Bowel obstruction

Depending on the level of obstruction, bowel obstruction can present with abdominal pain, abdominal distension, and constipation. Bowel obstruction may be complicated by dehydration and electrolyte abnormalities due to vomiting; respiratory compromise from pressure on the diaphragm by a distended abdomen, or aspiration of vomitus; bowel ischemia or perforation from prolonged distension or pressure from a foreign body and subsequently sepsis due to bowel flora.{{cite web |url=https://www.lecturio.com/concepts/large-bowel-obstruction/| title=Large Bowel Obstruction

|website=The Lecturio Medical Concept Library |access-date= July 10, 2021}}{{listen

| filename = SBOOgg louder.ogg

| title = Tinkly bowel sounds

| description = Tinkly bowel sounds as heard with a stethoscope in someone with a small bowel obstruction.

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In small bowel obstruction, the pain tends to be colicky (cramping and intermittent) in nature, with spasms lasting a few minutes. The pain tends to be central and mid-abdominal. Vomiting may occur before constipation.{{cite web |url=https://www.lecturio.com/concepts/large-bowel-obstruction/| title=Large Bowel Obstruction

|website=The Lecturio Medical Concept Library |access-date= July 10, 2021}} Common physical exam findings may include signs of dehydration, abdominal distension with tympany, nonspecific abdominal tenderness, and high pitched tinkly bowel sounds.{{Cite book |last1=Vercruysse |first1=Gary |url=http://www.ncbi.nlm.nih.gov/books/NBK572336/ |title=Evaluation and Management of Mechanical Small Bowel Obstruction in Adults |last2=Busch |first2=Rebecca |last3=Dimcheff |first3=Derek |last4=Al-Hawary |first4=Mahmoud |last5=Saad |first5=Richard |last6=Seagull |first6=F. Jacob |last7=Somand |first7=David |last8=Cherry-Bukowiec |first8=Jill |last9=Wanacata |first9=Lauren |date=2021 |publisher=Michigan Medicine University of Michigan |series=Michigan Medicine Clinical Care Guidelines |location=Ann Arbor (MI) |pmid=34314126}}

In large bowel obstruction, the pain is felt lower in the abdomen and the spasms last longer. Common symptoms include abdominal pain, distension, and severe constipation.{{Cite book |last=Ferri |first=Fred |title=Ferri's Clinical Advisor 2024 |date=July 12, 2023 |publisher=Elsevier |isbn=978-0-323-75576-4 |edition=1st |pages=829.e4–829.e6}} Constipation occurs earlier and vomiting may be less prominent. Proximal obstruction of the large bowel may present as small bowel obstruction.{{cite web |url=https://www.lecturio.com/concepts/large-bowel-obstruction/| title=Large Bowel Obstruction

|website=The Lecturio Medical Concept Library |access-date= July 10, 2021}} Patients may notice a history of bloating and narrowing of stools before the onset of more severe symptoms. Symptoms can present quickly in the cases of volvulus and can present over a longer period of time in the setting of cancer. Common physical exam findings may include a palpable hernia, abdominal distension with tympany, nonspecific lower abdominal tenderness, and a rectal mass.

File:PSBOCT.png

File:Diameters of the large intestine.svg

The main diagnostic tools are blood tests, X-rays of the abdomen, CT scanning, and ultrasound. If a mass is identified, biopsy may determine the nature of the mass.{{cn|date=May 2022}}

Radiological signs of bowel obstruction include bowel distension (small bowel loops dilated >3 cm) and the presence of multiple (more than 2) air-fluid levels on supine and erect abdominal radiographs.{{Citation |last1=Singh |first1=Ajay |title=Imaging of Bowel Obstruction |date=2018 |work=Emergency Radiology |pages=67–75 |editor-last=Singh |editor-first=Ajay |url=http://link.springer.com/10.1007/978-3-319-65397-6_5 |access-date=February 19, 2024 |place=Cham |publisher=Springer International Publishing |language=en |doi=10.1007/978-3-319-65397-6_5 |isbn=978-3-319-65396-9 |last2=Mansouri |first2=Mohammad|url-access=subscription }} Ultrasounds may be as useful as CT scanning to make the diagnosis.{{cite journal |vauthors=Gottlieb M, Peksa GD, Pandurangadu AV, Nakitende D, Takhar S, Seethala RR |date=February 2018 |title=Utilization of ultrasound for the evaluation of small bowel obstruction: A systematic review and meta-analysis |journal=The American Journal of Emergency Medicine |volume=36 |issue=2 |pages=234–242 |doi=10.1016/j.ajem.2017.07.085 |pmid=28797559 |s2cid=24769945}}

