Colonic Obstruction

Colonic Obstruction
Large bowel obstruction may be caused by neoplasms or anatomic abnormalities, such as volvulus,
incarcerated hernia, stricture, or obstipation. The challenges in managing this condition are
distinguishing colonic obstruction from ileus, ruling out nonsurgical causes, and determining the best
surgical management.
Causes
 Causes of adult large bowel obstruction include the following:

o Neoplasm (benign or malignant)
o Stricture (diverticular or ischemic)
o Incarcerated hernia
o Volvulus
o Intussusception, usually with an identifiable anatomic abnormality in adults but not in
children
o Impaction or obstipation
o Gallstone ileus
Laboratory Studies
 Studies are directed at evaluating the dehydration and electrolyte imbalance that may occur as
a consequence of large bowel obstruction and at ruling out ileus as a diagnosis.
 Routine serum chemistries and urine specific gravity should be evaluated.
 Suggestion of an abnormal anion gap also should prompt an arterial blood gas measurement
and/or a serum lactate level measurement.
 A decreased hematocrit level, particularly with evidence of chronic iron-deficiency anemia, may
suggest chronic lower gastrointestinal bleeding, particularly due to colon cancer.
 A stool guaiac test also should be performed, for similar reasons.
 Although bowel obstruction, or even constipation, may mildly elevate the WBC count,
substantial leukocytosis should prompt reconsideration of the diagnosis. Ileus, secondary to an
intra-abdominal or extra-abdominal infection or another process, is a possibility.
Imaging Studies
 Flat and upright abdominal roentgenography demonstrates dilation of the small and/or large
bowel and air fluid levels.
 An upright chest x-ray generally is ordered simultaneously to determine whether free air is
present, which would suggest perforation of a hollow viscus and ileus rather than organic
obstruction.
 Tracing colonic air around the colon, into the left gutter, and down into the rectum or
demonstrating an abrupt cut-off in colonic air suggests the anatomic location of the obstruction.
 A dilated colon without air in the rectum is more consistent with obstruction. The presence of
air in the rectum is consistent with obstipation, ileus, or partial obstruction.
 This finding can be misleading, particularly if the patient has undergone rectal examinations or
enemas.
 The characteristic bird's beak of volvulus may be seen.
 Radiopaque contrast material may be administered and imaging of the colon may be performed
under the following circumstances.
o Perform it if the diagnosis of large bowel obstruction is suspected but not proven.
o If differentiation between obstipation and obstruction is required, imaging with contrast
is indicated.
o If localization is required for surgical intervention, imaging with contrast is indicated.
 Water-soluble Gastrografin has important advantages over barium as a contrast agent and
generally should be used first.
o It usually does not cause chemical peritonitis if the patient has colonic perforation.
o It has an osmotic laxative effect that may actually wash out an obstipated colon.
 If large bowel perforation is ruled out using a Gastrografin study but a more detailed anatomic
definition is required (particularly of the right colon), a barium enema may be performed.
 Although CT scanning is useful to help rule out intra-abdominal abscess or other causes of ileus,
it generally is not used initially in patients with large bowel obstruction unless a diagnosis has
been made.
o CT scan, particularly with rectal contrast, may demonstrate a mass or evidence of
metastatic disease.
o Generally, the findings do not alter management because these patients will be
explored and operatively decompressed, regardless of the CT scan findings.
o CT colography may be useful in evaluating these patients, not only to delineate the
source of the obstruction but also to rule out synchronous proximal lesions, which may
occur in about 1% of patients and which might motivate a more extended resection if
identified and if the patient's condition will tolerate the more extensive procedure. 1
Other Tests
 Flexible endoscopy preceded by rectal enema may be useful in evaluating left-sided colonic
obstruction, including the anatomic location and pathology of the lesion.
 Because the cecum is not reached in such cases, the endoscopist must be alert to the possibility
of incorrectly identifying anatomic landmarks and the location of the obstruction.
 An abdominal roentgenogram with the tip of the endoscope at the site of the obstruction may
be extraordinarily helpful in identifying and documenting the location of the large bowel
obstruction.
 Although flexible endoscopy is relatively comfortable for the patient and provides a better view
than rigid sigmoidoscopy, the latter also may be used, depending on the availability of resources
and training of personnel.
 Right-sided colonic obstruction is more difficult to evaluate without first administering an oral
bowel preparation, which is contraindicated in the setting of bowel obstruction.
Procedures
 Endoscopic reduction of volvulus

