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Large Bowel Obstruction

LBO

Large bowel obstruction is a condition that leads to a blockage in a specific region of the colon, thus preventing the normal movement of stool and gas. It may lead to complications such as ischemia, necrosis, and peritonitis.


Presentation

A large bowel obstruction (LBO) can involve a blockage of the whole or part of the colonic lumen. Firstly, if the obstruction is complete, the patient presents with acute and profound symptomatology; in a partial large bowel obstruction the symptoms are milder and it is not a threatening condition.

A patient affected by partial large bowel obstruction presents with a medical history of constipation, but and reports the passing of a reduced amount of gas as well as stool. In a complete large bowel obstruction, the main symptoms are usually characteristic, with the individuals complaining of abdominal pain and distention, complete inability to pass fecal matter and gas, and vomiting [1] [2] [3]. Patients who report with severe abdominal pain, rigidity, guarding, fever and signs of shock, with a medical history of constipation and distention should be treated immediately, as a large bowel obstruction can likely evolve into a perforation and subsequent peritonitis.

Other findings that may also be noticed are usually not caused by LBO itself, but by the underlying pathology. Intermittent left-lower-quadrant pain in the abdomen over a long period of time and generally recurring constipation may be caused by diverticulitis. This sign together with colorectal cancer and volvulus forms the three primary causes of LBO [4]. Weight loss may be reported by individuals who are affected by colorectal cancer.

Soft Tissue Mass
  • Abdominal computed tomography revealed hugely dilated large bowel up to the sigmoid colon, with sigmoid soft tissue mass.[ncbi.nlm.nih.gov]
  • Normal Scout :  Always request: Supine, Erect and CXR  Gas pattern: Gastric,Colonic and 1-2 small bowel  Fluid Levels:  Free gas under diaphragm  Look for calcification  Look for soft tissue masses. 11.  look for free air under diaphragm, dilated[slideshare.net]
Sulfur Granules
  • A diverting loop colostomy was performed, and pathology revealed sulfur granules from the extracted IUD that grew Actinomyces.[ncbi.nlm.nih.gov]
Prolonged Bleeding
  • Many commonly prescribed drugs can interact with warfarin and prolong bleeding time beyond therapeutic limits. We report a patient who developed a rectus sheath haematoma following inadvertent over anticoagulation.[ncbi.nlm.nih.gov]
Pleural Effusion
  • These included elevation of the hemidiaphragm in one case, loss of definition of a portion of the hemidiaphragm due to adjacent confluent opacity in two cases, pleural effusion in two cases, and small cystic lucencies above the diaphragmatic contour in[ncbi.nlm.nih.gov]
Constipation
  • A patient affected by partial large bowel obstruction presents with a medical history of constipation, but and reports the passing of a reduced amount of gas as well as stool.[symptoma.com]
  • A 32-year-old female patient presented to the emergency department with complaints of diffuse abdominal pain and constipation for 10 days with progressive abdominal distention and vomiting.[ncbi.nlm.nih.gov]
Vomiting
  • A 27-year-old woman presented to the emergency department with a 24-hour history of severe left iliac fossa pain associated with vomiting.[ncbi.nlm.nih.gov]