Contrast enema or small bowel series or CT scan can be used to define the level of obstruction, whether the obstruction is partial or complete, and to help define the cause of the obstruction. The appearance of water-soluble contrast in the cecum on an abdominal radiograph within 24 hours of it being given by mouth predicts resolution of an adhesive small bowel obstruction with sensitivity of 97% and specificity of 96%.{{cite journal |vauthors=Abbas S, Bissett IP, Parry BR |date=July 2007 |title=Oral water soluble contrast for the management of adhesive small bowel obstruction |journal=The Cochrane Database of Systematic Reviews |volume=2010 |issue=3 |pages=CD004651 |doi=10.1002/14651858.CD004651.pub3 |pmc=6465054 |pmid=17636770}}

Colonoscopy, small bowel investigation with ingested camera or push endoscopy, and laparoscopy are other diagnostic options.

File:UOTW 20 - Ultrasound of the Week 1.webm|Small bowel obstruction on ultrasound{{cite web |date=1 October 2014 |title=UOTW #20 - Ultrasound of the Week |url=https://www.ultrasoundoftheweek.com/uotw-20/ |url-status=live |archive-url=https://web.archive.org/web/20170509081636/https://www.ultrasoundoftheweek.com/uotw-20/ |archive-date=May 9, 2017 |access-date=27 May 2017 |website=Ultrasound of the Week |df=mdy-all}}

File:UOTW 20 - Ultrasound of the Week 2.webm|Small bowel obstruction on ultrasound

File:UOTW 20 - Ultrasound of the Week 3.jpg|Small bowel obstruction on ultrasound

Differential diagnoses of bowel obstruction include:

• Ileus
• Pseudo-obstruction or Ogilvie's syndrome
• Intra-abdominal sepsis
• Pneumonia or other systemic illness{{cite web |title=Small Bowel Obstruction |url=https://www.lecturio.com/concepts/small-bowel-obstruction/ |access-date=July 10, 2021 |website=The Lecturio Medical Concept Library}}

File:Upright abdominal X-ray demonstrating a bowel obstruction.jpg

Causes of small bowel obstruction include:

• Adhesions from previous abdominal surgery (most common cause)
• Barbed sutures{{cite journal | vauthors = Segura-Sampedro JJ, Ashrafian H, Navarro-Sánchez A, Jenkins JT, Morales-Conde S, Martínez-Isla A | title = Small bowel obstruction due to laparoscopic barbed sutures: an unknown complication? | journal = Revista Espanola de Enfermedades Digestivas | volume = 107 | issue = 11 | pages = 677–80 | date = November 2015 | pmid = 26541657 | doi = 10.17235/reed.2015.3863/2015 | url = http://scielo.isciii.es/scielo.php?script=sci_arttext&pid=S1130-01082015001100005 | doi-access = free | hdl = 20.500.13003/12378 | hdl-access = free }}
• Pseudoobstruction
• Hernias containing bowel
• Crohn's disease causing adhesions or inflammatory strictures
• Neoplasms, benign or malignant
• Intussusception
• Volvulus
• Superior mesenteric artery syndrome, a compression of the duodenum by the superior mesenteric artery and the abdominal aorta
• Ischemic strictures
• Foreign bodies (e.g. gallstones in gallstone ileus, swallowed objects such as expandable water toys)
• Intestinal atresia
• Urinary retention

