Bowel obstruction

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Bowel obstruction is a mechanical or functional obstruction of the intestines, preventing the normal transit of the products of digestion. It can occur at any level distal to the duodenum of the small intestine and is a medical emergency. Although many cases are not treated surgically, it is a surgical problem.

Causes

Small bowel obstruction

Differential diagnosis by location

Causes of small bowel obstruction include:

Adhesions from previous abdominal surgery
Carcinoid rare, preferred location: ileum
Crohn's disease causing adhesions or inflammatory strictures
Foreign bodies (e.g. gallstones in gallstone ileus, swallowed objects)
Hernias containing bowel
Intestinal atresia
Intussusception in children
Ischaemic strictures
Neoplasms, benign or malignant
Volvulus

Upright abdominal X-ray demonstrating a small bowel obstruction. Note multiple air fluid levels.

Large bowel obstruction

Causes of large bowel obstruction include:

Neoplasms
Hernias
Inflammatory bowel disease
Colonic volvulus (sigmoid, caecal, transverse colon)
Faecal impaction
Colon atresia
Benign strictures (Diverticular Disease)

Upright abdominal X-ray of a patient with a large bowel obstruction showing multiple air fluid levels and dilated loops of bowel.

Differential diagnosis of causes of bowel obstruction by organ system

Trauma, mechanical and physical conditions

Intestinal stricture
Intususception of intestine

Miscellaneous syndromes

Pseudo-obstruction or Ogilvie's syndrome
Paralytic Ileus

Chromosomal abnormalities

Down syndrome

Autosomal dominant conditions

Neurofibromatosis type 1

Malignant neoplastic conditions

Carcinoid tumours and carcinoid syndrome
Colorectal cancer
Ovarian cancer
Pseudomyxoma peritonei
Small bowel lymphoma
Stomach cancer

Trauma, mechanical and physical conditions

Bowel strangulation
Femoral hernia
Ileus
Inguinal hernia
Intestinal volvulus
Large bowel obstruction
Obturator hernia
Peritoneal adhesions
Small bowel obstruction

Infectious disorders

Intra-abdominal sepsis
Pneumonia or other systemic illness
Ascariasis

Signs, symptoms and causes

Depending on the level of obstruction, bowel obstruction can present with abdominal pain, abdominal distension, vomiting, fecal vomiting, and constipation.

Obstruction may be due to causes within the bowel lumen, within the wall of the bowel, or external to the bowel (such as compression, entrapment or volvulus).

Bowel obstruction may be complicated by dehydration and electrolyte abnormalities due to vomiting; respiratory compromise from pressure on the diaphragm by a distended abdomen, or aspiration of vomitus; bowel ischaemia or perforation from prolonged distension or pressure from a foreign body.

In small bowel obstruction the pain tends to be colicky (cramping and intermittent) in nature, with spasms lasting a few minutes. The pain tends to be central and mid-abdominal. Vomiting occurs before constipation.

In large bowel obstruction the pain is felt lower in the abdomen and the spasms last longer. Constipation occurs earlier and vomiting may be less prominent. Proximal obstruction of the large bowel may present as small bowel obstruction.

Diagnosis

The main diagnostic tools are blood tests, X-rays of the abdomen, CT scanning and/or ultrasound. If a mass is identified, biopsy may determine the nature of the mass.

Radiological signs of bowel obstruction include bowel distension and the presence of multiple (more than six) gas-fluid levels on supine and erect abdominal radiographs.

Contrast enema or small bowel series or CT scan can be used to define the level of obstruction, whether the obstruction is partial or complete, and to help define the cause of the obstruction.

According to a meta-analysis of prospective studies by the Cochrane Collaboration, the appearance of water-soluble contrast in the cecum on an abdominal radiograph within 24 hours of oral administration predicts resolution of an adhesive small bowel obstruction with a pooled sensitivity of 96% and specificity of 96%. PMID 15674958

Colonoscopy, small bowel investigation with ingested camera or push endoscopy, and laparoscopy are other diagnostic options.

Treatment

Some causes of bowel obstruction may resolve spontaneously; many require operative treatment.

In adults, frequently the surgical intervention and the treatment of the causative lesion are required. In malignant large bowel obstruction, endoscopically placed self-expanding metal stents may be used to temporarily relieve the obstruction as a bridge to surgery, or as palliation.

Small bowel obstruction

In the management of small bowel obstructions it is often said that "[n]ever let the sun rise or set on small-bowel obstruction"^[1] because they are sometimes fatal if treatment is delayed.

Treatment for a small bowel obstruction is both non-surgical (conservative) and surgical.

Conservative treatment involves insertion of a nasogastric tube, correction of dehydration and electrolyte abnormalities. Opioid pain relievers may be used for patients with severe pain. Antiemetics may be administered if the patient is vomiting. Adhesive obstructions often settle without surgery. If obstruction is complete a surgery is required.

Small bowel obstruction caused by Crohn's disease, peritoneal carcinomatosis, sclerosing peritonitis, radiation enteritis and postpartum bowel obstruction are typically treated conservatively, i.e. without surgery. Conversely, a small bowel obstruction in a "virgin abdomen" (an abdomen that has not seen an operation) is almost never treated conservatively.