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Intestinal Obstruction

Intestinal obstruction is a blockage of the intestine that affects the passage of contents in the gut. The blockage may be seen in the small or large intestine, and may be partial or complete.


Presentation

Symptoms of bowel obstruction depend on underlying pathophysiology. Abdominal discomfort and distention are some of the first indications of this condition. In most of the cases, stool discharge may be affected. Vomiting, malnutrition, fever and hypotension are some other common symptoms.
In many cases, symptoms indicate the location and nature of blockage. Vomiting along with colicky pain is seen if the obstruction is in the proximal region of the small intestine. When the obstruction is in the distal part of the small intestine, pain may remain for main days. They may also present with abdominal distension. An increasing pain may indicate more serious conditions like ischemic bowel obstruction or a strangulated SBO.
Onset of symptoms in LBO is slower. Acute form of bowel obstruction often have abrupt onset of manifestations. Those with colon carcinoma or diverticulitis  may present with chronic constipation or a strain to pass stools. Strictures and diverticulitis may cause a chronic pain in the lower quadrant of the abdomen. Obstruction caused by neoplasms often have sudden weight loss as one of the symptoms. Inability to pass stools may be associated with complete blockage of the large intestine. It may also lead to anorexia and, at a later stage, feculent vomiting.

Inguinal Hernia
  • Manual reduction of inguinal hernia is unacceptable.[elearning.sumdu.edu.ua]
  • Dilated proximal loops of small bowel enter a large right inguinal hernia.[imagingpathways.health.wa.gov.au]
  • Parents may see a bulge in the groin area when an inguinal hernia is present. Incarceration occurs only rarely after eight years of age.[encyclopedia.com]
  • It is also important to look for possible causes of obstruction such as inguinal hernias so always include a genitourinary examination.[saem.org]
  • Small-bowel obstruction caused by an incarcerated inguinal hernia in a 2-month-old infant with bilateral inguinal hernias as well as an umbilical hernia. Incarcerated left inguinal hernia.[emedicine.medscape.com]
Hypothermia
  • In the obstructed patients with appearance of systemic compromission (hypothermia, tachycardia, fever, and renal failure), the complete clinical assessment requires arterial blood gas (ABG) and serum lactate.[intechopen.com]
  • […] stricture Ischaemic stricture Adhesions Hernias Volvulus Intussception Congenital bands Inflammatory masses Tumours Benign Malignant Constipation Foreign bodies Gallstones Parasites Bezoars Functional SYSTEMIC LOCAL Metabolic: Hypokalaemia Hyponatraemia Hypothermia[rcemlearning.co.uk]
Vomiting
  • Ondansetron use for nausea and vomiting during pregnancy has increased in the last years, although its maternal and fetal safety is not conclusive.[ncbi.nlm.nih.gov]
  • Intestinal obstruction presents with three classic clinical signs: vomiting, abdominal distention, and failure to pass meconium.[ncbi.nlm.nih.gov]
  • She developed persistent non-bilious vomiting that was associated with constipation soon after birth. She presented with failure to thrive and features suggestive of intestinal obstruction.[ncbi.nlm.nih.gov]
  • Vomiting, malnutrition, fever and hypotension are some other common symptoms. In many cases, symptoms indicate the location and nature of blockage.[symptoma.com]
  • We report a case of a 5-day-old previously healthy baby who presented to our pediatric emergency department with bilious vomiting, grossly bloody stool, and abdominal distention.[ncbi.nlm.nih.gov]
Abdominal Pain
  • This was associated with cyclical lower abdominal pains, abdominal swelling, and weight loss. Examination revealed hyperactive bowel sounds with scant fecal matter on rectal examination.[ncbi.nlm.nih.gov]
  • The management of abdominal pain in cystic fibrosis can be complicated. Distal intestinal obstruction syndrome is a common cause of pain and obstruction in these patients.[ncbi.nlm.nih.gov]
