruction of the large and small intestine |journal=Surg. Clin. North Am. |volume=68 |issue=2 |pages=355–76 |year=1988 |pmid=3279551 |doi= |url=}}</ref><ref name="pmid8435356">{{cite journal |vauthors=Ripamonti C, De Conno F, Ventafridda V, Rossi B, Baines MJ |title=Management of bowel obstruction in advanced and terminal cancer patients |journal=Ann. Oncol. |volume=4 |issue=1 |pages=15–21 |year=1993 |pmid=8435356 |doi= |url=}}</ref> | |||
*[[Laparoscopic]] adhesiolysis is another viable option that has the advantages of: | |||
**Lower [[morbidity]] | |||
**Less recovery time | |||
**Less complications | |||
**Lower risk of [[wound]] [[infection]] | |||
==Indications== | |||
===Indications based upon complicated clinical presentation=== | |||
*[[Fever]] | |||
*[[Leukocytosis]] | |||
*[[Tachycardia]] | |||
*Continuous or worsening [[abdominal pain]] | |||
*[[Metabolic acidosis]] | |||
*[[Peritonitis]] | |||
*[[Systemic inflammatory response syndrome]] ([[SIRS]]) | |||
===Indications based upon image findings=== | |||
*Free air on [[x-ray]] or [[CT]] | |||
**Indicates a [[perforation]] | |||
*Signs of [[ischemia]] | |||
**Such as [[pneumatosis intestinalis]] and [[portal venous gas]] | |||
*Complete or closed loop obstruction | |||
**Such as U-shaped or triangular loop, distended and fluid-filled loops, and a pair of collapsed loops near the obstruction site | |||
*Abnormal route of a [[mesenteric]] [[vessel]] | |||
*Fluid in the [[peritoneum]] | |||
*Presence of a transition point | |||
===Indications based on a point system=== | |||
*A score of more than or equal to 3 indicates [[surgery]], each criterion is allotted one point: | |||
**History of [[pain]] lasting > 4 days | |||
**[[Guarding]] on [[physical examination]] | |||
**Elevated [[CRP]] above 75 mg/L | |||
**Elevated [[WBC]] | |||
**Presence of free intraabdominal fluid on [[CT-scans|CT]] > 500 ml of | |||
**Reduced bowel wall [[contrast]] enhancement on [[CT]] | |||
===Bowel obstruction in Children=== | |||
*[[Fetal]] and [[neonatal]] bowel obstructions are often caused by an [[intestinal atresia]] where there is a narrowing or absence of a part of the [[intestine]]. | |||
*These [[Atresia|atresias]] are often discovered before birth via a [[sonogram]] and treated with using [[laparotomy]] after birth. | |||
*If the area affected is small then the surgeon may be able to remove the damaged portion and join the [[intestine]] back together. | |||
*In instances where the narrowing is longer, or the area is damaged and cannot be used for a period of time, a temporary [[stoma (medicine)|stoma]] may be placed. | |||
===Bowel obstruction in cancer patients=== | |||
*Patients with [[malignancy]] experience bowel obstruction due to: | |||
**Internal or external compression by a [[tumor]] | |||
**[[Adhesions]] | |||
**Postradiational [[fibrosis]] | |||
*On average, one third of patients have been found to experience bowel obstruction because of benign [[adhesions]], otherwise the obstructions are often inoperable. | |||
*If a [[cancer]] patient is in [[remission]] then the likelihood of a benign [[adhesion]] increases. | |||
*If a [[cancer]] patient is not in remission then the likelihood of recurrent [[cancer]] increases, meaning that the [[obstruction]] is inoperable. | |||
*A [[cancer]] patient may undergo a trial of non-operative management if they do not meet the indications for [[surgery]]. | |||
===Palliative surgery=== | |||
*[[Palliative]] [[surgery]] aims to relieve symptoms in those that have an inoperable [[malignancy]]. | |||
*[[Palliative]] [[surgeries]] include bowel resection, or a bypass surgery which includes: | |||
**Enteroenterostomy | |||
**Enterocolostomy | |||
**Colocolostomy | |||
===Alternatives to surgery=== | |||
*[[Stent]]: | |||
**A [[duodenal]] [[stent]] may be placed [[proximal]] to a [[small bowel]] [[tumor]] to relieve an [[obstruction]] in those that are not fit for [[surgery]]. | |||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
[[Category: | [[Category:Surgery]] | ||
[[Category:Gastroenterology]] | [[Category:Gastroenterology]] | ||
[[Category:Up-To-Date]] | |||
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[[Category:Emergency medicine]] | [[Category:Emergency medicine]] | ||
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Latest revision as of 16:16, 27 February 2018
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Hadeel Maksoud M.D.[2]
Overview
The mainstay of treatment for bowel obstruction is surgical. Surgery is specifically indicated for complicated bowel obstruction. Complications include: Complete obstruction, closed-loop obstruction, bowel ischemia, necrosis, and perforation.
