1. LARGE BOWEL OBSTRUCTION Katherine Jahnes MD Colorectal Conference St Luke’s Roosevelt Hospital Center November 10, 2005

2. Case A  83 yo male presents with increasing abdominal distention s/p failed sigmoidoscopy/ colonoscopy  PMH: Alzheimer’s Disease, HTN, COPD, glaucoma  PSH: pacemaker placement (2001 for bradycardia) and left hip repair (2001)  PE: Lungs clear, Abdomen distended but soft with hyperactive BS, TTP diffusely, LLQ>LUQ, no rebound

3. Case A  20 year history of sigmoid volvulus  Managed by sigmoidoscopy reduction as outpatient three time a week  On day of admission attempts at reduction where unsuccessful  Films were obtained

4. Case A

5.  Pt underwent a sigmoid resection  Findings:  Sigmoid volvulus with 3 360 degree turns around mesentery  No sigmoid ischemia  Rectum, descending colon healthy and viable  Sigmoid resected with primary anastomosis of descending colon to rectum

6. Case B  71 year old female with 2 week history of increasing abdominal distention and no bowel movements  PMH: HTN, DM, CVA- residual aphasia, hemiparesis  PSH: none  PE: Abdomen:  (? Rectal- gas in vault?)  NT, Bowel sounds present, tympanitic

7. Case B  Radiology:

8. Case B  Operative findings:

9. Large Bowel Obstruction: Causes  Obstruction- mechanical interruption of the flow of intestinal contents  Volvulus  Intussuception  Neoplasia (60% of cases) Colorectal CLL  Diverticular Strictures/ IBD  Pseudo-obstruction- dilation of the bowel in the absence of a causative anatomic lesion

10. Pseudoobstruction- Ogilvie’s syndrome  Distention of colon with signs and symptoms of colonic obstruction without a mechanical cause for the obstruction  May be acute or chronic  Acute: usually involves only colon, and more commonly effects patients with chronic renal, respiratory, cerebral or cardiovascular disease  Chronic: can effect other parts of the GI tract and tends to recur  Primary pseudoobstruction- a motility disorder  familial visceral myopathy  Diffuse disorder involving autonomic innervation of intestinal wall  Secondary – more common.  Associated with: neuroleptics, opiates, metabolic illness, myxedema, DM, uremia, hyperPTH, lupus, scleroderma, Parkinson’s, traumatic retroperitoneal hematomas Associated with sympathetic overactivity suppressing parasympathetics

11. Pseudoobstruction- Ogilvie’s syndrome  Diagnosis  Water soluable contrast enema Can differentiate between mechanical and pseudoobstruction  Colonoscopy Can also be used for treatment  Initial treatment  NGT  Resuscitation  Neostigmine (parasympathomimetic) 2.5 mg IV over 3 minutes, with resolution in 10 minutes Bradycardia is a side effect- atropine must be available

12. Volvulus  Bowel is twisted on mesenteric axis resulting in complete or partial obstruction of the bowel lumen as well as possible vascular impairment  Represents about 5% of large bowel obstructions  Associated factors-  chronic constipation  Aging  institutionalization (neuropyschiatric conditions treated with pyschotrophic drugs)  in the developing world- possible association with high fiber diets  Characteristically affected bowel is attached to long floppy mesentery fixed to retroperitoneum with a narrow base

13. Volvulus  Most commonly sigmoid, also right colon and terminal ileum (cecal volvulus), cecum alone (due to a highly mobile cecum called a cecal bascule- mobile in caudad to cephalad direction), and rarely transverse colon  (photo: barium enema of cecal volvulus, contrast stops at hepatic flexure (arrowhead) and air filled cecum crosses midline of abdomen in LUQ)

14. Volvulus  Presentation: may be acute or subacute  Sudden onset of severe abdominal pain, vomiting, obstipation  Abdomen is distended and tympanitic, often dramatically  Radiographic findings-  AXR: markedly dilated colon with an air-fluid level, no gas in rectum  CT: mesenteric whirl (at right)  Contrast enema: bird’s beak

15. Volvulus  Treatment:  Decompression with rectal tube placed via proctoscope or colonoscopy, with rectal tube left in place for 1-2 days. Often a sudden gush of gas and fluid is released upon decompression  Detorsion with colonoscope  Sigmoid resection Hartmann’s procedure- emergent if decompression not successful If decompression is successful; redundant bowel may be removed laparoscopically with primary anastomosis electively (perform colonoscopy first to r/o neoplasm)