  • Diagnosis is based on suggestive symptoms of abdominal pain in the right lower quadrant, a palpable mass on examination and signs of obstruction on plain radiography. Treatment consists of intensive laxative treatment with oral laxatives and enemas.[ncbi.nlm.nih.gov]
  • Kinking of bowel within the accessory peritoneal layer or adhesions between the bowel loops and the peritoneal layer causes symptoms ranging from colicky abdominal pain to rarely intestinal obstruction.[ncbi.nlm.nih.gov]
  • It may be asymptomatic but it commonly presents with abdominal pain. Some individuals may have a palpable abdominal mass and affected individuals may develop small bowel obstruction or acute abdomen.[ncbi.nlm.nih.gov]
Constipation
  • Dehydration has been proposed as a risk factor for DIOS and constipation in CF. The study primarily aimed to determine whether warmer ambient temperature and lower rainfall are risk factors for DIOS and constipation in CF.[ncbi.nlm.nih.gov]
  • CF patients operated for MI were in long-term risk for constipation/DIOS; their growth was normal. Interestingly, underlying atresia/volvulus neither increased constipation/DIOS risk nor affected growth.[ncbi.nlm.nih.gov]
  • Primary central nervous system lymphoma (PCNSL) with initial manifestations of constipation and intestinal obstruction (IO) is rare.[ncbi.nlm.nih.gov]
  • However, gastrointestinal problems such as constipation and distal intestinal obstruction syndrome (DIOS) are also important and well-recognised complications in CF.[ncbi.nlm.nih.gov]
  • It usually presents as severe constipation with colonic dilatation proximal to the aganglionic segment. The treatment is surgical, removing the aganglionic segment and restoring continuity of digestive tract.[ncbi.nlm.nih.gov]
Nausea
  • Ondansetron use for nausea and vomiting during pregnancy has increased in the last years, although its maternal and fetal safety is not conclusive.[ncbi.nlm.nih.gov]
  • A 27-year-old male presented with a history of gastric pain combined with nausea and abdominal distension that had been present for 5 d.[ncbi.nlm.nih.gov]
  • She had fallen from the monkey bars the day before presenting to our hospital, and was admitted with signs of abdominal pain, vomiting, and nausea.[ncbi.nlm.nih.gov]
  • We describe the case of a 34-year-old man admitted in the emergency department with diffuse abdominal pain, nausea, flatulence and lack of transit for feces and gas. The patient had been previously operated for peritonitis due to a perforated ulcer.[ncbi.nlm.nih.gov]
  • Nausea. Vomiting. Abdominal bloating and swelling. Abdominal pain, usually crampy. The pain usually comes in sharp waves and may get better for a while. Cleveland Clinic News & More Cleveland Clinic News & More[my.clevelandclinic.org]
Abdominal Distension
  • A 27-year-old male presented with a history of gastric pain combined with nausea and abdominal distension that had been present for 5 d.[ncbi.nlm.nih.gov]
  • Vomiting (161, 74.2%), abdominal pain (152, 70%), abdominal tenderness (113, 52.1%), constipation (111, 51.2%), and abdominal distension (104, 47.9%) were the predominant signs and symptoms.[ncbi.nlm.nih.gov]
  • Clinical examination revealed abdominal distension and/or diffuse tenderness with or without signs of peritonitis. The use of CT scans, X-rays or ultrasound did not differ significantly between patients.[ncbi.nlm.nih.gov]
  • Abdominal distension should be considered the most frequent physical sign of intestinal obstruction [ 22 – 24 ]. The degree of abdominal distension varies depending upon the site of the obstacle or the extension of the obstructed bowel.[intechopen.com]
  • There was no significant difference at six months between cisapride and placebo for abdominal distension, MD -0.90 (95% CI -2.39 to 0.59) or abdominal pain, MD -0.4 (95% CI -2.05 to 1.25).[ncbi.nlm.nih.gov]

Workup

Differentiating the different types of obstruction is important in deciding the treatment. Some of the essential laboratory tests that is helpful in diagnosis include serum levels of blood urea nitrogen and creatinine, complete blood count, lactate dehydrogenase tests and urinalysis. Measuring levels of phosphate, creatinine kinase and liver panels help in differentiating bowel obstruction from biliary or hepatic disease.