After abdominal surgery, the incidence of small bowel obstruction from any cause is 9%. In those where the cause of the obstruction was clear, adhesions are the single most common cause (more than half).{{cite journal | vauthors = ten Broek RP, Issa Y, van Santbrink EJ, Bouvy ND, Kruitwagen RF, Jeekel J, Bakkum EA, Rovers MM, van Goor H | title = Burden of adhesions in abdominal and pelvic surgery: systematic review and met-analysis | journal = BMJ | volume = 347 | issue = oct03 1 | pages = f5588 | date = October 2013 | pmid = 24092941 | pmc = 3789584 | doi = 10.1136/bmj.f5588 }}

File:LargeBowelObsUp2008.jpg

Causes of large bowel obstruction include:{{cite web |url=https://medlineplus.gov/ency/article/000260.htm| title=Intestinal obstruction and Ileus|website=MedlinePlus |access-date= July 10, 2021}}

• Neoplasms / cancer
• Diverticulitis / Diverticulosis
• Hernias
• Inflammatory bowel disease
• Colonic volvulus (sigmoid, caecal, transverse colon)
• Adhesions
• Constipation
• Fecal impaction
• Fecaloma
• Colon atresia
• Intestinal pseudoobstruction
• Endometriosis
• Narcotic induced (especially with the large doses given to cancer or palliative care patients)

Outlet obstruction is a sub-type of large bowel obstruction and refers to conditions affecting the anorectal region that obstruct defecation, specifically conditions of the pelvic floor and anal sphincters. Outlet obstruction can be classified into four groups.{{cite book| first1 = Andrew P | last1 = Zbar | first2 = Steven D | last2 = Wexner |title=Coloproctology|year=2010|publisher=Springer|location=New York|isbn=978-1-84882-755-4|page=140}}

• Functional outlet obstruction
• Inefficient inhibition of the internal anal sphincter
• Short-segment Hirschsprung's disease
• Chagas disease
• Hereditary internal sphincter myopathy
• Inefficient relaxation of the striated pelvic floor muscles
• Anismus (pelvic floor dyssynergia)
• Multiple sclerosis
• Spinal cord lesions
• Mechanical outlet obstruction
• Internal intussusception
• Enterocele
• Dissipation of force vector
• rectocele
• Descending perineum
• Rectal prolapse
• Impaired rectal sensitivity
• Megarectum
• Rectal hyposensitivity

Treatment of small and large bowel obstructions are initially similar and non-operative management is usually the initial management strategy as the majority of small bowel obstruction resolve spontaneously with non-operative management.{{Cite book |last1=Vercruysse |first1=Gary |url=http://www.ncbi.nlm.nih.gov/books/NBK572336/ |title=Evaluation and Management of Mechanical Small Bowel Obstruction in Adults |last2=Busch |first2=Rebecca |last3=Dimcheff |first3=Derek |last4=Al-Hawary |first4=Mahmoud |last5=Saad |first5=Richard |last6=Seagull |first6=F. Jacob |last7=Somand |first7=David |last8=Cherry-Bukowiec |first8=Jill |last9=Wanacata |first9=Lauren |date=2021 |publisher=Michigan Medicine University of Michigan |series=Michigan Medicine Clinical Care Guidelines |location=Ann Arbor (MI) |pmid=34314126}}{{Cite book |last=Ferri |first=Fred |title=Ferri's Clinical Advisor 2024 |date=July 12, 2023 |publisher=Elsevier |isbn=978-0-323-75576-4 |edition=1st}} Patients are monitored by the surgical team for signs of improvement and resolution of the obstruction on imaging; if the obstruction does not clear then surgical management for the treatment of the causative lesion is required.{{Cite journal |last1=Bower |first1=Katie Love |last2=Lollar |first2=Daniel I. |last3=Williams |first3=Sharon L. |last4=Adkins |first4=Farrell C. |last5=Luyimbazi |first5=David T. |last6=Bower |first6=Curtis E. |date=October 1, 2018 |title=Small Bowel Obstruction |url=https://www.sciencedirect.com/science/article/pii/S0039610918300719 |journal=Surgical Clinics of North America |series=Emergency General Surgery |volume=98 |issue=5 |pages=945–971 |doi=10.1016/j.suc.2018.05.007 |pmid=30243455 |s2cid=265759123 |issn=0039-6109|url-access=subscription }} In malignant large bowel obstruction, endoscopically placed self-expanding metal stents may be used to temporarily relieve the obstruction as a bridge to surgery,{{cite journal | vauthors = Young CJ, Suen MK, Young J, Solomon MJ | title = Stenting large bowel obstruction avoids a stoma: consecutive series of 100 patients | journal = Colorectal Disease | volume = 13 | issue = 10 | pages = 1138–41 | date = October 2011 | pmid = 20874797 | doi = 10.1111/j.1463-1318.2010.02432.x | s2cid = 12724976 }} or as palliation.{{cite journal | vauthors = Mosler P, Mergener KD, Brandabur JJ, Schembre DB, Kozarek RA | title = Palliation of gastric outlet obstruction and proximal small bowel obstruction with self-expandable metal stents: a single center series | journal = Journal of Clinical Gastroenterology | volume = 39 | issue = 2 | pages = 124–8 | date = February 2005 | pmid = 15681907 }} Diagnosis of the type of bowel obstruction is normally conducted through initial plain radiograph of the abdomen, luminal contrast studies, computed tomography scan, or ultrasonography prior to determining the best type of treatment.{{cite book| last =Holzheimer| first =Rene G.| title =Surgical Treatment| publisher =NCBI Bookshelf| year =2001| url =https://www.ncbi.nlm.nih.gov/books/NBK6880/| isbn =3-88603-714-2| url-status =live| archive-url =https://web.archive.org/web/20110827075739/http://www.ncbi.nlm.nih.gov/books/NBK6880/| archive-date =August 27, 2011| df =mdy-all}}

