Bowel Obstruction

Bowel Obstruction

Tad Kim, M.D.Connie Lee, M.D.

Bowel Obstruction

Definitions• Ileus = obstruction 2/2 dysfunctional

motility of bowel

• Mechanical obstruction = 85% SB, 15% large bowel

• Simple obstruction

• Closed loop obstruction

• Strangulation

Bowel Obstruction

SBO: Etiology• Adhesion #1 (80-90% of SBO in pt’s w/prior abdominal surgery)• Hernia #2 overall - #1 cause of SBO in pts w/o prior abdominal

surgery• Tumor• Abscess• Hematoma• Annular pancreas• SMA syndrome• Congenital lesions• Gallstone ileus• Intussusception• Foreign body (bezoars, worms, etc)• Meconium ileus• Malrotation

Bowel Obstruction

Colonic Obstruction: Etiology• Cancer #1 (60%)• Volvulus (sigmoid > cecum)• Adhesions• Hernia• UC• Diverticulitis• Congenital lesions• Fecal impaction• Adynamic ileus• Hirschsprung’s• Meconium ileus• Foreign body

Bowel Obstruction

Age & DDx• Age matters!

– Neonate: meconium ileus, Hirschsprung’s, malrotation, atresia

– Child: intussusception, Hirschsprung’s– Adult: hernia, IBD, CA, diverticular disease– Elderly: CA, diverticular disease, Ogilvie’s

Bowel Obstruction

History & DDx

• Proximal obstruction: early bilious vomiting, +flatus/BM• Distal obstruction: obstipation, distension, vomiting feculent material

(2/2 bacterial overgrowth of SB contents)• Pain w/obstruction: begins as cramping pain, changes to continuous

severe pain w/strangulation & peritonitis• PMHx: remember to ask about cardiac history (arrhythmias, prior

MI, Afib - think about intestinal ischemia), IBD, gallstones, cancer• PSHx: remember to ask about ostomy output• Meds: narcotics (ileus), antipsychotics (ileus), diuretics (hypoK a/w

ileus)• ROS: recent weight loss (CA, SMA syndrome)

Bowel Obstruction

PE• Start with ABCs• Look for surgical scars• Bowel sounds • Distention: distal obstruction >> proximal• Localized tenderness: think peritonitis• Look for hernias/masses• Do a rectal exam

Bowel Obstruction

Labs• WBC (nml in uncomplicated SBO)

• CBC (anemia w/CA)

• BMP (hypoK)

• Alkalosis (a/w proximal obstruction)

• Acidosis (a/w bowel infarction)

• Amylase (may be elevated in SBO)

Bowel Obstruction

Studies

• Upright CXR: look for free air• Flat and upright/left lateral decubitus: look for

dilated bowel loops, air-fluid levels• Note: if cecal diameter >12cm, there is a risk of

perforation. At 12-14cm, the wall tension > perfusion pressure, increasing risk of necrosis

• Barium enema• UGI series w/SB follow-through• CT scan

Bowel Obstruction

SBO: Management

• NPO, NGT, Foley, IVF• Electrolyte replacement• Many partial obstructions will resolve• “Don’t let the sun set on a (complete) SBO”• Complete bowel obstruction w/concern for

strangulation/perforation requires immediate operative intervention (resuscitate first)

Bowel Obstruction

Dedouit F and Otal P. N Engl J Med 2008;358:1381

A 72-year-old woman presented with a 2-day history of abdominal pain associated with nausea and vomiting

Bowel Obstruction

Liu K and Lin B. N Engl J Med 2007;356:1152

A 48-year-old healthy woman presented with anorexia of 2 days' duration and abdominal pain in the right lower quadrant

Bowel Obstruction

Jang M and Lee K. N Engl J Med 2008;358:e16

A 60-year-old woman presented to the outpatient clinic with vague abdominal discomfort that had developed over the previous several weeks

Bowel Obstruction

Miryala R and Neilan R. N Engl J Med 2009;360:e32

A 68-year-old man with alcoholic cirrhosis, portal hypertension, ascites, and an umbilical hernia presented to the emergency department after an episode of coughing that was followed by a

rush of fluid and fat from the umbilicus

Bowel Obstruction

Avolio L and Martucciello G. N Engl J Med 2009;360:2770

Ingested magnets

Bowel Obstruction

Rosmarin D and Tan C. N Engl J Med 2006;355:601

A 68-year-old man with chronic dysuria and increased urinary frequency presented with three weeks of weakness and fever

Bowel Obstruction

Traub S et al. N Engl J Med 2003;349:2519-2526

Radiographic Findings in Body Packers

Bowel Obstruction

Graham J and Rothwell B. N Engl J Med 2004;351:1119

An 83-year-old woman was hospitalized with nausea, vomiting, and obstipation

Bowel Obstruction

Chan D. N Engl J Med 2006;355:1714

A previously healthy 102-year-old woman was admitted with abdominal pain and a 3-day history of vomiting

Bowel Obstruction

Kurer M and Chintapatla S. N Engl J Med 2007;356:1656

A 64-year-old woman with ulcerative colitis presented with abdominal pain

Bowel Obstruction

Take Home Points• Always start with ABC, resuscitation

– Includes 2 large bore IV, Foley, NGT, monitor

• DDX is simple:– SBO: Adhesions, Bulges, Cancer, Crohn’s– LBO: CANCER, Volvulus, Diverticulitis

• Labs to assess dehydration & leukocytosis• Imaging to assess obstruction & etiology• If hypoTN/shock, “toxic”, or signs of

strangulation or ischemia, resusc & OR stat• Otherwise, for SBO, NGT & treat etiology• LBO is different: really must rule out cancer,

colonoscopy plays a larger role than w SBO