Bowel obstruction
Bowel obstruction | |
---|---|
Other names | Intestinal obstruction, intestinal occlusion |
Frequency | 3.2 million (2015)[3] |
Deaths | 264,000 (2015)[4] |
Bowel obstruction, also known as intestinal obstruction, is a mechanical or
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
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
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.[9] Common physical exam findings may include signs of dehydration, abdominal distension with tympany, nonspecific abdominal tenderness, and high pitched tinkly bowel sounds.[10]
In large bowel obstruction, the pain is felt lower in the abdomen and the spasms last longer. Common symptoms include abdominal pain, distension, and severe constipation.[11] Constipation occurs earlier and vomiting may be less prominent. Proximal obstruction of the large bowel may present as small bowel obstruction.[12] Patients may notice a history of bloating and narrowing of stools before the onset of more severe symptoms. Symptoms can present quickly in the cases of volvulus and can present over a longer period of time in the setting of cancer. Common physical exam findings may include a palpable hernia, abdominal distension with tympany, nonspecific lower abdominal tenderness, and a rectal mass.[6]
Diagnosis
Diameter | Assessment |
---|---|
<2.5 cm | Non-dilated |
2.5-2.9 cm | Mildly dilated |
3-4 cm | Moderately dilated |
>4 cm | Severely dilated |
The main diagnostic tools are
Colonoscopy, small bowel investigation with ingested camera or push endoscopy, and laparoscopy are other diagnostic options.
-
Small bowel obstruction on ultrasound[18]
-
Small bowel obstruction on ultrasound[18]
-
Small bowel obstruction on ultrasound[18]
Differential diagnosis
Differential diagnoses of bowel obstruction include:
Causes
Small bowel obstruction
Causes of
- Adhesions from previous abdominal surgery (most common cause)
- Barbed sutures[20]
- Pseudoobstruction
- Hernias containing bowel
- Crohn's disease causing adhesions or inflammatory strictures
- Neoplasms, benign or malignant
- Intussusception
- Volvulus
- Superior mesenteric artery syndrome, a compression of the duodenum by the superior mesenteric artery and the abdominal aorta
- Ischemicstrictures
- )
- Intestinal atresia
- Urinary retention
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).[21]
Large bowel obstruction
Causes of large bowel obstruction include:[22]
- Neoplasms / cancer
- Diverticulitis / Diverticulosis
- Hernias
- Inflammatory bowel disease
- Colonic volvulus (sigmoid, caecal, transverse colon)
- Adhesions
- Constipation
- Fecal impaction
- Fecaloma
- Colon atresia
- Intestinal pseudoobstruction
- Endometriosis
- Narcotic induced (especially with the large doses given to cancer or palliative care patients)
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.[23]
- Functional outlet obstruction
- Inefficient inhibition of the internal anal sphincter
- Short-segment Hirschsprung's disease
- Chagas disease
- Hereditary internal sphincter myopathy
- Inefficient relaxation of the striated pelvic floor muscles
- Anismus (pelvic floor dyssynergia)
- Multiple sclerosis
- Spinal cord lesions
- Inefficient inhibition of the internal anal sphincter
- Mechanical outlet obstruction
- Internal intussusception
- Enterocele
- Dissipation of force vector
- rectocele
- Descending perineum
- Rectal prolapse
- Impaired rectal sensitivity
- Megarectum
- Rectal hyposensitivity
Treatment
Treatment of small and large bowel obstructions are initially similar and non-operative management is usually the initial management strategy as the majority of small bowel obstruction resolve spontaneously with non-operative management.
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.[30]
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"[31] because about 5.5%[31] 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] Exam findings of bowel compromise requiring immediate surgery include: severe abdominal pain, signs of peritonitis such as rebound tenderness, elevated heart rate, fever, and elevated inflammatory markers on lab work, such as lactic acid.[32][33]
A small flexible tube (
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
Conservative treatment involves insertion of a
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.[38]
Small bowel obstruction caused by
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%.[39]
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 a more poor prognosis.[40] Surgical options in patients with malignant bowel obstruction need to be considered carefully as while it may provide relief of symptoms in the short term, there is a high risk of mortality and re-obstruction.[41]
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.[42] More than 90% of patients also form adhesions after major abdominal surgery.[43] Common consequences of these adhesions include small-bowel obstruction, chronic abdominal pain, pelvic pain, and infertility.[43]
See also
- Impaction (animals) – A blockage of the intestines in animals
- Neonatal bowel obstruction – A blockage of the intestines in children
- Spastic intestinal obstruction
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