Further research is needed to find out if parenteral nutrition is of benefit to people with an inoperable blockage of the bowel caused by advanced cancer.{{cite journal | vauthors = Sowerbutts AM, Lal S, Sremanakova J, Clamp A, Todd C, Jayson GC, Teubner A, Raftery AM, Sutton EJ, Hardy L, Burden S | title = Home parenteral nutrition for people with inoperable malignant bowel obstruction | journal = The Cochrane Database of Systematic Reviews | volume = 8 | pages = CD012812 | date = August 2018 | issue = 8 | pmid = 30095168 | pmc = 6513201 | doi = 10.1002/14651858.cd012812.pub2 }}

In the management of small bowel obstructions, a commonly quoted surgical aphorism is: "never let the sun rise or set on small-bowel obstruction"{{cite journal | vauthors = Maglinte DD, Kelvin FM, Rowe MG, Bender GN, Rouch DM | title = Small-bowel obstruction: optimizing radiologic investigation and nonsurgical management | journal = Radiology | volume = 218 | issue = 1 | pages = 39–46 | date = January 2001 | pmid = 11152777 | doi = 10.1148/radiology.218.1.r01ja5439 | url = http://radiology.rsnajnls.org/cgi/content/full/218/1/39 | url-status = dead | archive-url = https://web.archive.org/web/20080418050916/http://radiology.rsnajnls.org/cgi/content/full/218/1/39 | df = mdy-all | archive-date = April 18, 2008 | access-date = June 6, 2008 | url-access = subscription }} because about 5.5% of small bowel obstructions are ultimately fatal if treatment is delayed. Improvements in radiological imaging of small bowel obstructions allow for confident distinction between simple obstructions, that can be treated conservatively, and obstructions that are surgical emergencies (volvulus, closed-loop obstructions, ischemic bowel, incarcerated hernias, etc.). Exam findings of bowel compromise requiring immediate surgery include: severe abdominal pain, signs of peritonitis such as rebound tenderness, elevated heart rate, fever, and elevated inflammatory markers on lab work, such as lactic acid.{{Cite book |last1=Vercruysse |first1=Gary |url=http://www.ncbi.nlm.nih.gov/books/NBK572336/ |title=Evaluation and Management of Mechanical Small Bowel Obstruction in Adults |last2=Busch |first2=Rebecca |last3=Dimcheff |first3=Derek |last4=Al-Hawary |first4=Mahmoud |last5=Saad |first5=Richard |last6=Seagull |first6=F. Jacob |last7=Somand |first7=David |last8=Cherry-Bukowiec |first8=Jill |last9=Wanacata |first9=Lauren |date=2021 |publisher=Michigan Medicine University of Michigan |series=Michigan Medicine Clinical Care Guidelines |location=Ann Arbor (MI) |pmid=34314126}}{{Cite book |last=Ferri |first=Fred |title=Ferri's Clinical Advisor 2024 |date=July 12, 2023 |publisher=Elsevier |isbn=978-0-323-75576-4 |edition=1st}}

