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Updated: Dec 15 2021

Large Bowel Obstruction

  • Snapshot
    • A 65-year-old man presents to the emergency room for increased abdominal pain and distention. He has a history of diverticulosis and chronic constipation. He last had a bowel movement 1 week ago and has not had any flatus in the past day. He reports 2 episodes of vomiting at home. On physical exam, his abdomen is distended and there is diffuse tenderness to palpation. A CT of his abdomen and pelvis shows dilated loops of bowel and a suspicious mass at the transition point. The surgery team is consulted and he is prepped for surgical intervention.
  • Introduction
    • Overview
      • large bowel obstruction, or LBO, is a surgical emergency and requires intervention
        • obstruction may be partial or complete
        • complete obstructions require immediate surgical intervention
    • Demographics
      • elderly patients
    • Risk factors
      • chronic constipation
  • Etiology
    • Volvulus
    • Intussusception
    • Colonic mass/malignancy
    • Diverticular disease
    • Fecal impaction
    • Stricture
    • Incarcerated hernia
    • Pathogenesis
      • mechanism
        • mechanical obstruction in the large bowel causes bowel dilatation above the point of obstruction
          • causes bowel edema and ischemia
          • causes electrolyte abnormalities
  • Presentation
    • History
      • chronic constipation
      • lack of flatus
        • indicates complete obstruction
        • some passage of flatus or stool
          • indicates partial obstruction
    • Symptoms
      • crampy abdominal pain
      • nausea and vomiting
      • bloating
    • Physical exam
      • inspection
        • abdominal distention
      • motion
        • tenderness to palpation
        • abdominal rigidity
        • quiet or absent bowel sounds
      • provocative tests
        • digital rectal exam
          • may reveal hard stool in the rectal vault
  • Imaging
    • Abdominal radiographs
      • indications
        • all patients
        • screen for free air under the diaphragm
      • views
        • flat
        • upright
      • findings
        • dilated bowel
    • Contrast radiography with enema
      • indication
        • if CT findings are equivocal and volvulus is suspected
      • findings
        • “bird’s beak” appearance
    • Computed tomography (CT) of abdomen and pelvis with contrast
      • indications
        • imaging of choice for diagnosis of LBO
        • distinguishes between a partial or complete obstruction
      • findings
        • mechanical obstruction identified
        • dilated loops of bowel
      • contrast agent
        • gastrografin should be used if bowel perforation is suspected
  • Studies
    • Serum labs
      • basic metabolic panel
        • to correct any electrolyte abnormalities
      • lactate
        • to evaluate for bowel ischemia
      • complete blood cell count
        • white blood cells are only mildly elevated
  • Differential
    • Small bowel obstruction
      • key distinguishing factor
        • dilated loops of small bowel seen on imaging, rather than dilated loops of large bowel
    • Ogilvie syndrome
      • key distinguishing factor
        • no mechanical lesion on CT imaging that can cause the obstruction
  • Treatment
    • Lifestyle
      • modified diet
        • indications
          • for patients with history of obstruction
        • modalities
          • high-fiber diet
          • stool softeners
    • Medical
      • observation and bowel rest
        • indications
          • mild symptoms without vomiting
        • modalities
          • intravenous fluids
          • correct electrolyte abnormalities
      • nasogastric decompression and bowel rest
        • indications
          • abdominal distention
          • vomiting
    • Surgical
      • exploratory laparotomy
        • indications
          • complete LBO
          • bowel ischemia
          • volvulus
  • Complications
    • Ischemic colitis
    • Bowel perforation
  • Prognosis
    • Prognostic variable
      • if treated early, mortality for LBO is low
      • if there is bowel ischemia or perforation, mortality is higher
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