James Zeng

Bowel Obstruction

A blockage of bowel lumen prohibiting the passage of materials[1]

8% of abdo pain in ED (3rd leading cause)[2]

24% require surgery[3]300,000 admissions, 800,000 in-pt

days, $1.3bil[4]

Causes

Extrinsic (extraluminal)Intrinsic (luminal)Intraluminal

Extrinsic Causes

AdhesionsHerniasVolvulus

Intrinsic

NeoplasticInflammatoryCongenital

Intraluminal

FaecesGallstonesIntussceptionBezoar

Bowel Obstruction

Small v. LargeAcute v. subacute

Differential

Paralytic -ileusPseudo-obstructionConstipation

Diagnosis

ClinicalRadiological

Symptoms

PainDistensionObstructive symptoms

VomitingInability to pass motions/slowingInability to pass flatus

Past history

Past abdominal surgeryPast obstructionsHerniasCrohn’s Malignancy

Signs

Volume statusScars, volumeGuarding, peritonitis“Tinkling” bowel sounds, no BSHerniasPR

Investigations

Abdo pain bloodsLactate

Radiology (AxR)

Radiology (AxR)Large bowel obs

Radiology (AxR)

SizeWallsDistal collapseEmpty rectum

Radiology (AxR)

Small LargeCentralSmaller calibreValvulae coniventesMore loopsLong fluid levels

PeripheralLarger calibreHaustra1-2 loopsShort fluid levels

Radiology (CT)

Inconclusive XRSystemically unwell, local peritonitisHelps to determine cause>2.5cm with distal collapseHigh accuracy

Conservative Management

FluidsNBMAnalgesiaNG tube

ComplicationsElectrolytes

Specific Management

Adhesions - conservative ± gastrograffinPerforation, hernia – urgent theatreStrictures, colitis – surgical resectionSigmoid volvulus – rectal tube

Beware of ischaemia – test intraoperatively

Obstruction in Cancer Patients

Various opinionsDepends on when last operation wasTrial of conservative treatmentGastrograffin/CTConsider early resection,

stent+resection

Non-operative candidates

References1. www.medical-dictionary.com2. Lewis LM et al. Etiology and clinical course of

abdominal pain in senior patients: a prospective, multicenter study. Gerontol A Biol Sci Med Sci. 2005. 60:8 (1071-6).

3. Foster NM; McGory ML; Zingmond DS; Ko CY. Small bowel obstruction: a population-based appraisal. J Am Coll Surg. 2006. 203:2 (170-6).

4. Ray NF; Denton WG; Thamer M; Henderson SC; Perry S. Abdominal adhesiolysis: inpatient care and expenditures in the United States in 1994. J Am Coll Surg. 1998. 186:1 (1-9).