A small flexible tube (nasogastric tube) may be inserted through the nose into the stomach to help decompress the dilated bowel. This tube is uncomfortable but relieves the abdominal cramps, distention, and vomiting. Intravenous therapy is utilized and the urine output may be monitored with a catheter in the bladder.[http://www.smallbowelobstruction.net/ Small Bowel Obstruction overview] {{webarchive|url=https://web.archive.org/web/20100212215648/http://smallbowelobstruction.net/ |date=February 12, 2010 }}. Retrieved February 19, 2010.{{Cite book |last1=Vercruysse |first1=Gary |url=http://www.ncbi.nlm.nih.gov/books/NBK572336/ |title=Evaluation and Management of Mechanical Small Bowel Obstruction in Adults |last2=Busch |first2=Rebecca |last3=Dimcheff |first3=Derek |last4=Al-Hawary |first4=Mahmoud |last5=Saad |first5=Richard |last6=Seagull |first6=F. Jacob |last7=Somand |first7=David |last8=Cherry-Bukowiec |first8=Jill |last9=Wanacata |first9=Lauren |date=2021 |publisher=Michigan Medicine University of Michigan |series=Michigan Medicine Clinical Care Guidelines |location=Ann Arbor (MI) |pmid=34314126}}

Most people with SBO are initially managed conservatively because in many cases, the bowel will open up. Some adhesions loosen up and the obstruction resolves. The patient is examined several times a day, and X-ray images are made to ensure he or she is not getting clinically worse.[http://www.clearpassage.com/small-bowel-obstruction.php Small Bowel Obstruction: Treating Bowel Adhesions Non-Surgically] {{webarchive|url=https://web.archive.org/web/20100227012047/http://www.clearpassage.com/small-bowel-obstruction.php |date=February 27, 2010 }}. Clear Passage treatment center online portal Retrieved February 19, 2010

Conservative treatment involves insertion of a nasogastric tube, correction of dehydration and electrolyte abnormalities. Opioid pain relievers may be used for patients with severe pain but alternate pain relievers are preferred as opioids can decrease bowel motility.{{Cite book |last1=Vercruysse |first1=Gary |url=http://www.ncbi.nlm.nih.gov/books/NBK572336/ |title=Evaluation and Management of Mechanical Small Bowel Obstruction in Adults |last2=Busch |first2=Rebecca |last3=Dimcheff |first3=Derek |last4=Al-Hawary |first4=Mahmoud |last5=Saad |first5=Richard |last6=Seagull |first6=F. Jacob |last7=Somand |first7=David |last8=Cherry-Bukowiec |first8=Jill |last9=Wanacata |first9=Lauren |date=2021 |publisher=Michigan Medicine University of Michigan |series=Michigan Medicine Clinical Care Guidelines |location=Ann Arbor (MI) |pmid=34314126}}Antiemetics may be administered if the patient is vomiting. Adhesive obstructions often settle without surgery. If the obstruction is complete surgery is usually required.

Most patients improve with conservative care in 2–5 days. When the obstruction is cancer, surgery is the only treatment. Those with bowel resection or lysis of adhesions usually stay in the hospital a few more days until they can eat and walk.[http://www.east.org/tpg/sbo.pdf Small Bowel Obstruction] {{webarchive|url=https://web.archive.org/web/20100705063225/http://www.east.org/tpg/sbo.pdf |date=July 5, 2010 }} The Eastern Association for the Surgery of Trauma. February 19, 2010

Small bowel obstruction caused by Crohn's disease, peritoneal carcinomatosis, sclerosing peritonitis, radiation enteritis, and postpartum bowel obstruction are typically treated conservatively, i.e. without surgery.