Surgery
- Open abdominal surgery is commonly performed in small bowel obstruction.[1][2][3][4][5][6][7][8][9]
- Laparoscopic adhesiolysis is another viable option that has the advantages of:
Indications
Indications based upon complicated clinical presentation
- Fever
- Leukocytosis
- Tachycardia
- Continuous or worsening abdominal pain
- Metabolic acidosis
- Peritonitis
- Systemic inflammatory response syndrome (SIRS)
Indications based upon image findings
- Free air on x-ray or CT
- Indicates a perforation
- Signs of ischemia
- Such as pneumatosis intestinalis and portal venous gas
- Complete or closed loop obstruction
- Such as U-shaped or triangular loop, distended and fluid-filled loops, and a pair of collapsed loops near the obstruction site
- Abnormal route of a mesenteric vessel
- Fluid in the peritoneum
- Presence of a transition point
Indications based on a point system
- A score of more than or equal to 3 indicates surgery, each criterion is allotted one point:
Bowel obstruction in Children
- Fetal and neonatal bowel obstructions are often caused by an intestinal atresia where there is a narrowing or absence of a part of the intestine.
- These atresias are often discovered before birth via a sonogram and treated with using laparotomy after birth.
- If the area affected is small then the surgeon may be able to remove the damaged portion and join the intestine back together.
- In instances where the narrowing is longer, or the area is damaged and cannot be used for a period of time, a temporary stoma may be placed.
Bowel obstruction in cancer patients
- Patients with malignancy experience bowel obstruction due to:
- On average, one third of patients have been found to experience bowel obstruction because of benign adhesions, otherwise the obstructions are often inoperable.
- If a cancer patient is in remission then the likelihood of a benign adhesion increases.
- If a cancer patient is not in remission then the likelihood of recurrent cancer increases, meaning that the obstruction is inoperable.
- A cancer patient may undergo a trial of non-operative management if they do not meet the indications for surgery.
Palliative surgery
- Palliative surgery aims to relieve symptoms in those that have an inoperable malignancy.
- Palliative surgeries include bowel resection, or a bypass surgery which includes:
- Enteroenterostomy
- Enterocolostomy
- Colocolostomy
Alternatives to surgery
- Stent:
- A duodenal stent may be placed proximal to a small bowel tumor to relieve an obstruction in those that are not fit for surgery.
References
- ↑ Chen JH, Huang TC, Chang PY, Dai MS, Ho CL, Chen YC, Chao TY, Kao WY (2014). "Malignant bowel obstruction: A retrospective clinical analysis". Mol Clin Oncol. 2 (1): 13–18. doi:10.3892/mco.2013.216. PMC 3915666. PMID 24649301.
- ↑ Butler JA, Cameron BL, Morrow M, Kahng K, Tom J (1991). "Small bowel obstruction in patients with a prior history of cancer". Am. J. Surg. 162 (6): 624–8. PMID 1727026.
- ↑ Tang E, Davis J, Silberman H (1995). "Bowel obstruction in cancer patients". Arch Surg. 130 (8): 832–6, discussion 836–7. PMID 7632142.
- ↑ Dalal KM, Gollub MJ, Miner TJ, Wong WD, Gerdes H, Schattner MA, Jaques DP, Temple LK (2011). "Management of patients with malignant bowel obstruction and stage IV colorectal cancer". J Palliat Med. 14 (7): 822–8. doi:10.1089/jpm.2010.0506. PMID 21595546.
- ↑ Oyasiji T, Angelo S, Kyriakides TC, Helton SW (2010). "Small bowel obstruction: outcome and cost implications of admitting service". Am Surg. 76 (7): 687–91. PMID 20698371.
- ↑ Diaz JJ, Bokhari F, Mowery NT, Acosta JA, Block EF, Bromberg WJ, Collier BR, Cullinane DC, Dwyer KM, Griffen MM, Mayberry JC, Jerome R (2008). "Guidelines for management of small bowel obstruction". J Trauma. 64 (6): 1651–64. doi:10.1097/TA.0b013e31816f709e. PMID 18545135.
- ↑ Paul Olson TJ, Pinkerton C, Brasel KJ, Schwarze ML (2014). "Palliative surgery for malignant bowel obstruction from carcinomatosis: a systematic review". JAMA Surg. 149 (4): 383–92. doi:10.1001/jamasurg.2013.4059. PMC 4030748. PMID 24477929.
- ↑ Richards WO, Williams LF (1988). "Obstruction of the large and small intestine". Surg. Clin. North Am. 68 (2): 355–76. PMID 3279551.
- ↑ Ripamonti C, De Conno F, Ventafridda V, Rossi B, Baines MJ (1993). "Management of bowel obstruction in advanced and terminal cancer patients". Ann. Oncol. 4 (1): 15–21. PMID 8435356.