16. Neoplasm  Presentation, treatment, and multivariate anaysis of risk factors for obstructive and perforative colorectal carcinoma  Alvarez et al, American Journal of Surgery 190(3): Sept 2005  A high proportion of colon cancers present as surgical emergencies  Acute obstruction, perforation or both  Associated with high morbidity and mortality

17.  Retrospective study  936 consecutive pts underwent surgery for primary colorectal carcinoma  107 (11.4%) underwent emergency surgery Indications: history and physical consistent with peritonitis Intrabdominal abscess with systemic signs of sepsis Clinical signs of obstruction and radiographic evidence thereof not responding to conservative measures within 4 days of hospitalization Study excluded pts with crohn’s, UC, other types of neoplasm, FAP, h/o operations at outside hospitals, and those not requiring surgery

18.  Of 107 pts, 83 (78%) had complete obstruction and 24 (22%) had perforation  Sigmoid was most common location  Comorbid conditions were present in 70% of pts- HTN, CV, COPD, DM.  Males predominated in the obstruction group  Advance tumor stage was seen in 70% of the obstructing pts and in 54% of the perforated pts  Overall/ curative resection rate for obstructed pts was 85/ 83% respectively  Mean OR time was 145.7 minutes (SD 57.1)  37% required a blood transfusion

19. Tables  Table 2. Surgical procedures in patients with complicated colorectal carcinoma Obstruction (n = 83)Perforation (n = 24)Total n (%)Right colon nLeft colon nRight colon nLeft colon nNo resection16 (14.9)†Colostomy only7411Colostomy only with intention for staged resection22Bypass anastomosis only22Laparotomy only11Resection91 (85.1)†Resection + anastomosis19214347Resection + stoma3111244 Two patients had proximal diverting colostomy and primary anastomosis. † The comparison between the obstructing and perforating groups was not significant.†

20.  Major postop complications in 33%- most frequently GI and pulmonary  Factors associated with major complications or mortality included:  Older age, female sex, perioperative blood transfusion, high ASA or APACHE II score  Not associated: location of lesion

21. Diverticular Strictures/ IBD  Crohn’s disease  Obstruction most commonly in terminal ileum

22. Intussusception  A segment of bowel and its associated mesentery (intussusceptum) invaginates into the lumen of an adjacent bowel segment (intussuscipiens)  Leading cause of bowel obstruction in children  May be caused by intramural, mural, or extramural process-  intraluminal mass pulled forward by peristalsis and drags bowel wall with it Ie pedunculated tumors, inverted meckel’s diverticulum or appendix  Segment of bowel wall that does not contract normally and the opposite wall rotates the abnormal segment inward causing a kink that acts as a lead point Ie sessile malignancies, local inflammation, suture lines, lymphoid hyperplasia  Adhesion causes focal area of abnormal peristalsis and kinking

23. Intussusception  In the colon, most frequently are colocolic or sigmoidrectal, and comprise 38% of adult intussusceptions  Neoplasia causes 2/3 of cases in adults  Adenocarcinoma, leiomyosarcoma, reticular cell sarcoma, mets  Association with AIDS- secondary to lymphoma, Kaposi’s sarcoma, reative lymphoid hyperplasia, atypical mycobacteria infection, CMV, Camphylobacter enteritis  Childhood presenting symptoms: acute presentation with episodic crampy abdominal pain and bloody currant jelly stool  Adult presentation: often nonspecific chronic or subacute symptoms- crampy abdominal pain, nausea and vomiting, constipation or diarrhea, rarely bleeding or presence of a palpable mass

24. Intussusception  Radiology:  Abdominal plain film Air crescent sign- intraluminal air between the walls of the the intussusceptum and the intussuscipiens  Barium enema Coiled spring appearance (fig 12)- a thin central barium stream with or without a leading mass  US More useful in childhood intussusceptions Target or doughnut mass with outer hypoechoic rim  Ct Target lesion, whirling pattern of mesenteric vessels May see air bubble between opposed layers of bowel Underlying etiology may be difficult to determine  Treatment  Surgery Reduce or not?