Timothy M. Farrell Department of Surgery UNC-Chapel Hill Bowel Obstruction Timothy M. Farrell Department of Surgery UNC-Chapel Hill

Small Bowel Obstruction

Small Bowel Obstruction Signs & Symptoms Intermittent, Crampy Abdominal Pain Nausea / Emesis Distension Obstipation Peristaltic Rushes on Auscultation Focal Tenderness Diffuse Peritonitis

Small Bowel Obstruction Etiologies Adhesions Malignancy External or Internal Hernia Volvulus Crohn’s Disease Intra-abdominal Abscess

Small Bowel Obstruction Etiologies (Cont.) Radiation Stricture Foreign Body Gallstone Ileus Meckel’s Diverticulum Intramural Hematoma Mesenteric Ischemia Intussusception

Intestinal Ileus Etiologies Postoperative State Sepsis Electrolyte Imbalance Drugs Ureteral and Biliary Colic Retroperitoneal Hemorrhage Spinal Cord Injury Myocardial Infarction Pneumonia

Small Bowel Obstruction Partial vs. Total Why Not Just Wait?? Potential for Closed Loop Obstruction Risk of Ischemia / Perforation (4-6 hrs)

Small Bowel Obstruction Radiologic Evaluation Xrays: ? AFLs, ? Free Air, ? Distal Gas UGI / SBFT: Identify mechanical obstruction Enteroclysis: Independent of gastric emptying CT Scan: ? Free Air, ? Pneumatosis, ? Tumor

Small Bowel Obstruction Laboratory Evaluation May see hypochloremic, hypokalemic metabolic alkalosis if having frequent emesis (proximal obstruction). May see evidence of contraction alkalosis Increased H/H, BUN. WBC usually normal early.

Small Bowel Obstruction Treatment Correct intravascular volume deficit NGT vs. Miller-Abbott or Cantor Tubes Serial Exams Operation if no improvement or if signs of complete (closed loop) obstruction or incarceration. Evaluation of Bowel Viability

Small Bowel Obstruction Special Cases Early Postoperative SBO <1% risk in first month Must be considered after 7 days of “ileus” since adhesions become dense in 2-3 weeks. Recurrent SBO (5-15%) Malignant Obstruction Radiation Fibrosis

Large Bowel Obstruction

Large Bowel Obstruction Etiologies Colon Cancer Diverticulitis Extrinsic Cancer Fecal Impaction Intussusception Volvulus Incarcerated Hernias

Large Bowel Obstruction Colon Cancer 20% of colon cancers present with obstruction Left-sided lesions are more prone to obstruct (more narrow lumen, more solid fecal stream)

Large Bowel Obstruction Diagnosis Crampy Pain Onset may be acute or insidious Distension (50-60% have competent ileo-cecal valve and develop severe distension) Xrays: 12-14 cm cecum, perforation risk Contrast enema: Obstruction vs Oglive’s Consider rigid sigmoidoscopy to r/o and treat sigmoid volvulus

Large Bowel Obstruction Treatment IVF NGT Operation Emergently if signs of peritonitis / perforation Prep bowel if possible Is an ostomy necessary? Right vs. Left-sided Lesions Traditional vs. Newer Attitudes right colon - can reanastamose transverse colon - extended right hemi left colon 3 stage (ostomy, resection, takedown) 2 stage (resect with protecting ostomy, takedown) 1 stage (resect, anastamose with or without colonic lavage) leak rate 5% 1 stage (resect whole colon and do an ileoproctostomy to avoid fecal loading)

Oglive’s Syndrome (Colonic Pseudo-Obstruction) May mimic mechanical obstruction Associated Conditions Treatment: Rectal tube / enemas /exams (work in most) Colonoscopic decompression (80-90% eff.) Surgery (Cecostomy vs. Resection) - cecum >12 cm or peritoneal signs Associated Conditions: Amyloidosis Blunt trauma Cardiopulmonary Bypass C-section Chemotherapy Dermatofibrosis Diabetes Electrolyte abnormalities Hypothyroidism Medications (anticholinergics, ganglionic blockers, narcotics, phenothiazines, tricyclic antidepressants) Ortho or Neurologic Procedures Renal Failure RenalTransplantation Scleroderma Dementia / Stroke SLE