Bowel obstruction

Bowel obstruction
Other names: Intestinal obstruction
Upright abdominal X-ray demonstrating a small bowel obstruction. Note multiple air fluid levels.
SpecialtyGeneral surgery
SymptomsAbdominal pain, vomiting, bloating, not passing gas[1]
ComplicationsSepsis, bowel ischemia, bowel perforation[1]
CausesAdhesions, hernias, volvulus, endometriosis, inflammatory bowel disease, appendicitis, tumors, diverticulitis, ischemic bowel, tuberculosis, intussusception[2][1]
Diagnostic methodMedical imaging[1]
TreatmentConservative care, surgery[2]
Frequency3.2 million (2015)[3]
Deaths264,000 (2015)[4]

Bowel obstruction, also known as intestinal obstruction, is a mechanical or functional obstruction of the intestines which prevents the normal movement of the products of digestion.[2][5] Either the small bowel or large bowel may be affected.[1] Signs and symptoms include abdominal pain, vomiting, bloating and not passing gas.[1] Mechanical obstruction is the cause of about 5 to 15% of cases of severe abdominal pain of sudden onset requiring admission to hospital.[1][2]

Causes of bowel obstruction include adhesions, hernias, volvulus, endometriosis, inflammatory bowel disease, appendicitis, tumors, diverticulitis, ischemic bowel, tuberculosis and intussusception.[1][2] Small bowel obstructions are most often due to adhesions and hernias while large bowel obstructions are most often due to tumors and volvulus.[1][2] The diagnosis may be made on plain X-rays; however, CT scan is more accurate.[1] Ultrasound or MRI may help in the diagnosis of children or pregnant women.[1]

The condition may be treated conservatively or with surgery.[2] Typically intravenous fluids are given, a tube is placed through the nose into the stomach to decompress the intestines, and pain medications are given.[2] Antibiotics are often given.[2] In small bowel obstruction about 25% require surgery.[6] Complications may include sepsis, bowel ischemia and bowel perforation.[1]

About 3.2 million cases of bowel obstruction occurred in 2015 which resulted in 264,000 deaths.[3][4] Both sexes are equally affected and the condition can occur at any age.[6] Bowel obstruction has been documented throughout history, with cases detailed in the Ebers Papyrus of 1550 BC and by Hippocrates.[7]

Signs and symptoms

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

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 ischemia 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 may occur 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.

Causes

Small bowel obstruction

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

Causes of small bowel obstruction include:[2]

After abdominal surgery, the incidence of small bowel obstruction from any cause is 9%. In those where the cause of the obstruction was clear, adhesions are the single most common cause (more than half).[9]

Large bowel obstruction

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

Causes of large bowel obstruction include:

Outlet obstruction

Outlet obstruction is a sub-type of large bowel obstruction and refers to conditions affecting the anorectal region that obstruct defecation, specifically conditions of the pelvic floor and anal sphincters. Outlet obstruction can be classified into four groups.[10]

Diagnosis

A small bowel obstruction as seen on CT
Small bowel dilation on CT scan in adults[11]
<2.5 cmNon-dilated
2.5-2.9 cmMildly dilated
3-4 cmModerately dilated
>4 cmSeverely dilated
Average inner diameters and ranges of different sections of the large intestine.[12]

The main diagnostic tools are blood tests, X-rays of the abdomen, CT scanning, and 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. Ultrasounds may be as useful as CT scanning to make the diagnosis.[13]

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. The appearance of water-soluble contrast in the cecum on an abdominal radiograph within 24 hours of it being given by mouth predicts resolution of an adhesive small bowel obstruction with sensitivity of 97% and specificity of 96%.[14]

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

  • Small bowel obstruction on ultrasound.[15]
  • Small bowel obstruction on ultrasound.[15]
  • Small bowel obstruction on ultrasound.
    Small bowel obstruction on ultrasound.[15]

Differential diagnosis

Differential diagnoses of bowel obstruction include:

Treatment

Some causes of bowel obstruction may resolve spontaneously;[16] many require operative treatment.[17] 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,[18] or as palliation.[19] Diagnosis of the type of bowel obstruction is normally conducted through initial plain radiograph of the abdomen, luminal contrast studies, computed tomography scan, or ultrasonography prior to determining the best type of treatment.[20]

Further research is needed to find out if parenteral nutrition is of benefit to people with an inoperable blockage of the bowel caused by advanced cancer.[21]

Small bowel obstruction

In the management of small bowel obstructions, a commonly quoted surgical aphorism is: "never let the sun rise or set on small-bowel obstruction"[22] because about 5.5%[22] of small bowel obstructions are ultimately fatal if treatment is delayed. Improvements in radiological imaging of small bowel obstructions allow for confident distinction between simple obstructions, that can be treated conservatively, and obstructions that are surgical emergencies (volvulus, closed-loop obstructions, ischemic bowel, incarcerated hernias, etc.).[2]

A small flexible tube (nasogastric tube) may be inserted through the nose into the stomach to help decompress the dilated bowel. This tube is uncomfortable but relieves the abdominal cramps, distention, and vomiting. Intravenous therapy is utilized and the urine output is monitored with a catheter in the bladder.[23]

Most people with SBO are initially managed conservatively because in many cases, the bowel will open up. Some adhesions loosen up and the obstruction resolves. The patient is examined several times a day, and X-ray images are made to ensure he or she is not getting clinically worse.[24]

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 the obstruction is complete a surgery is usually required.

Most patients improve with conservative care in 2–5 days. When the obstruction is cancer, surgery is the only treatment. Those with bowel resection or lysis of adhesions usually stay in the hospital a few more days until they can eat and walk.[25]

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.

Children

Main article: Neonatal bowel obstruction

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 an ultrasound, 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.

Prognosis

The prognosis for non-ischemic cases of SBO is good with mortality rates of 3–5%, while prognosis for SBO with ischemia is fair with mortality rates as high as 30%.[26]

Cases of SBO related to cancer are more complicated and require additional intervention to address the malignancy, recurrence, and metastasis, and thus are associated with poorer prognosis.

All cases of abdominal surgical intervention are associated with increased risk of future small-bowel obstructions. Statistics from U.S. healthcare report 18.1% re-admittance rate within 30 days for patients who undergo SBO surgery.[27] More than 90% of patients also form adhesions after major abdominal surgery.[28] Common consequences of these adhesions include small-bowel obstruction, chronic abdominal pain, pelvic pain, and infertility.[28]

