Large or Small Bowel Obstruction
Etiology of bowel obstruction
Assessment and diagnosis of bowel obstruction
Treatment of acute bowel obstruction
Management of chronic, malignant bowel obstruction
There are four types of obstruction:
- Simple.
- Closed-loop.
- Strangulated.
-
Incarcerated.
A simple obstruction is blocked in one place; a
closed-loop obstruction is blocked in two places. A closed-loop obstruction may develop
when the bowel twists around on itself, isolating the looped section of the
bowel and obstructing the portion above it. With a strangulated obstruction,
there is decreased blood flow to the bowel that, if not relieved, will develop
into an incarcerated obstruction, and the bowel will become necrotic.
The obstructing mechanism can be mechanical or nonmechanical. Mechanical
factors can be anything that causes a narrowing of the intestinal lumen (e.g.,
inflammation or trauma to the bowel, neoplasms, adhesions, hernias, volvulus,
or a compression from outside the intestinal tract).[1] Nonmechanical factors
include those that interfere with the muscle action or innervation of the
bowel: paralytic ileus, mesenteric embolus or thrombus, and hypokalemia.
Eighty percent of bowel obstructions occur in the small intestine; the other
20% occur in the colon.[2] Bowel obstructions are frequently seen in the
ileum. Small bowel obstructions are caused often by adhesions or hernias,
whereas large bowel obstructions are caused by carcinomas, volvulus,
or diverticulitis. The presentation of obstruction will relate to whether the
small or large intestine is involved.
Etiology of bowel obstruction
The most common malignancies that cause bowel obstruction are cancers of the
colon, stomach, and ovary. Extra-abdominal cancers (such as lung and breast
cancers and melanoma) can spread to the abdomen, causing bowel obstruction.[3]
Patients who have had abdominal surgery or abdominal radiation are also at
higher risk of developing bowel obstruction.[2] Bowel obstructions are most
common during advanced stages of disease.
Assessment and diagnosis of bowel obstruction
Examination of the patient will determine the presence or absence of abdominal
pain, vomiting, and evidence of the passage of flatus or stool. A complete
blood cell count, electrolyte panel, and urinalysis are obtained to evaluate
fluid and electrolyte imbalance and/or sepsis. An elevated white blood cell
count (15,000–20,000/mm3) suggests bowel necrosis. Flat
and upright abdominal films as well as a barium enema may be necessary to
determine where the obstruction is located. While it remains controversial, an
upper gastrointestinal series is contraindicated with an acutely presenting
obstruction because it can cause a partial obstruction to become complete or
may further complicate a total obstruction. If the patient is exhibiting
dehydration, oliguria, or shock, perforation of the bowel may have occurred,
and immediate medical or surgical intervention is indicated. (Refer to the Nausea, Vomiting, Constipation, and Bowel Obstruction in Advanced Cancer section in the PDQ summary on Nausea and Vomiting for more information.)
Treatment of acute bowel obstruction
Careful serial examinations are necessary in the management of patients with
progressive abdominal symptoms that may be due to acute bowel obstruction. The
principles of supportive care in this setting include volume resuscitation,
correction of electrolyte imbalances, and transfusion support (if necessary).
These measures should precede or accompany decompression efforts.
When bowel obstruction is partial, decompression of the distended bowel may be
attempted with nasogastric or intestinal tubes. Although use of these tubes
may be successful in reducing edema, relieving fluid and gas accumulation, or
decreasing the need for multiple stage procedures,[4] surgery may be necessary
within 24 hours if there is complete, acute obstruction.
