Bowel obstruction Classification and external resources
Upright abdominal X-ray demonstrating a small bowel obstruction. Note multiple air fluid levels.
ICD-10 K56 ICD-9 560 DiseasesDB 15838 MedlinePlus 000260 MeSH D007415
Bowel obstruction (or intestinal 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. The condition is often treated conservatively over a period of 2-5 days with the patient's progress regularly monitored by an assigned physician. Surgical procedures are performed on occasion however in life-threatening cases, such as when the root cause is a fully lodged foreign object or malignant tumor.
Signs and symptoms
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.
Small bowel obstruction
Causes of small bowel obstruction include:
- Adhesions from previous abdominal surgery
- Hernias containing bowel
- Crohn's disease causing adhesions or inflammatory strictures
- Neoplasms, benign or malignant
- Intussusception in children
- Superior mesenteric artery syndrome, a compression of the duodenum by the superior mesenteric artery and the abdominal aorta
- Ischaemic strictures
- Foreign bodies (e.g. gallstones in gallstone ileus, swallowed objects)
- Intestinal atresia
- Carcinoid rare, preferred location: ileum
Large bowel obstruction
Causes of large bowel obstruction include:
- Inflammatory bowel disease
- Colonic volvulus (sigmoid, caecal, transverse colon)
- Adhesion (medicine)
- Fecal impaction
- Colon atresia
- Intestinal pseudoobstruction
- Benign strictures (diverticular disease)
Differential diagnoses of bowel obstruction include:
- Pseudo-obstruction or Ogilvie's syndrome
- Intra-abdominal sepsis
- Pneumonia or other systemic illness.
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
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" because they are sometimes fatal if treatment is delayed. This traditional surgical canon is no longer followed, largely because of improvements in radiologic imaging of small bowel obstruction, which allow confident distinction between simple obstructions, that can be treated conservatively, and obstructions associated with surgical emergencies (volvulus, closed-loop obstructions, ischemic bowel, incarcerated hernias, etc.).
A small flexible tube may be inserted from the nose into the stomach to help decompress the dilated bowel. This tube is uncomfortable but does relieve the abdominal cramps, distension and vomiting. Intravenous therapy is utilized and the urine output is monitored with a catheter in the bladder.
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. However, when conservative management is undertaken, the patient is examined several times a day and X rays are obtained to ensure that the individual is not getting clinically worse.
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.
Most patients do improve with conservative care in 2–5 days. However, in some occasions, the cause of obstruction may be a cancer and in such cases, surgery is the only treatment. These individuals undergo surgery where the cause of SBO is removed. Individuals who have bowel resection or lysis of adhesions usually stay in the hospital a few more days until they are able to eat and walk.
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.
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 a sonogram, 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.
The prognosis for most cases of SBO is excellent. Most non cancerous causes of SBO do well. However, when cancer is the cause of SBO, patients are generally worked up to ensure that there has been no spread. If the cancer is localized to the small bowel, the patient will do well. If the cancer has spread, then the individual may require radiation or chemotherapy.
- ^ Maglinte DD, Kelvin FM, Rowe MG, Bender GN, Rouch DM (1 January 2001). "Small-bowel obstruction: optimizing radiologic investigation and nonsurgical management". Radiology 218 (1): 39–46. PMID 11152777. http://radiology.rsnajnls.org/cgi/content/full/218/1/39.
- ^ Small Bowel Obstruction overview Retrieved on February 19, 2010
- ^ Small Bowel Obstruction:Treating Bowel Adhesions Non-Surgically Clear Passage treatment center online portal. Retrieved on 2010-02-19
- ^ Small Bowel Obstruction The Eastern Association for the Surgery of Trauma. February 19, 2010
- Podcast on the management of small bowel obstruction
- Podcast on the management of large bowel obstruction
- Obstruction, Small Bowel at eMedicine
- Obstruction, Large Bowel at eMedicine
- UCSF Fetal Treatment Center: Bowel Obstructions
- Intestinal Obstruction in Adults
- A Lecture on Bowel Obstruction
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