1. Large Bowel Obstruction
M K Alam
Al Maarefa College

2. ILOs
At the end of this presentation students will be able to describe:
Pathophysiology, clinical features, diagnostic work up and management of large bowel obstruction.
Pathophysiology, clinical features, diagnostic work up and management of large bowel volvulus.
Pathophysiology, clinical features, diagnostic work up and management of pseudo-obstruction.
Types and indications of different type of colostomies

3. ANATOMY

4. ANATOMY General characteristics larger internal diameter
Presence of epiploic appendices
Presence of taeniae coli
Presence of the haustra

5. PHYSIOLOGY Primary function of the large intestine absorption of water
Normal flora manufacture- B complex, K
Formation, storage and expulsion of feces

6. Large bowel obstruction
Early identification
Prompt surgical intervention
Delay- risk of perforation → fecal peritonitis.

7. MECHANISM OF OBSTRUCTION
Mechanical obstruction- neoplasm, volvulus, stricture
Functional obstruction- pseudo obstruction (Ogilvie’s syndrome)

8. PATHOPHYSIOLOGY - Mechanical obstruction
Interruption to the flow  bowel dilatation above the obstruction  mucosal edema + impaired venous drainage & arterial blood flow → ischemia ↓
↑mucosal permeability  bacterial translocation +systemic toxicity + dehydration + electrolyte disturbances.
Perforation → fecal peritonitis
The process is accelerated in closed loop obstruction

9. PATHOPHYSIOLOGY Pseudo-obstruction (Ogilvie’s syndrome)
Colonic dilatation without mechanical lesion
Multiple medical and surgical illness ↓PSY & ↑SY activity  loss of peristalsis, distension by gas & fluid Maximum in the caecum
Perforation leading to faecal peritonitis (3-15%)

10. Prevalence- increases with age as does its main causes
Aetiology of LBO
Prevalence- increases with age as does its main causes
Neoplasm (benign or malignant) 60%
Stricture (diverticular or ischemic) 20%
Volvulus (colonic, sigmoid or caecal) 10%
Intussusceptions
Adynamic obstruction (Ogilvie’s syndrome)

11. Aetiology of LBO (contd.)
Fecal impaction, foreign body
Adhesions
Hernia
IBD
Pediatrics: Hirschsprung’s, meconium ileus, imperforate anus

12. Etiology of LBO

13. Neoplasm & Diverticular disease
Growth  luminal narrowing  gradual onset of obstruction.
Diverticular disease:
Muscular hypertrophy of the colonic wall with repeated inflammation & fibrosis  luminal narrowing

14. Colonic volvulus
Twisting of the bowel on its mesentery  ischemia  perforation.
20% of LBO.
Sigmoid volvulus:
Elderly & frail: long h/ o constipation and laxative use
Young - association with high fiber diet.
The twist is ante-clockwise
Caecal volvulus:
Less common
Clockwise twist

16. Intussusception Pediatric- usually with no leading point.
Adult- caused by tumor (60-70%)
Entero-colic or Colo-colic types

17. Acute colonic pseudo obstruction (Ogilvie’s syndrome)
Functional obstruction.
Elderly debilitated patients Medical (infections, Cardiac disease) Trauma (operative, non operative).

18. Clinical presentation
Crampy abdominal pain
Constipation
Abdominal distention
Nausea and Vomiting
Symptoms suggestive of peritonitis
Internal fistula (passage of air, mucus or feces in the urine)

19. Assessment of symptoms should attempt to distinguish the following:
Acute Vs acute on chronic obstruction
Onset, H/o bowel movement, stool caliber, recurrent LLQ pain and weight loss
Complete Vs partial obstruction
By symptoms and rectal examination

20. Mechanical Vs functional obstruction (illeus or Ogilvie’s syndrome)
In ACPO (acute colonic pseudo obstruction)- symptoms develop over 1-2 days up to 1 week, distention is early sign, fever is a bad sign
Intussusception
Recurrent, intermittent colicky pain relieved by fetal position with weight loss and fatigability

21. Physical examination
Abdomen: Distension, ? Asymmetrical, tenderness, ↑ BS, mass
Inguinal and femoral region
Rectum: empty, blood, mass

22. Laboratory investigation
CBC
Serum chemistry
Serum lactate
Coagulation profile
Stool for Occult blood

23. Plain radiograph

24. AXR- small bowel obstruction

25. Plain radiograph- sigmoid volvulus

26. Contrast radiography (Barium enema)

27. CT- contrast enhanced
Can distinguish between partial & complete obstruction
Site of obstruction
Tumour stage
Gastrographine (water soluble contrast) if perforation suspected.