o This procedure is indicated for sigmoid volvulus when peritoneal signs are absent, which
would imply dead bowel or perforation. It also is indicated when evidence of mucosal
ischemia is not present upon endoscopy.
o This procedure is not indicated for the less common cecal or transverse colon volvulus.
o An experienced person should perform the procedure.
o A rigid sigmoidoscope may be used if a flexible instrument is not available. The
endoscopist must have sufficient experience with this technique.
o Reduction of a volvulus does not imply cure. The sigmoid usually revolvulizes if definitive
treatment is not carried out.
o These patients generally are admitted, subjected to mechanical bowel preparation, and
managed surgically by sigmoid resection, unless contraindications are present.
 Barium enema for reduction of intussusception
o This is useful and often successful in children in whom a pathological leading point for
the intussusception is unlikely.
o It should be performed by an experienced radiologist because the risk of perforation is
significant.
o In adults, typically a pathologic leading point for the intussusception is present. Success
is far less likely, and patients still require surgery to deal with their pathology.
 Cleansing enemas
o Perform these if obstipation is suspected rather than true large bowel obstruction.
o Also perform them to prepare the distal colon for endoscopic evaluation.
 Endoscopic dilation and stenting of colonic obstruction
o This procedure is indicated for colonic near total obstruction through which some small
amount of lumen remains.
o The procedure may be palliative in a high-risk patient with an unresectable malignancy,
accepting a risk of reobstruction of the stent, or preparatory to surgical resection.
o In cases in which the stent is deployed prior to surgery, it permits relief of the acute
obstruction, resuscitation of the patient, and mechanical bowel preparation prior to a
one-stage colonic resection and reanastomosis, thus avoiding temporary or permanent
colostomy.
o The procedure should be performed only by an endoscopist experienced in such
procedures.
o Surgical consultation and backup should be available, as the risk of perforation is
increased during attempts at such procedures, with a potentially catastrophic result.
o Although some experience with stenting has been positive, 2 with some retrospective
preference for the Ultraflex stent over the Wallstent because of ease of placement, a
recent multicenter trial of endoscopic stenting using the Wallstent versus surgery for
stage IV left-sided colorectal cancer was terminated early because of an unacceptably
high incidence of perforation.3 Whether this reflects the technical aspects of the
procedure in that study, the particular stent used, or a truly unacceptable incidence of
this dangerous complication awaits further study.
Medical Care
 Medical care of colonic obstruction involves resuscitation, correction of the fluid and electrolyte
imbalance, and nasogastric decompression to temporarily treat the obstruction and to prevent
vomiting and aspiration.
 Medical care is directed primarily at supporting the patient and treating any comorbid illnesses.
 For a small subset of patients, in whom the obstruction not only is malignant but also reflects
substantially disseminated or even inoperable disease, consideration of completely
nonoperative palliative therapy within the context of a palliative care or hospice approach may
be appropriate. This might include somatostatin therapy and may or may not include
nasogastric decompression.4
Surgical Care
 Surgical care is directed at relieving the obstruction.

 In most patients, the obstructing lesion is resected.
o Because the colon has not been cleansed, anastomosis often is risky.
o After resection, most surgeons perform a proximal colostomy if the obstruction is on the
left side or ileostomy if it is on the right side.
 In patients with substantial comorbidity and surgical risk or in the presence of an unresectable
tumor, a diverting proximal colostomy or ileostomy may be performed without resection.
 A diverting transverse loop colostomy may be the least invasive procedure for a very ill patient
with a left colonic obstruction. It permits relief of the obstruction and further resuscitation
without compromising chances for a subsequent resection. A recent case report describes the
use of hand-assisted laparoscopy via the loop colostomy site for subsequent resection of the
obstructing lesion.5
 A sigmoid colostomy without resection may be used in patients with a rectal obstruction that
cannot be managed without a combined abdominoperineal approach.
 Cecostomy should not be performed because the diversion is inadequate.
 In younger patients without substantial comorbidity, some surgeons would consider primary
anastomosis, rather than ileostomy, in the right colon, assuming no intraoperative hypotension,
blood loss, or other complications are present.
 If resection and proximal colostomy or ileostomy are performed, a mucous fistula generally is
extracted from the distal end, unless the obstruction is rectosigmoid, in which case the distal
end may be oversewn or stapled and left to drain transanally.
 If the cause of the obstruction can be relieved nonsurgically, through procedures such as
decompressing a volvulus, or if the obstruction is only partial, deferring surgery temporarily and
supporting the patient while the large bowel is cleansed so that primary anastomosis may be
performed more safely is preferable.
Consultations
 Gastroenterologist or surgeon for assessment and probable endoscopy
Diet
 Patients with complete large bowel obstruction should receive nothing by mouth.
 Patients with a partial obstruction may tolerate minimal clear liquids, oral medications, and a
gradual bowel preparation.
Medication
Oral laxatives are contraindicated if large bowel obstruction is suspected. If any evidence
suggests simple constipation, patients should be managed with transrectal enemas. Tap water,
isotonic sodium chloride solution, and a variety of other fluids may be used. In patients with
renal insufficiency, the physician should be sensitive to the electrolyte content of the fluid.

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Colonic Obstruction

 Causes of adult large bowel obstruction include the following:

 Endoscopic reduction of volvulus

 Surgical care is directed at relieving the obstruction.

 Gastroenterologist or surgeon for assessment and probable endoscopy

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