The prognosis for non-ischemic cases of SBO is good with mortality rates of 3–5%, while prognosis for SBO with ischemia is fair with mortality rates as high as 30%.{{cite conference |vauthors=Kakoza R, Lieberman G |title=Mechanical Small Bowel Obstruction |date=May 2006 |url=http://eradiology.bidmc.harvard.edu/LearningLab/gastro/Kakoza.pdf |url-status=dead |archive-url=https://web.archive.org/web/20130507080137/http://eradiology.bidmc.harvard.edu/LearningLab/gastro/Kakoza.pdf |archive-date=May 7, 2013 |access-date=October 9, 2012 }}

Cases of SBO related to cancer are more complicated and require additional intervention to address the malignancy, recurrence, and metastasis, and thus are associated with a more poor prognosis.{{cite web |url=https://www.lecturio.com/concepts/small-bowel-obstruction/| title=Small Bowel Obstruction|website=The Lecturio Medical Concept Library |access-date= July 10, 2021}} Surgical options in patients with malignant bowel obstruction need to be considered carefully as while it may provide relief of symptoms in the short term, there is a high risk of mortality and re-obstruction.{{Cite journal |last1=Song |first1=Yun |last2=Metzger |first2=Daniel Aryeh |last3=Bruce |first3=Adrienne N. |last4=Krouse |first4=Robert S. |last5=Roses |first5=Robert E. |last6=Fraker |first6=Douglas L. |last7=Kelz |first7=Rachel R. |last8=Karakousis |first8=Giorgos C. |date=January 2022 |title=Surgical Outcomes in Patients With Malignant Small Bowel Obstruction: A National Cohort Study |url=https://journals.lww.com/10.1097/SLA.0000000000003890 |journal=Annals of Surgery |language=en |volume=275 |issue=1 |pages=e198–e205 |doi=10.1097/SLA.0000000000003890 |pmid=32209901 |s2cid=214643950 |issn=0003-4932|url-access=subscription }}

All cases of abdominal surgical intervention are associated with increased risk of future small-bowel obstructions. Statistics from U.S. healthcare report 18.1% re-admittance rate within 30 days for patients who undergo SBO surgery.{{cite news| title =Readmissions to U.S. Hospitals by Procedure| newspaper =Agency for Healthcare Research and Quality| date =April 2013| url =http://www.hcup-us.ahrq.gov/reports/statbriefs/sb154.pdf| access-date=August 27, 2013 |url-status=live |archive-url=https://web.archive.org/web/20131020102447/http://www.hcup-us.ahrq.gov/reports/statbriefs/sb154.pdf | archive-date =October 20, 2013| df =mdy-all}} More than 90% of patients also form adhesions after major abdominal surgery.{{cite journal | vauthors = Liakakos T, Thomakos N, Fine PM, Dervenis C, Young RL | title = Peritoneal adhesions: etiology, pathophysiology, and clinical significance. Recent advances in prevention and management | journal = Digestive Surgery | volume = 18 | issue = 4 | pages = 260–73 | year = 2001 | pmid = 11528133 | doi = 10.1159/000050149 | s2cid = 30816909 }}

Common consequences of these adhesions include small-bowel obstruction, chronic abdominal pain, pelvic pain, and infertility.

• {{Annotated link|Impaction (animals)}}
• {{Annotated link|Neonatal bowel obstruction}}
• Spastic intestinal obstruction

{{Reflist}}

• {{eMedicine|emerg|66|Obstruction, Small Bowel}}
• {{eMedicine|emerg|65|Obstruction, Large Bowel}}

{{Medical condition classification and resources

| ICD10 = {{ICD10|K|56||k|55}}

| ICD9 = {{ICD9|560}}

| ICDO =

| OMIM =

| MedlinePlus = 000260

| eMedicineSubj =

| eMedicineTopic =

| DiseasesDB = 15838

| MeshID = D007415

}}

{{Gastroenterology}}

Category:Gastrointestinal tract disorders

Category:General surgery

Category:Medical emergencies

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Category:Wikipedia medicine articles ready to translate