Plain radiographs in two position, supine and upright, are useful in identifying simple obstructions in small intestine [5]. The sensitivity of plain radiograph is around 75% and specificity 53%. Mean level width above 25 mm is considered as a diagnostic indicator of complete obstruction [6]. Partial blockages can be differentiated from complete blockages using enteroclysis. It can be used to distinguish neoplasms from adhesions. The method uses two contrasts for better differentiation. Barium is avoided as a contrast if perforations are suspected. Patients presenting with fever, tachycardia and abdominal pain are recommended to undergo a CT scan. This imaging technique is useful in differentiating strangulated obstruction from other types of blockages, particularly when radiography records are not confirmatory. It also helps in distinguishing the extrinsic cause of blockages from intrinsic lesions. Magnetic resonance imaging is also helpful in differentiating the different types of obstructions [7]. The site of obstruction and the actual cause also can be defined using MRI. To opt for a less invasive procedure, ultrasonography may be a good option and has very good specificity.

Bowel Distention
  • Abdominal radiographs showed air-fluid levels with mild bowel distention and shadows of roundworms. The diagnosis of IO by A lumbricoides. infestation was established and surgical approach scheduled.[ncbi.nlm.nih.gov]
  • Reinelt H – Anesthesiology – 01-FEB-2002; 96(2): 512-3 Subspecialty Related Media Keyword history 47%/2011 62%/2014 See Also: ABA:Nitrous oxide – bowel distention Sources PubMed[openanesthesia.org]
  • distention Evident air-fluid levels differential height, regular arranged disposition Bowel distention.[intechopen.com]
  • Symptoms Crampy, colicky, poorly localized abdominal pain Decreased or absent stool and flatus Nausea and/or vomiting, which often contains occult blood ('coffee grounds' in color) due to bowel distention with mucosal hemorrhage In general, more proximal[clinicaladvisor.com]
  • The abdomen may be distended and tympanic, depending on the degree of abdominal and bowel distention, and may be tender. A distinguishing feature is absent or hypoactive bowel sounds, in contrast to the high-pitched sound of obstruction.[intranet.tdmu.edu.ua]

Treatment

Treatment of the condition depends on the type and the potential risk factors. Intestinal tube is a conservative method of treatment which keeps the lumen open for the movement of bowel contents. Nasogastric tube is used to suction out the contents of the lumen and to prevent aspiration. This method helps in improving the usual symptoms of the condition. Surgical resection is the suggested method in the treatment of obstruction caused by tumor. Drainage will help to remove obstruction in case of intra-abdominal abscess. Obstruction that occurs after a radiation therapy may be treated with steroids. Under emergency, bowel decompression, fluid resuscitation followed by analgesic and antiemetic are recommended. Surgical intervention is recommended for strangulated form of SBO. Patients with complete obstruction may have to undergo surgery if other non-surgical methods do not show improvement. One of the safe methods for SBO is laparoscopy [8].

In LBO, fluid resuscitation and antibiotics are the initial treatment modalities. Patients are suggested surgical consultation, when needed. Nasogastric tubes are used in case of colonic distension. Patients with volvulus, bowel ischemia or loop obstructions need surgery. Patients with pseudo-obstruction are recommended bowel rest, hydration and treatment of the underlying disease. Pseudo-obstruction that do not show improvement with conservative treatment need pharmacologic management [9]. Surgical resection is recommended for colonic pseudo-obstruction with perforation [10].

Prognosis

Outcome of intestinal obstruction, both large and small bowel obstruction, is good if treated early. Strangulated obstructions in the small intestine, if left untreated, lead to death in all patients. Surgery reduce the mortality rate considerably in the case of strangulated SBO, particularly if it is performed within two days. Delayed surgery reduces the chances of survival. Some of the factors that affect prognosis in SBO include age, comorbidity, and treatment time. SBO is associated with complications like wound dehiscence, aspiration, sepsis and intra-abdominal abscesses.
In LBO, bowel ischemia and perforation have poor prognosis. Mortality rate for LBO ranges from 20% to 40%, with the highest for colonic obstruction with perforation. When treatment is provided early enough, pseudo-obstruction also has a good prognosis. Some of the common complications associated with LBO include peritonitis, sepsis, dehydration, perforation and intra-abdominal abscesses.

Etiology

Based on the site of obstruction, intestinal obstruction is classified into small bowel obstruction (SBO) and large bowel obstruction (LBO).

