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Small Bowel Obstruction


Presentation

The signs and symptoms of small bowel obstruction include the following:

Dutch
  • For the purpose of generalization we used the costs of medication and interventions as provided by the Dutch Healthcare Authority and only if these were not available local hospital costs.[ncbi.nlm.nih.gov]
  • , Small bowel obstruction NOS (disorder) , Small intestine obstruction , Small intestinal obstruction , SBO - Small bowel obstruction , Small bowel obstruction (disorder) Italian Ostruzione dell'intestino tenue , Ostruzione dell'intestino tenue NAS Dutch[fpnotebook.com]
Abdominal Pain
  • Small bowel obstruction (SBO) is a common cause of acute abdominal pain presenting to the emergency department (ED).[ncbi.nlm.nih.gov]
  • The clinical presentations varied, ranging from asymptomatic, chronic abdominal pain, or acute abdominal pain as acute abdomen. Most of the patients usually have early presentation in adult life with average age of 38.5 years at time of diagnosis.[ncbi.nlm.nih.gov]
  • A 54-year-old postmenopausal woman presented with severe abdominal pain and vomiting. Before menopause, she sometimes had abdominal pain associated with menses.[ncbi.nlm.nih.gov]
  • Of the 69 patients with SBO, 27 patients had intestinal strangulation and were awarded one point each towards the overall clinical score: intractable continuous abdominal pain, tachycardia, white blood cell count 13,600/mm3, and abdominal distention.[ncbi.nlm.nih.gov]
  • A 58-year-old man visited our emergency room with acute abdominal pain. Computed tomography (CT) showed obstructive ileus as well as a foreign body penetrating the duodenum, which was identified as a toothpick and removed endoscopically.[ncbi.nlm.nih.gov]
Vomiting
  • Patients with no signs of strangulation and vomiting supported with the characteristic signs of partial small bowel obstruction may be managed medically.[symptoma.com]
  • They presented with abdominal pain and bilious vomiting, with no medical or surgical history.[ncbi.nlm.nih.gov]
  • A 66-year-old man presented to the emergency department complaining of lower abdominal pain with nausea and vomiting. His last bowel movement had occurred on the morning of presentation.[ncbi.nlm.nih.gov]
  • We report a patient who presented with acute abdominal pain and vomiting 6 weeks after renal transplantation in the right iliac fossa. A noncontrast abdominal computed tomography scan showed signs of small bowel obstruction.[ncbi.nlm.nih.gov]
  • A 45-year-old woman presented to emergency services with severe pain in abdomen and bilious vomiting in the past 2 days, having a history of abdominal hysterectomy 10 years ago. The abdominal examination was suggestive of bowel obstruction.[ncbi.nlm.nih.gov]
Constipation
  • A 29-year-old woman presented to the emergency department with abdominal pain, constipation, nausea, and vomiting. CT scan revealed dilated loops of small bowel suggestive of SBO and an IUD that did not appear within the uterine cavity.[ncbi.nlm.nih.gov]
  • A 61-year old patient was admitted to our General Surgical and Emergency Unit because of sudden abdominal pain, vomit and constipation. He had eaten raw fish 3 days before admission. Laboratory data showed high levels of WBC and PCR.[ncbi.nlm.nih.gov]
  • We report a case of a 58-year-old man who presented to the emergency department with constipation and abdominal distension, and signs of an obstructing mass on computed tomography scan.[ncbi.nlm.nih.gov]
  • Classical clinical tetrad is abdominal pain, nausea and emesis, abdominal distention, and constipation-to-obstipation.[ncbi.nlm.nih.gov]
  • Symptoms Symptoms of small bowel obstruction include nausea accompanied by vomiting, abdominal cramps, abdominal distention, constipation, diarrhea, flatulence and bad breath.[symptoma.com]
Nausea
  • A 66-year-old man presented to the emergency department complaining of lower abdominal pain with nausea and vomiting. His last bowel movement had occurred on the morning of presentation.[ncbi.nlm.nih.gov]
  • Here we describe the case of a 62-year-old male presented with a 24-h history of continual colicky abdominal pain, which was accompanied with nausea and vomiting. Accurate diagnosis of abdominal cocoon was made intraoperatively.[ncbi.nlm.nih.gov]
  • A 29-year-old woman presented to the emergency department with abdominal pain, constipation, nausea, and vomiting. CT scan revealed dilated loops of small bowel suggestive of SBO and an IUD that did not appear within the uterine cavity.[ncbi.nlm.nih.gov]
  • On the first postoperative day (POD), the patient presented persistent abdominal pain, sense of fullness, nausea, and vomiting with traces of blood.[ncbi.nlm.nih.gov]
  • Critical Essential Core Tested Community Questions (7) Sorry, this question is for PEAK Premium Subscribers only Sorry, this question is for PEAK Premium Subscribers only (M2.GI.76) A 65-year-old female presents to the emergency department for nausea,[medbullets.com]
Abdominal Distension
  • Compared with the control group, the patients in the observation group with abdominal distension had earlier pain relief.[ncbi.nlm.nih.gov]
  • On physical examination, there was abdominal distension with a huge mobile mass on left side of umbilicus extending up to the epigestrium. There were dilated small bowel loops on abdominal radiograph.[ncbi.nlm.nih.gov]
  • We report a case of a 58-year-old man who presented to the emergency department with constipation and abdominal distension, and signs of an obstructing mass on computed tomography scan.[ncbi.nlm.nih.gov]
  • Abdominal distension? 2. What is the sensitivity and specificity of imaging modalities for small bowel obstruction? 2a. A normal abdominal X-ray? 2b. Air fluid levels seen on abdominal X-ray 2c. CT findings. 3.[sinaiem.org]
  • Physical Exam Physical examination findings include: abdominal distension (more prevalent in distal obstructions), hyperactive bowel sounds (early), or hypoactive bowel sounds (late).[saem.org]
Cryptorchidism
  • Idiopathic ACS with abdominal cryptorchidism and greater omentum hypoplasia is even rarer clinically. We successfully treated a 26-year-old male case of small bowel obstruction with acute peritonitis.[ncbi.nlm.nih.gov]
Neglect
  • However, we cannot be overlooked or neglected the complication of laparoscopic inguinal hernia repair although it brings us lots of benefits.[ncbi.nlm.nih.gov]
Guillain-Barré Syndrome
  • Bezoar formation has even been observed in case of reduced gastric motility and secretion due to diabetes, hypothyroidism, pernicious anemia, myotonic syndromes, and Guillain-Barré syndrome.[ncbi.nlm.nih.gov]