The use of self-expandable stents to decompress complete, acute malignant bowel obstruction has been noted to decrease the frequency of unnecessary surgery by permitting staging of the disease, increasing the rate of primary anastomosis relative to colostomy, and decreasing morbidity in patients with left-sided colon and rectal malignancies. Further study is warranted including cost analysis.[5]
Management of chronic, malignant bowel obstruction
Patients with advanced cancer may have chronic, progressive bowel obstruction
that is inoperable.[6,7] The most frequent causes of inoperability are extensive
tumor and multiple partial obstructions.[8-10] A retrospective review evaluating surgical palliation of malignant bowel obstruction secondary to peritoneal carcinomatosis in 63 patients with nongynecological cancer used the ability to tolerate solid food at hospital discharge as the criterion for successful palliation. Multiple logistic regression analysis identified the absence of ascites and obstruction not involving the small bowel as predictors of successful surgical palliation in this population. Successful palliation was achieved in 45% of patients and was maintained in 76% of this group at a median follow-up of 78 days, for an overall success rate of 35%. Postoperative mortality was 15%, and postoperative complications occurred in 44%.[11]
For some patients with malignant obstructions of the gastrointestinal tract, the use of expandable metal stents may provide palliation of obstructive symptoms. Available stents include esophageal, biliary, gastroduodenal, and colorectal.[12-16,5,17]
Stents may be placed under endoscopic guidance, with or without fluoroscopy, or by an interventional radiologist using fluoroscopy. Morbidity with stent placement may be lower than with surgery. Adequate imaging of the stricture itself and the gastrointestinal tract distal to the stricture is recommended to assess stricture length, detect multifocal disease, and determine the appropriateness of stenting.[18-20].
When neither surgery nor stenting is possible, the accumulation
of the unabsorbed secretions produce nausea, vomiting, pain, and colicky
activity as a consequence of the partial or complete occlusion of the lumen.
In this case, a gastrostomy tube is commonly used to provide decompression of
air and fluid that may be accumulating and causing visceral distention and
pain. The gastrostomy tube is placed into the stomach and is attached to a drainage bag
that can be easily concealed under clothing. When the valve between the
gastrostomy tube and the bag is open, the patient may be able to eat or drink
by mouth without creating discomfort since the food is drained directly into
the bag. Dietary discretion is advised to minimize the risk of tube
obstruction by solid food. If the obstruction improves, the valve can be
closed and the patient may once again benefit from enteral nutrition.
Sometimes, decompression is difficult even with a gastrostomy tube in place.
This problem may be caused by the accumulation of fluid, since several liters per day of
gastrointestinal secretions may be produced. To relieve continuous abdominal
pain, opioid analgesics via continuous subcutaneous or intravenous infusion may
be necessary. Effective antispasmodics in this situation include
anticholinergics (such as hyoscine butylbromide) [21] and possibly
corticosteroids as well as centrally acting agents. If the bowel obstruction
is thought to be functional (rather than mechanical) in origin, metoclopramide
is the drug of choice because of its prokinetic effects on the bowel. For complete
bowel obstruction thought to be irreversible, a trial of an antispasmodic such
as hyoscyamine may decrease bowel contractions and therefore yield pain
relief. Another option for management of refractory pain and/or nausea is the
synthetic somatostatinanalog octreotide. This agent inhibits the release of
several gastrointestinal hormones and reduces gastrointestinal
secretions.[22-24] Octreotide is usually given subcutaneously at 50 to 200 µg
3 times per day and may reduce the nausea, vomiting, and abdominal pain of malignant bowel obstruction. For selected patients, the addition of an anticholinergic such as scopolamine may be helpful in reducing the associated painful colic of malignant bowel obstruction when octreotide alone is ineffective. When either scopolamine or octreotide is used alone, each is ineffective.[12,25-27] Corticosteroids are widely used in treating
bowel obstruction, but empirical support is limited.[28] They may be useful as
adjuvant antiemetics and analgesics in this setting given as dexamethasone at a
starting dose of 6 to 10 mg subcutaneously or intravenously 3 to 4 times per
day.[12,25] (Refer to the Nausea, Vomiting, Constipation, and Bowel Obstruction
in Advanced Cancer section in the PDQ summary on Nausea and Vomiting for more information.)
References
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Ripamonti C, De Conno F, Ventafridda V, et al.: Management of bowel obstruction in advanced and terminal cancer patients. Ann Oncol 4 (1): 15-21, 1993.
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