  • .  Abdominal pain  Distention  Constipation  Nausea  Vomiting 8.  Proximal obstruction: early bilious vomiting.  Distal obstruction: constipation, distension, vomiting feculent material (bacterial overgrowth of contents).  Distal obstruction:[slideshare.net]
  • […] pain more constant, vomitting later, much more distension •Presentation: Colicky abdominal pain,constipation/obstipation –Vomiting - late( faeculent) abdominal distension –Fever, sepsis and shock, peritonism •Leftsided tumours: Change in bowel habit,[cram.com]
Abdominal Pain
  • Abnormalities of the left hemidiaphragmatic contour on plain radiographs of the chest should suggest the diagnosis in patients who have abdominal pain, colonic dilatation, and a history of abdominal injury.[ncbi.nlm.nih.gov]
  • In a complete large bowel obstruction, the main symptoms are usually characteristic, with the individuals complaining of abdominal pain and distention, complete inability to pass fecal matter and gas, and vomiting.[symptoma.com]
Nausea
  • The diagnosis of adult obstruction was made from a history of constipation, abdominal distension, abdominal pain, nausea, and radiographic features of large bowel obstruction. Laparotomy was performed on all patients after resuscitation.[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]
  • Causes include Carcinoma (60%) Diverticulitis (20%) Volvulus Strictures, such as from Crohn disease Fecal impaction Hernia Imperforate anus or meconium ileus in pediatric population Increases in prevalence with age Clinical Findings Abdominal distension Nausea[learningradiology.com]
  • Secondary Objectives: are to evaluate the symptom response (including abdominal pain, distention, bowel frequency and consistency, and nausea and emesis) and complication rate of treatment of malignant large bowel obstruction with endoscopic stent placement[clinicaltrials.gov]
  • This is the characteristic presentation of a sigmoid volvulus 19.  20 year old woman presented to the ED with 12 hours of abdominal pain, nausea. and vomiting low grade fever.  No past surgical history  PMH: Polycystic ovarian disease 20.[slideshare.net]
Abdominal Distension
  • Snap Shot A 65 yo presents with abdominal distension and colicky pain . Introduction Adhesions are the most common cause of all bowel obstructions.[medbullets.com]
  • The diagnosis of adult obstruction was made from a history of constipation, abdominal distension, abdominal pain, nausea, and radiographic features of large bowel obstruction. Laparotomy was performed on all patients after resuscitation.[ncbi.nlm.nih.gov]
  • […] obstruction of the colon Causes include Carcinoma (60%) Diverticulitis (20%) Volvulus Strictures, such as from Crohn disease Fecal impaction Hernia Imperforate anus or meconium ileus in pediatric population Increases in prevalence with age Clinical Findings Abdominal[learningradiology.com]
  • A 64-year-old man presented with abdominal distension, pain, and vomiting for 5 days. Computed tomography scan of the abdomen showed dilated small intestine and colon, air in the biliary tree, and a calcified mass in the sigmoid colon.[amjmed.org]
  • […] pain more constant, vomitting later, much more distension •Presentation: Colicky abdominal pain,constipation/obstipation –Vomiting - late( faeculent) abdominal distension –Fever, sepsis and shock, peritonism •Leftsided tumours: Change in bowel habit,[cram.com]
Bladder Distention
  • Later the patient underwent surgery to remove an enlarged benign prostatic adenoma, which was the underlying cause of the bladder distention.[ncbi.nlm.nih.gov]