28. Carcinoma right colon Intussusception

29. Management Initial therapy: Specific management:
Correction of fluid and electrolytes imbalance
Bowel rest
NGT
? Preoperative antibiotic
Specific management:

30. Ogilvie’s syndrome (pseudo obstruction)
Treatment of the underlying disorder
Cessation of drugs slowing colonic motility
If no perforation  conservative treatment Management of the underlying disorder for 24hr If failed- neostigmine or colonic decompression (success rate 80%)
If perforation or failed conservative treatment  surgical intervention (colectomy). High mortality and morbidity.

31. Sigmoid Volvulus Sigmoidoscopy/colonoscopy: Deflation, flatus tube
Surgery- later, during same hospitalization.
Failed sigmoidoscopy/ colonoscopy or presented with features of ischemia/ peritonitis: Urgent laparotomy, un-twisting, sigmoid resection, Hartmann’s procedure/ primary anastomosis Fixation of the sigmoid loop “if viable”. (High recurrence.)

32. Caecal or transverse colon volvulus
Surgery- volvulus reduced, fixation (caecopexy) or right hemicolectomy.
Cecum ischemic or gangrenous  right hemicolectomy.

33. Children: No peritonitis  contrast enema reduction.
Intussusception
Children: No peritonitis  contrast enema reduction.
If failed or with signs of peritonitis  surgery
Adult: Surgery  why?
Recurrence: 3% after contrast & 1%after surgery.

34. Colonic obstruction due to neoplasms- management
Endoscopic: Dilatation & stenting of obstructed colon.
Palliative- high risk patients with unresectable tumor
Preparation for surgery:
Relieve the acute obstruction.
Allow time for resuscitation & bowel preparation
Surgery: Right colon  right hemicolectomy
Left colon  Hartmann procedure

35. Diverticular disease Obstruction due to stricture
Trial of conservative management
If failed- Hartman (emergency)
or resection & primary anastomosis

36. Hartmann's procedure
Resection of the rectosigmoid colon, closure of the rectal stump & formation of an end colostomy.

37. Prognosis Depends on: Patient’s factors Underlying disease
Management timing and procedures
Development of complications
Mortality:
Mechanical obstruction: 20%-40% (with perforation)
ACPO: 15%-36% (with ischemia, perforation)

38. Colostomies

39. Colostomy
Colostomy: a surgical procedure where a portion of the large intestine is brought through the abdominal wall to carry stool out of the body.
Permanent or temporary.
End or loop colostomy

40. Indications in adults Colorectal carcinoma Large bowel Obstruction
Traumatic perineal injury
High anal fistulae
Protection of distal anastomosis
Diverticular disease
Ischemia
IBD

41. Indications in children
Hirschsprung's disease
Meconium ileus
Imperforate anus
Complex hindgut anomalies
Volvulus
Trauma

42. End colostomy
Proximal end as colostomy. Damaged /diseased distal bowel is removed/ closed
Temporary- allow bowel rest or heal, following tumor resection, traumatic injury or inflammation of the bowel.
Permanent- distal colon is resected or unresectable
Hartmann procedure involves leaving the distal portion of the colon in place, which is closed to create a Hartmann’s pouch.

43. Loop colostomy
A loop of the bowel is brought through the abdomen to the skin surface.
Temporarily supported by a plastic bridge/ rod.
A communicating wall remains between the proximal & distal bowel.
Created in transverse colon (transverse loop colostomy) or in sigmoid colon (sigmoid loop colostomy)
Typically an emergency procedure- intestinal obstruction, perforation.
Opened at the time of surgery or a few days later.
Two openings through the stoma – the proximal end drains stool, the distal portion drains mucus.
Loop colostomies are typically temporary.

44. Loop colostomy

45. Double-barrel colostomy
Both ends of the bowel are brought out.
The proximal stoma (colostomy) , diverts feces
The distal stoma- mucous fistula
Indications: trauma, tumors, or inflammation
Temporary or permanent.

46. Complications Excessive bleeding Ischemic stoma
Surgical wound infection
Retraction
Prolapse
Stenosis
Parastomal hernia

47. Thank You !