Small bowel obstruction – post-surgical adhesions are the most common cause of this condition. In acute cases, the adhesions develop within three to four weeks of surgery. In chronic SBO, adhesions develop several years after the surgery. Groin hernia, tumor, inflammatory bowel disease and volvulus also lead to obstruction in small intestine. In patients who have had abdominal surgery earlier, Crohn’s disease may lead to chronic form of SBO by progressive fibrosis. In children, SBO may be caused by congenital atresia, pyloric stenosis and intussusception.

Large bowel obstruction – the most prominent etiologic factor for LBO is neoplasms, accounting to 60% of obstructions in the large intestine. Some other common causes of this intestinal obstruction include strictures, volvulus, intussusception and impaction. Colonic wall diverticulitis results in fibrosis and thickening of the wall which reduces the lumen of large intestine.

Causes of bowel obstruction may be divided into three types – extraluminal, intrinsic, and intraluminal. Extrinsic lesions that lead to bowel obstructions include adhesions, hernia, volvulus, extrinsic neoplasms, intra-abdominal abscesses, aneurism, hematomas, and endometriosis. Intussusception, congenital malformation, neoplasms, and inflammatory strictures belonging to internal lesions that cause bowel obstruction.

Epidemiology

About 20% of emergency admissions for surgery is due to bowel obstruction. In elderly patients, mortality rate for the different types of obstruction ranges from 7% to 14% [2]. SBO accounts for about 80% of surgical admissions due to intestinal obstruction. Colonic obstruction is more common among elderly patients as neoplasms and other etiologic factors are prevalent in this age group [3]. Intussusceptions account for 80%-90% of bowel obstructions in children. This condition forms one of the most common causes of abdominal emergency in infants and children. In neonates, anatomic defects like imperforate anus may cause bowel obstruction. Around 3.2% of the patients who have undergone bariatric surgery develops SBO. More than half the cases of LBO is caused by colon carcinoma, out of which 5%-10% are complete obstructions that require surgery.

Sex distribution
Age distribution

Pathophysiology

Nervous and vascular defects of the intestine and structural changes in the intestinal wall leads to the pathophysiology of intestinal obstruction. Nervous and vascular incompetence may reduce peristalsis while alterations in the intestinal wall reduces the size of the lumen affecting the passage of content in the tract. Damage caused by bowel obstruction depend on factors like degree of blockage, loss of functionality, and the pressure inside the lumen of the intestine. As the lumen size decreases, malabsorption syndrome results. Complete obstruction of the lumen is a potentially life-threatening condition. It leads to changes in the fluid and electrolyte balance resulting in their leakage to surrounding peritoneum.

In SBO, air and secretions may collect in the intestine favoring further accumulation of fluid. Thus, peristalsis increases in the regions above and below the site of obstruction. If obstruction is in the proximal region of the intestine, it may lead to vomiting. With the progress of the disease, intraluminal pressure may increase considerably, leading to spacing of the electrolytes and proteins into the intestinal lumen. Loss of fluid along with fluid and electrolytes result in dehydration which may be severe. Necrosis and ischemia results from strangulation of the small intestine. This can lead to peritonitis and perforation in the intestine.

When blockage is caused by mechanical obstruction factors, it results in dilatation of large bowel above the site of obstruction. This impairs vascular and nervous supplies to the bowel. Mucosal edema in the intestine along with ischemia lead to systemic toxicity and dehydration. Perforation may also follow, and the process may be expedited in the presence of hernia or a closed ileocecal valve. Pseudo-obstruction of the colon may reduce peristalsis and allow fluid and gas to accumulate. The right colon and cecum are the two regions that are most commonly affected by pseudo-obstruction. Obstruction leads to perforation in about 15% of the cases [4].

Prevention

Prevention of intestinal blockage depends on the etiology of the condition. Treating the causative factors like hernias and tumors help in preventing the development of blockage in the intestine.