Workup

The diagnosis of large bowel obstruction is made primarily via the use of imaging modalities, as well as laboratory tests that do not exactly serve the diagnostic purposes but help to comprehensively evaluate the patient's status. The elimination of ileus as a possible alternative diagnosis is also carried out via laboratory tests.

Blood tests involve:

  • Complete blood count. A significantly raised white blood count indicates peritonitis, as opposed to uncomplicated large bowel obstruction.
  • Biochemical profile, including electrolytes, lactate dehydrogenase (LDH), glucose, alkaline phosphatase (ALP), urea, creatinine, cholesterol, triglycerides, c-reactive protein (CRP), erythrocyte sedimentation rate (ESR) etc. Prothrombin type (PT-INR) and serum lactate should also be measured, with the latter helping in the detection of potential perforation. Liver function tests are also recommended.
  • Stool guaiac test
  • Crossmatch

Imaging modalities include the following:

  • Radiography: It constitutes the very initial imaging method used, with a specificity and sensitivity of approximately 70 and 80% [5]. Abdominal radiographs are obtained in a supine and erect position and can illustrate air-fluid levels and colonic diameter; free air indicative of pneumoperitoneum due to perforation is also depicted.
  • Computerized Tomography scan (CT scan): It can provide the physician more information than a plain radiograph; this accounts for the rising replacement of X-rays by a CT scan in the present day [6]. The administration of contrast media can differentiate between partial and complete obstruction, small and large bowel obstruction and ileus [6].
  • Multiple detector computed tomography (MDCT). Its sensitivity is 96%, while the specificity is approximately 93% [7] [8]. The cause of LBO, potential complications, and its ability to differentiate between pseudo-obstruction, volvulus of the colon and other pathologies render it an extremely useful means of evaluating a possible large bowel obstruction.
Pneumoperitoneum
  • This sign can be more frequently mistaken for pneumoperitoneum which is usually an indication of bowel perforation and can lead to needless surgical intervention.[ncbi.nlm.nih.gov]
  • Abdominal radiographs are obtained in a supine and erect position and can illustrate air-fluid levels and colonic diameter; free air indicative of pneumoperitoneum due to perforation is also depicted.[symptoma.com]
  • ., pneumoperitoneum) Disadvantages Typically does not provide the cause, degree, or precise location of obstruction, which would often affect clinical management Often not diagnostic Barium enema Advantages Can clearly identify transition point in sigmoid[cancertherapyadvisor.com]
  • […] small bowel dilatation, depends on duration of obstruction incompetence of the ileocecal valve In advanced cases one may see the stigmata of an ischemic colon , namely: intramural gas ( pneumatosis coli ) portal venous gas free intra-abdominal gas ( pneumoperitoneum[radiopaedia.org]
Bowel Distention
  • During the freeze cycle of endoscopic spray cryotherapy, high-flow nitrogen was injected onto the tumor, which caused bowel distention.[acgcasereports.gi.org]
  • Pathophysiologic effects of bowel distention on intestinal blood flow. Am J Surg. 1969;117(2):228–34. PubMed Google Scholar 9. Stillwell GK. The law of Laplace. Some clinical applications. Mayo Clinic Proc. 1973;48(12):863–9. Google Scholar 10.[link.springer.com]
X-Ray Abnormal
  • Home » Tutorials » Abdominal X-ray Tutorials » Abdominal X-ray - Abnormal bowel gas pattern » Introduction » 1 2 3 4 5 6 » Conclusion Key points Dilatation of the caecum 9cm is abnormal Dilatation of any other part of the colon 6cm is abnormal Abdominal[radiologymasterclass.co.uk]
Pleural Effusion
  • These included elevation of the hemidiaphragm in one case, loss of definition of a portion of the hemidiaphragm due to adjacent confluent opacity in two cases, pleural effusion in two cases, and small cystic lucencies above the diaphragmatic contour in[ncbi.nlm.nih.gov]

Treatment
  • Twenty-five studies of the diagnosis and treatment of obstruction and 34 studies of the use of stents were assessed.[ncbi.nlm.nih.gov]

Prognosis
  • It is regarded as a distinct form of osteosarcoma with better prognosis than conventional osteosarcoma.[ncbi.nlm.nih.gov]
  • Prognosis of Large Bowel Obstruction The prognosis for someone with a large bowel obstruction depends on many factors, including the timing of treatment, the patient’s age, the cause of the obstruction, and the presence of other illnesses, particularly[newhealthadvisor.com]
  • Treatment and prognosis Treatment depends on the underlying cause and presentation, but in all cases resuscitation and correction of electrolyte imbalances should be carried out.[radiopaedia.org]
  • Prognosis and Patient Counseling. Sigmoid volvulus carries a 40-50% recurrence rate. Early intervention with elective sigmoidectomy is key to preventing serious complications.[clinicaladvisor.com]

Etiology
  • For malignant etiology, the SEMS procedure was a technical and clinical success in 97.4% of the cases. Complications occurred in 21%, mortality rate 2,6%.[ncbi.nlm.nih.gov]
  • The etiology of LBO is usually divided into neoplastic diseases and nonneoplastic diseases. However, the most common cause is the neoplastic etiology.[jhu.pure.elsevier.com]
  • Etiology The underlying etiology of large bowel obstructions is age-dependent, but in adulthood, the most common cause is colonic cancer (50-60%), typically in the sigmoid 1-4 .[radiopaedia.org]