Workup

Prompt diagnosis of the condition is required in order to prevent complications from setting in. A physical examination will be performed to hear out the bowel sounds from the stomach. No bowel sounds indicate paralytic ileus. On the other hand, if very hyperactive bowel sounds are heard they are indicative of mechanical obstruction.

In addition to physical examination, various imaging studies such as CT scan [4], MRI, radiography and X-ray will be carried out to study the abdominal structures and confirm diagnosis. Contrast enhanced abdominal CT may reveal the small bowel feces sign indicative of low grade partial obstruction that could still be managed conservatively [5].

A complete blood work also has to be carried out to study blood urea nitrogen, white blood cells count, and hematocrit. Urine analysis and lactose dehydrogenase tests are also done. It is important to rule out certain underlying disease conditions such as biliary or hepatic disease and therefore several tests governing these also have to be carried out.

Bowel Distention
  • Abdominal X-Ray Small bowel distention Nasogastric tube is seen coiled in the gastric fundus CT Head Left occipital extracranial soft tissue hematoma Left occipital epidural hematoma subjacent to the fracture site in addition to subarachnoid hemorrhage[ddxof.com]
  • ED) Test Sensitivity : 60% (up to 80-90% in high grade obstruction) False negative in early obstruction and high jejunal or duodenal obstruction Typical findings of Bowel Obstruction Bowel distention proximal to obstruction Bowel collapsed distal to obstruction[fpnotebook.com]
Hyponatremia
  • However, hyponatremia ( 134 mmol/L) and CT scan findings of wall thickening or a suspected closed loop were independently associated with bowel ischemia.[ncbi.nlm.nih.gov]
Helicobacter Pylori
  • Extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue (MALT Lymphoma) of the gastrointestinal tract commonly involves the stomach in the setting of concurrent Helicobacter pylori (H. pylori) infection.[ncbi.nlm.nih.gov]

Treatment

Treatment of small bowel obstruction is geared towards the nature and type of obstruction. Patients with no signs of strangulation and vomiting supported with the characteristic signs of partial small bowel obstruction may be managed medically [6].