Summary

Intestinal obstruction, or bowel obstruction, refers to the partial or complete blockage to the transit of contents in the small or large intestine. Intestinal obstruction is a serious condition requiring early diagnosis and treatment. It can be categorized on the basis of different factors like site of obstruction, severity of blockage, and absence or presence of ischemia. Blockage can be due to mechanical interruption of movement or a pseudo-obstruction. The treatment modalities differ for mechanical and pseudo-obstruction and hence it is important to differentiate the cause of blockage in intestine [1]. Symptoms of the condition depend on severity of obstruction. A number of factors lead to bowel obstruction including neoplasms, diseases, strictures and postoperative adhesions. Obstructions are one of the most common causes of acute abdominal pain and account for one fifth of the admissions in emergency.

Patient Information

Intestinal obstruction refers to blockage of the intestine that affects the passage of contents in the tract. The blockage may be seen in the small or large intestine and may be partial or complete. When blockage develops, contents accumulate above the site of obstruction resulting in distention of bowel. If the lumen of the bowel is completely blocked it is considered as an emergency. Intestinal obstruction is one of the most common causes of acute abdominal pain and admission to emergency.

Both mechanical and non-mechanical factors lead to blockage. Stoppage of peristalsis causes distention of the bowel as the contents of the gut stop moving. Formation of scar tissue after a surgery of the abdomen, hernia, and volvulus are some other common causes of blockages in the small intestine. Severe constipation, Crohn’s disease, gallstones, congenital abnormalities of the bowel, tumors, infections inside the abdomen, and some foreign bodies may also cause bowel obstruction.

Symptoms of bowel obstruction depend on the site and degree of blockage. Abdominal pain is one of the earliest and most common symptoms of obstruction. Distension, constipation or diarrhea, vomiting, inability to pass gas, failure to pass stool, decreased appetite and bloating are other common symptoms. It is important to call the doctor if the pain is severe and constant. This may indicate perforations in the intestine and that blood supply to the gut is cut off. Medical history helps the doctor to assess the cause of the disease. Thorough physical examination followed by CT scan or an X-ray helps in locating the obstruction and identifying the cause of the condition.

Treatment of intestinal obstruction is based on the actual cause. Nasogastric tube inserted into the throat helps remove the contents from the gut. Fluid and electrolyte balance has to be maintained for improving the symptoms. If the blockage is partial, surgery may not be needed. Less invasive laparoscopy may be suggested to locate and remove the obstruction. To keep the lumen of the gut open, stents may be used, particularly in elderly patients. Surgery is used to remove the cause of blockage or to remove a part of the bowel which is completely blocked. Steroids, painkillers, antiemetics and antibiotics are often suggested to control symptoms of blockage. Outcome of the condition often depends on the cause. When treated early and appropriately, blockage can be easily treated.

References

Article

  1. Kahi CJ, Rex DK. Bowel obstruction and pseudo-obstruction. Gastroenterol Clin North Am. 2003;32(4):1229-47.
  2. Shelton BK. Intestinal Obstruction. AACN Clinical Issues. 1999;10(4):478-491.
  3. Yeh EL, McNamara RM. Abdominal pain. Clin Geriatr Med. 2007;23(2):255-70, v.
  4. Fazel A, Verne GN. New solutions to an old problem: acute colonic pseudo-obstruction. J Clin Gastroenterol. 2005;39(1):17-20.
  5. Thompson WM, Kilani RK, Smith BB, et al. Accuracy of abdominal radiography in acute small-bowel obstruction: does reviewer experience matter?. AJR Am J Roentgenol. 2007;188(3):W233-8.
  6. Lappas JC, Reyes BL, Maglinte DD. Abdominal radiography findings in small-bowel obstruction: relevance to triage for additional diagnostic imaging. AJR Am J Roentgenol. 2001;176(1):167-74.
  7. Diaz JJ Jr, Bokhari F, Mowery NT, et al. Guidelines for management of small bowel obstruction. J Trauma. 2008;64(6):1651-64.
  8. Khaikin M, Schneidereit N, Cera S, et al. Laparoscopic vs. open surgery for acute adhesive small-bowel obstruction: patients' outcome and cost-effectiveness. Surg Endosc. 2007;21(5):742-6.
  9. Saunders MD, Kimmey MB. Systematic review: acute colonic pseudo-obstruction. Aliment Pharmacol Ther. 2005;22(10):917-25.
  10. De Giorgio R, Knowles CH. Acute colonic pseudo-obstruction. Br J Surg. 2009;96(3):229-39.

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Last updated: 2018-06-22 00:29