Other animals

References

  1. 1 2 3 4 5 6 7 8 9 10 11 12 Gore RM, Silvers RI, Thakrar KH, Wenzke DR, Mehta UK, Newmark GM, Berlin JW (November 2015). "Bowel Obstruction". Radiologic Clinics of North America. 53 (6): 1225–40. doi:10.1016/j.rcl.2015.06.008. PMID 26526435.
  2. 1 2 3 4 5 6 7 8 9 10 11 Fitzgerald, J. Edward F. (2010). "Small Bowel Obstruction". Emergency Surgery. Oxford: Wiley-Blackwell. pp. 74–79. doi:10.1002/9781444315172.ch14. ISBN 9781405170253. Archived from the original on September 8, 2017.
  3. 1 2 Vos, Theo; Allen, Christine; Arora, Megha; Barber, Ryan M.; Bhutta, Zulfiqar A.; Brown, Alexandria; Carter, Austin; Casey, Daniel C.; Charlson, Fiona J.; Chen, Alan Z.; Coggeshall, Megan; Cornaby, Leslie; Dandona, Lalit; Dicker, Daniel J.; Dilegge, Tina; Erskine, Holly E.; Ferrari, Alize J.; Fitzmaurice, Christina; Fleming, Tom; Forouzanfar, Mohammad H.; Fullman, Nancy; Gething, Peter W.; Goldberg, Ellen M.; Graetz, Nicholas; Haagsma, Juanita A.; Hay, Simon I.; Johnson, Catherine O.; Kassebaum, Nicholas J.; Kawashima, Toana; Kemmer, Laura (October 2016). "Global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015". Lancet. 388 (10053): 1545–1602. doi:10.1016/S0140-6736(16)31678-6. PMC 5055577. PMID 27733282. {{cite journal}}: Unknown parameter |displayauthors= ignored (help)
  4. 1 2 Wang, Haidong; Naghavi, Mohsen; Allen, Christine; Barber, Ryan M.; Bhutta, Zulfiqar A.; Carter, Austin; Casey, Daniel C.; Charlson, Fiona J.; Chen, Alan Zian; Coates, Matthew M.; Coggeshall, Megan; Dandona, Lalit; Dicker, Daniel J.; Erskine, Holly E.; Ferrari, Alize J.; Fitzmaurice, Christina; Foreman, Kyle; Forouzanfar, Mohammad H.; Fraser, Maya S.; Fullman, Nancy; Gething, Peter W.; Goldberg, Ellen M.; Graetz, Nicholas; Haagsma, Juanita A.; Hay, Simon I.; Huynh, Chantal; Johnson, Catherine O.; Kassebaum, Nicholas J.; Kinfu, Yohannes; Kulikoff, Xie Rachel (October 2016). "Global, regional, and national life expectancy, all-cause mortality, and cause-specific mortality for 249 causes of death, 1980-2015: a systematic analysis for the Global Burden of Disease Study 2015". Lancet. 388 (10053): 1459–1544. doi:10.1016/s0140-6736(16)31012-1. PMC 5388903. PMID 27733281. {{cite journal}}: Unknown parameter |displayauthors= ignored (help)
  5. ↑ Adams, James G. (2012). Emergency Medicine: Clinical Essentials (Expert Consult -- Online). Elsevier Health Sciences. p. 331. ISBN 978-1455733941. Archived from the original on September 8, 2017.
  6. 1 2 Ferri, Fred F. (2014). Ferri's Clinical Advisor 2015: 5 Books in 1. Elsevier Health Sciences. p. 1093. ISBN 9780323084307. Archived from the original on September 8, 2017.
  7. ↑ Yeo, Charles J.; McFadden, David W.; Pemberton, John H.; Peters, Jeffrey H.; Matthews, Jeffrey B. (2012). Shackelford's Surgery of the Alimentary Tract. Elsevier Health Sciences. p. 1851. ISBN 978-1455738076. Archived from the original on September 8, 2017.
  8. ↑ Segura-Sampedro JJ, Ashrafian H, Navarro-Sánchez A, Jenkins JT, Morales-Conde S, Martínez-Isla A (November 2015). "Small bowel obstruction due to laparoscopic barbed sutures: an unknown complication?". Revista Espanola de Enfermedades Digestivas. 107 (11): 677–80. doi:10.17235/reed.2015.3863/2015. PMID 26541657. Archived from the original on September 18, 2008. Retrieved July 8, 2019.
  9. ↑ ten Broek RP, Issa Y, van Santbrink EJ, Bouvy ND, Kruitwagen RF, Jeekel J, et al. (October 2013). "Burden of adhesions in abdominal and pelvic surgery: systematic review and met-analysis". BMJ. 347 (oct03 1): f5588. doi:10.1136/bmj.f5588. PMC 3789584. PMID 24092941.
  10. ↑ Zbar, Andrew P; Wexner, Steven D (2010). Coloproctology. New York: Springer. p. 140. ISBN 978-1-84882-755-4.
  11. ↑ Jacobs SL, Rozenblit A, Ricci Z, Roberts J, Milikow D, Chernyak V, Wolf E (April 2007). "Small bowel faeces sign in patients without small bowel obstruction". Clinical Radiology. 62 (4): 353–7. doi:10.1016/j.crad.2006.11.007. PMID 17331829.