Epidemiology
  • Details about this forecast and other discussions of sepsis epidemiology can be found in the EpiCast Report: Sepsis and Septic Shock – Epidemiology Forecast to 2026 and the EpiCast Model: Sepsis and Septic Shock – Epidemiology Forecast to 2026.[hospitalmanagement.net]
  • “Epidemiology of pediatric inflammatory bowel disease: A systematic review of international trends”. Inflammatory Bowel Disease 2011; 17 (1), 423–439. Castro M., Papadatou B., Baldassare M., Balli F. et al.[ragazzicoraggiosi.it]
  • Organ dysfunctions during severe sepsis and septic-like syndromes: epidemiology, classification, and mechanism. Cavaillon J-M, Adrie C, eds.[medscape.com]
  • Parazzini F, Esposito G, Tozzi L, Noli S, Bianchi S: Epidemiology of endometriosis and its comorbidities. Eur J Obstet Gynecol Reprod Biol 2017;209:3-7.[karger.com]
  • Lever A, Mackenzie I: Sepsis: definition, epidemiology, and diagnosis. BMJ 2007, 335: 879-883. 7.[ccforum.biomedcentral.com]
Sex distribution
Age distribution

Pathophysiology
  • Pathophysiology The prevalence of mechanical large-bowel obstruction (LBO) increases with age, as does that of its main causes, colon cancer and diverticulitis.[emedicine.medscape.com]
  • PubMed Google Scholar Andrus CH, Ponsky JL: Bezoars: classification, pathophysiology, and treatment. Am J Gastroenterol. 1988, 83 (5): 476-8.[jmedicalcasereports.biomedcentral.com]
  • Focus is on predisposing factors, microbiology, pathophysiology, and the 4 components of therapy -- antibiotics, volume replacement, steroids, and surgical drainage.[ncbi.nlm.nih.gov]
  • Pathophysiology: A mechanical obstruction (intrinsic or extrinsic) of the colon leads to luminal stasis, allowing more anerobic bacteria to proliferate, leading to fermentation and increased gas production.[clinicaladvisor.com]

Prevention
  • Surgical management is the treatment of choice to prevent the disastrous complications of large-bowel obstruction. We describe the case of a 92-year-old man who presented with symptoms and signs of large-bowel obstruction.[ncbi.nlm.nih.gov]
  • How to Prevent Large Bowel Obstruction To prevent a large bowel obstruction, you should live a healthy lifestyle.[newhealthadvisor.com]

References

Article

  1. Ramanathan S, Ojil V, Vassa R, Nagar A. Large Bowel Obstruction in the Emergency Department: Imaging Spectrum of Common and Uncommon Causes. J Clin Imaging Sci. 2017; 7: 15.
  2. Zielinski MD, Eiken PW, Bannon MP, et al. Small bowel obstruction-who needs an operation? A multivariate prediction model. World J Surg. 2010;34:910–19.
  3. Pujahari AK. Decision Making in Bowel Obstruction: A Review. J Clin Diagn Res. 2016 Nov;10(11).
  4. Yeo HL, Lee SW. Colorectal emergencies: Review and controversies in the management of large bowel obstruction. J Gastrointest Surg. 2013;17:2007–12.
  5. Gore RM, Levine MS. Textbook of Gastrointestinal Radiology. 3rd ed. Philadelphia, PA: Saunders, Elsevier; 2008.
  6. Jaffe T, Thompson WM. Large-bowel obstruction in the adult: classic radiographic and CT findings, etiology, and mimics. Radiology. 2015 Jun;275(3):651-63.
  7. Frager D, Rovno HD, Baer JW, Bashist B, Friedman M. Prospective evaluation of colonic obstruction with computed tomography. Abdom Imaging. 1998;23:141–6.
  8. Godfrey EM, Addley HC, Shaw AS. The use of computed tomography in the detection and characterisation of large bowel obstruction. N Z Med J. 2009;122:57–73.

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Last updated: 2019-06-28 10:27