Non-operative patients may be managed by adequate fluid resuscitation and naso-gastric drainage which can help patients to recover spontaneously within 72 hours in a majority of cases [7]. Medications however form the primary basis of the treatment regime and surgery may have to be opted for when the situation gets severe.

Whichever be the case, hospitalization would be required in order to stabilize the patient’s condition, after which treatment would be initiated. The following are the modes carried out for treating small bowel obstruction:

  • The patient is put on intravenous fluids to replace the fluid loss.
  • A tube is inserted either through the nose or mouth in order to expel the gas buildup in the abdomen.
  • Hyperbaric oxygen introduction to the small bowel may relieve low grade forms of small bowel obstruction [8].
  • Surgery may be required when the affected part of the intestine has died. In such cases, the diseased portion of the intestine part is removed and the two healthy ends are joined. Laparoscopic may offer a safer alternative option in some cases of small bowel obstruction [9]. The role of the small intestine decompression tube with gastrografin in the surgical management of the inflammatory small bowel obstruction has reduced the incidence or unnecessary re-operations [10]. 

Prognosis

The prognosis is usually good if diagnosis is made on time and prompt treatment is carried out. If cases of complete obstructions are treated with medications, then the patients fully recover but the chances of recurrence of the obstruction are higher than those treated with surgery.

Partial obstructions are successfully treated with medications and the chances of recurrence are low. Morbidity and mortality profile of the disease depends on how soon the diagnosis was made and treatment initiated.

It has been estimated that if the obstructions are left untreated then it causes death in 100% of cases. If the surgery is performed within 36 hours then the mortality rate is as low as 8%. However, if the surgery is postponed beyond 36 hours, then the mortality rate rises to 25%.

Complications

Untreated small bowel obstruction can present the following life threatening complications:

Etiology

Small bowel obstruction can be mechanical or non-mechanical in nature. In the mechanical type, some foreign body blocks the passage of intestinal contents making it difficult for its passage through the intestine.

In the latter type, there is no mechanical obstruction, but non–functioning small intestine does not allow the contents to move through the digestive system.

Non–mechanical obstruction is also known as paralytic ileus or pseudoobstruction. Children and infants are common victims of such type of obstruction.

The causes of mechanical obstruction have been explained below:

  • Abdominal surgery that has not healed properly and has caused scars inside the tissues contributing to obstruction like uterine perforation [1]
  • Intussusception
  • Volvulus
  • Foreign bodies from certain objects or items that were swallowed and got stuck
  • Colon cancer
  • Diseases such as Crohn’s disease and Parkinson’s disease
  • Strangulated hernia
  • Persistent vestigial structure like the omphalomesenteric duct in children [2] 

Epidemiology

Small bowel obstruction is a common phenomenon with abdominal surgery being the root cause for majority of the cases. Statistics reveal that as high as 300,000 laparotomies every year were carried out to treat small bowel obstruction. Males and females are at an equal risk for contracting this disease condition.

Sex distribution
Age distribution

Pathophysiology

Small bowel obstruction can be partial or complete; with the complete one being a life threatening condition. Under normal circumstances, the small intestine carries out the function of absorption of nutrients from the food that is digested.

When there is an obstruction, there is proximal dilation of the intestine due to buildup of stomach contents and fluid. The dilation further stimulates the cell secretion activity which leads to buildup of more fluid. This is in turn causes peristalsis above and below the area of obstruction resulting in loose motions and flatulence in the preliminary stages. If the obstruction is in the proximal levels then individuals experience vomiting.

Prevention

So far no guidelines have been issued to prevent this disease condition. However, it is suggested that underlying disease conditions should be promptly treated in order to avoid the onset of small bowel obstruction as a secondary complication to other diseases.

Summary

Small bowel obstruction (SBO), a type of intestinal obstruction, is a blockage in the small intestine that prevents the passage of the intestinal contents. This leads to accumulation of stool, fluid and gas inside the intestine causing discomfort.