  12. ↑ Nguyen H, Loustaunau C, Facista A, Ramsey L, Hassounah N, Taylor H, et al. (July 2010). "Deficient Pms2, ERCC1, Ku86, CcOI in field defects during progression to colon cancer". Journal of Visualized Experiments (41). doi:10.3791/1931. PMC 3149991. PMID 20689513.
  13. ↑ Gottlieb M, Peksa GD, Pandurangadu AV, Nakitende D, Takhar S, Seethala RR (February 2018). "Utilization of ultrasound for the evaluation of small bowel obstruction: A systematic review and meta-analysis". The American Journal of Emergency Medicine. 36 (2): 234–242. doi:10.1016/j.ajem.2017.07.085. PMID 28797559.
  14. ↑ Abbas S, Bissett IP, Parry BR (July 2007). "Oral water soluble contrast for the management of adhesive small bowel obstruction". The Cochrane Database of Systematic Reviews (3): CD004651. doi:10.1002/14651858.CD004651.pub3. PMC 6465054. PMID 17636770.
  15. 1 2 3 "UOTW #20 - Ultrasound of the Week". Ultrasound of the Week. October 1, 2014. Archived from the original on May 9, 2017. Retrieved May 27, 2017.
  16. ↑ Ludmir J, Samuels P, Armson BA, Torosian MH (December 1989). "Spontaneous small bowel obstruction associated with a spontaneous triplet gestation. A case report". The Journal of Reproductive Medicine. 34 (12): 985–7. PMID 2621741.
  17. ↑ "Abdominal Adhesions and Bowel Obstruction". University of California San Francisco. Archived from the original on August 2, 2013. Retrieved August 11, 2013.
  18. ↑ Young CJ, Suen MK, Young J, Solomon MJ (October 2011). "Stenting large bowel obstruction avoids a stoma: consecutive series of 100 patients". Colorectal Disease. 13 (10): 1138–41. doi:10.1111/j.1463-1318.2010.02432.x. PMID 20874797.
  19. ↑ Mosler P, Mergener KD, Brandabur JJ, Schembre DB, Kozarek RA (February 2005). "Palliation of gastric outlet obstruction and proximal small bowel obstruction with self-expandable metal stents: a single center series". Journal of Clinical Gastroenterology. 39 (2): 124–8. PMID 15681907.
  20. ↑ Holzheimer, Rene G. (2001). Surgical Treatment. NCBI Bookshelf. ISBN 3-88603-714-2. Archived from the original on August 27, 2011.
  21. ↑ Sowerbutts AM, Lal S, Sremanakova J, Clamp A, Todd C, Jayson GC, et al. (August 2018). "Home parenteral nutrition for people with inoperable malignant bowel obstruction". The Cochrane Database of Systematic Reviews. 8: CD012812. doi:10.1002/14651858.cd012812.pub2. PMC 6513201. PMID 30095168.
  22. 1 2 Maglinte DD, Kelvin FM, Rowe MG, Bender GN, Rouch DM (January 2001). "Small-bowel obstruction: optimizing radiologic investigation and nonsurgical management". Radiology. 218 (1): 39–46. doi:10.1148/radiology.218.1.r01ja5439. PMID 11152777. Archived from the original on April 18, 2008. Retrieved June 6, 2008.
  23. ↑ Small Bowel Obstruction overview Archived February 12, 2010, at the Wayback Machine. Retrieved February 19, 2010.
  24. ↑ Small Bowel Obstruction: Treating Bowel Adhesions Non-Surgically Archived February 27, 2010, at the Wayback Machine. Clear Passage treatment center online portal Retrieved February 19, 2010
  25. ↑ Small Bowel Obstruction Archived July 5, 2010, at the Wayback Machine The Eastern Association for the Surgery of Trauma. February 19, 2010
  26. ↑ Kakoza R, Lieberman G (May 2006). "Mechanical Small Bowel Obstruction" (PDF). Archived from the original (PDF) on May 7, 2013. Retrieved October 9, 2012. {{cite journal}}: Cite journal requires |journal= (help)
  27. ↑ "Readmissions to U.S. Hospitals by Procedure" (PDF). Agency for Healthcare Research and Quality. April 2013. Archived (PDF) from the original on October 20, 2013. Retrieved August 27, 2013.
  28. 1 2 Liakakos T, Thomakos N, Fine PM, Dervenis C, Young RL (2001). "Peritoneal adhesions: etiology, pathophysiology, and clinical significance. Recent advances in prevention and management". Digestive Surgery. 18 (4): 260–73. doi:10.1159/000050149. PMID 11528133.
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