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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.

Entire Body System

Sulfur Granules

A diverting loop colostomy was performed, and pathology revealed sulfur granules from the extracted IUD that grew Actinomyces.[ncbi.nlm.nih.gov]

Respiratoric

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]

Gastrointestinal

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]
Author information 1 Department of Surgery, Soroka University Medical Center, Beer Sheva, Israel. [email protected] Abstract A 76-year-old man presented to the emergency department with diffuse abdominal pain and constipation.[ncbi.nlm.nih.gov]
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]
An 81-year-old, Caucasian, fully independent woman without significant comorbidities presented with absolute constipation, faecal vomiting and abdominal pain.[ncbi.nlm.nih.gov]

Vomiting

Abstract 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]
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]
An 81-year-old, Caucasian, fully independent woman without significant comorbidities presented with absolute constipation, faecal vomiting and abdominal pain.[ncbi.nlm.nih.gov]
[…] 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]
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 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]
Abstract We present a case of a 58 year old white male who entered the hospital with abdominal pain and developed large bowel obstruction, simulating malignant disease.[ncbi.nlm.nih.gov]
Moreover, some patients with intermittent abdominal pain deserve anatomic investigation before being dismissed as having irritable bowel.[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]
Author information 1 Department of Surgery, Soroka University Medical Center, Beer Sheva, Israel. [email protected] Abstract A 76-year-old man presented to the emergency department with diffuse abdominal pain and constipation.[ncbi.nlm.nih.gov]

Nausea

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]
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]
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]
Causes include: adhesions adenocarcinoma divirticulitis scaring volvulus Presentation Symptoms constipation nausea/vomiting Physical exam abdominal distension surgical scars high pitched "tinkly" bowel sounds t enderness hernias Evaluation Abdominal X-ray[medbullets.com]

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]

Neurologic

Meningism

The shunt was contaminated with faeces leading to postoperative shunt infection and meningitis. Histology of the resected sigmoid colon revealed endometriosis at the site of perforation.[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.

X-Ray

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]

Bowel Distention

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]

Pleura

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

Its causes and treatments are an important part of general surgical and colon and rectal surgery practices.[ncbi.nlm.nih.gov]
BACKGROUND: The goal of this study is to evaluate our long-term experience with the decision of optimal urgent surgical treatment.[ncbi.nlm.nih.gov]
RESULTS: Forty-six patients (21.3 %) developed MLBO during the treatment or follow-up periods. The mean duration between diagnosis and MLBO was 9.8 9.3 months.[ncbi.nlm.nih.gov]
Depending on the individual circumstances, surgical resection is the treatment of choice for colon cancer even for oligometastasis.[ncbi.nlm.nih.gov]
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]
Stent insertion does not seem to have a deleterious effect on prognosis.[ncbi.nlm.nih.gov]
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.[ncbi.nlm.nih.gov]
LBO etiology comprises two main categories: neoplastic and nonneoplastic disease.[ncbi.nlm.nih.gov]
Large bowel obstruction has numerous etiologies including colorectal cancer, volvulus and diverticular disease. The current techniques for diagnosis and operative and non operative management will be discussed.[facs.org]

Epidemiology

Author information 1 Department of Accident and Emergency, Horton General Hospital, Banbury, UK. 2 Neonatal Perinatal Epidemiology Unit, University of Oxford, Headington, UK. 3 Department of Upper GI Surgery, Royal Berkshire Hospital, Reading, UK.[ncbi.nlm.nih.gov]
He has since completed further training in emergency medicine, clinical toxicology, clinical epidemiology and health professional education.[lifeinthefastlane.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]
Epidemiology Of all patients admitted to hospital with intestinal obstruction, most have small intestinal obstruction. Significant numbers of colorectal malignancies present with obstruction.[patient.info]

Sex distribution

Age distribution

Pathophysiology

PubMed Google Scholar Andrus CH, Ponsky JL: Bezoars: classification, pathophysiology, and treatment. Am J Gastroenterol. 1988, 83 (5): 476-8.[jmedicalcasereports.biomedcentral.com]
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]
[…] common), tumors, Meckel diverticulum , Crohn disease (uncommon), Ascaris infestation , midgut volvulus, intussusception by tumor (rare), foreign body , and gallstones (rare) Neonates Meconium ileus , volvulus of a malrotated gut, atresia, intussusception Pathophysiology[merckmanuals.com]
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]

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]
Treatment of this condition is early surgical intervention to prevent the sequalae of a colonic volvulus and its associated mortality.[ncbi.nlm.nih.gov]
Management of this condition should be expedited to prevent a fatal outcome. We present the case of a 56-year-old woman with synchronous volvulus of the caecum and splenic flexure of the colon. 2016 BMJ Publishing Group Ltd.[ncbi.nlm.nih.gov]
Two sigmoidoscopic removals were attempted but were unsuccessful as the gallstone's size prevented removal with an endoscopic basket. A laparotomy was performed and the stone extracted via a sigmoid enterotomy.[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

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.
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.
Pujahari AK. Decision Making in Bowel Obstruction: A Review. J Clin Diagn Res. 2016 Nov;10(11).
Yeo HL, Lee SW. Colorectal emergencies: Review and controversies in the management of large bowel obstruction. J Gastrointest Surg. 2013;17:2007–12.
Gore RM, Levine MS. Textbook of Gastrointestinal Radiology. 3rd ed. Philadelphia, PA: Saunders, Elsevier; 2008.
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.
Frager D, Rovno HD, Baer JW, Bashist B, Friedman M. Prospective evaluation of colonic obstruction with computed tomography. Abdom Imaging. 1998;23:141–6.
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: 2018-06-21 23:31