The obstruction can be either partial or complete. If urgent medical attention is not provided then the condition can turn life threatening. In certain cases, medications for 2 to 5 days can do the job; whereas in some other cases, surgical procedures have to be employed to remove the obstacle.

Patient Information

Definition

Obstruction occurring in the small intestine which prevents the emptying of the stomach contents is defined as small bowel obstruction. Obstruction can either be partial or complete in nature. There are 2 types of obstruction; namely mechanical and non–mechanical. Mechanical obstruction occurs due to obstruction usually created by foreign particles that have been swallowed. Non–mechanical obstruction is the result of a non - functional small intestine, a condition also known as paralytic ileus.

Cause

Causes of small bowel obstruction include scars due to certain operative procedure, volvulus, intussusceptions, and foreign bodies.

Symptoms

Symptoms of small bowel obstruction include nausea accompanied by vomiting, abdominal cramps, abdominal distention, constipation, diarrhea, flatulence and bad breath.

Diagnosis

Diagnosis of the disease includes a physical examination geared towards studying the bowel sounds. In addition, imaging studies such as CT scan, MRI, and X- ray also may have to be carried out to study the intestinal structures. Blood work to test presence of underlying disease condition and also to study the hemoglobin, white blood cells and blood urea nitrogen also needs to be done.

Treatment

Treatment of small bowel obstruction requires hospitalization following administration of intravenous fluids to compensate for the fluid loss. Post this, a tube is inserted through the mouth or nose in order to expel out the accumulated gas. Surgical procedures may be required in severe cases.

References

Article

  1. Augustin G, Majerović M, Luetić T. Uterine perforation as a complication of surgical abortion causing small bowel obstruction: a review. Arch Gynecol Obstet. 2013; 288(2):311-23 (ISSN: 1432-0711)
  2. Nouira F, Sarrai N, Chariag A, Ould Med Sghair Y, Chaouachi B. Persistent omphalomesenteric duct causing small bowel obstruction in children. Tunis Med. 2011; 89(3):285-7 (ISSN: 0041-4131)
  3. Wiesner W, Mortele K. Small bowel ischemia caused by strangulation in complicated small bowel obstruction. CT findings in 20 cases with histopathological correlation. JBR-BTR. 2011; 94(6):309-14 (ISSN: 0302-7430)
  4. Wang Q, Chavhan GB, Babyn PS, Tomlinson G, Langer JC. Utility of CT in the diagnosis and management of small-bowel obstruction in children. Pediatr Radiol. 2012; 42(12):1441-8 (ISSN: 1432-1998
  5. Deshmukh SD, Shin DS, Willmann JK, Rosenberg J, Shin L, Jeffrey RB. Non-emergency small bowel obstruction: assessment of CT findings that predict need for surgery. Eur Radiol. 2011; 21(5):982-6 (ISSN: 1432-1084)
  6. Di Saverio S, Coccolini F, Galati M, Smerieri N, Biffl WL, Ansaloni L, et al. Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2013 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group. World J Emerg Surg. Oct 10 2013; 8(1):42.
  7. Diaz JJ Jr, Bokhari F, Mowery NT, Acosta JA, Block EF, Bromberg WJ, et al. Guidelines for management of small bowel obstruction. J Trauma. Jun 2008; 64(6):1651-64
  8. Fukami Y, Kurumiya Y, Mizuno K, Sekoguchi E, Kobayashi S. Clinical effect of hyperbaric oxygen therapy in adhesive postoperative small bowel obstruction. Br J Surg. 2014; 101(4):433-7 (ISSN: 1365-2168)
  9. Khaikin M, Schneidereit N, Cera S, Sands D, Efron J, Weiss EG, et al. Laparoscopic vs. open surgery for acute adhesive small-bowel obstruction: patients' outcome and cost-effectiveness. Surg Endosc. May 2007; 21(5):742-6.
  10. Li W, Li Z, An D, Liu J, Zhang X. Role of the small intestinal decompression tube and Gastrografin in the treatment of early postoperative inflammatory small bowel obstruction. Zhonghua Wei Chang Wai Ke Za Zhi. 2014; 17(3):275-8 (ISSN: 1671-0274)

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Last updated: 2018-06-21 23:08