Ay, but to die, and go we know not where; To lie in cold obstruction and to rot. - William Shakespeare

Prof A walid elsahzly MD Bowel Obstruction Prof A walid elsahzly MD Professor of General Surgery, Colon and rectal Unit, University of Alexandria

Bowel Obstruction - Outline Small Bowel Obstruction Adynamic Ileus Large Bowel Obstruction Colonic Pseudo-Obstruction Pediatric Bowel Obstruction

Bowel Obstruction Defined Any disorder in which the intestine fails to allow for the regular passage of food or bowel contents. Thus, mechanical, hypo-peristaltic, or neurological causes are all “obstructions”.

SBO - Historical Perspective 350 BC: Praxagoras creates a therapeutic entero-cutaneous fistula. Praxagoras, the sophist, is also known for the discovery of arteries. He states "We have long known about the existence of veins which carry blood. We now know what carries the air throughout our bodies.” (295 BC)

SBO - Historical Perspective 350 BC - 1912 AD: Nothing Happens

SBO - Historical Perspective 1912: Hartwell and Hoguet discover that saline therapy prolongs the life of experimental dogs. (JAMA 59:82 1912) 1950’s: Nasogastric tube decompression and antibiotics are advocated for treatment of SBO. Advances in surgical techniques. Mortality decreases: 60% in 1900 3-5% in 2000

SBO - Epidemiology 20% of all hospital admissions for patients with abdominal pain. 300,000 operations annually. Causes: Non-Mechanical/Ileus - Most Common 64-79% - Adhesions 15% - Hernias 10-15% - Cancer Others - intussusception, gallstones, inflammation, abscess, bezoar.

SBO- Etiology 64-79% 15%

SBO- Etiology

SBO - History Pain: Crampy, diffuse, Spasmodic (q3-10 min depending on location of obstruction) Nausea/Vomiting (bilious or feculent) Distention (may be mild) Obstipation (once contents have passed) Presentation within hours or days of onset Focal, constant pain = strangulation

SBO - Physical Exam Early - vital signs normal, afebrile. Distention Scars Borborygmi, Singultus Tympani High Pitched, musical bowel sounds Diffuse, mild tenderness Heme-negative stool, rectal masses.

SBO - Physical Exam Later - Tachycardia, low grade fever Focal tenderness Tender mass Peritoneal Signs, guarding, rebound Heme-positive stool (specific causes)

SBO - Laboratory Analysis Generally not helpful to diagnose strangulation Mild Leukocytosis with left shift WBC>20, think necrosis Hypovolemia, elevated HCT, BUN/Cr Electrolytes normal until late, then severely deranged, especially hypokalemia Pre-op labs

SBO - Radiology KUB - Supine and upright, Upright CXR Demonstrate obstruction in 50-60% of cases Suggest obstruction in 20-30% of cases Normal or misleading in 10-20% Failed to diagnose strangulation in 50-85% (Am J Surg 132:-29-303, 1976) (Arch Surg 85:121-129 , 1962) Does not show etiology

SBO - Supine KUB Small Bowel: Dilated loops Stepladder pattern smaller diameter central location valvulae conniventes occupy transverse diameter of bowel Dilated loops Stepladder pattern May be absent with fluid in bowel

SBO - Upright KUB Dilated loops More air if distal Air/fluid levels No air in colon Makes Diagnosis

SBO - Upright KUB String of Pearls Sign Coffee-Bean Sign

SBO - Upright KUB Pseudo-tumor Sign

Air in biliary tree SBO Gallstone Gallstone Ileus

Gummi Bear Bezoar 7 year old male presents to Albert Einstein Hospital in Philadelphia with complaint of vomiting and abdominal pain. Ill appearing, distended, tender abdomen Further history reveals that patient had eaten 12 bags of Gummi Bears 6 hours prior to onset of symptoms (J Emerg Med Vol. 7, pp. 143-44, 1989)

SBO - CT Scan I+/O+ Scan helpful when KUB suggestive but not diagnostic Can clarify etiology and strangulation 95% Accurate 94% Sensitive 96% Specific (AJR 158:765-9 1992) (Radiology 180:313-8 1991) CT remains the investigation of choice Thompson Ann. Surg 2002 Peck, JJ Am J Surg 1999

SBO - CT Scan Closed Loop Obstruction: Strangulation: U-Shaped dilated loops Mesenteric vessels converging Beak sign, or two adjacent collapsed loops Strangulation: circumfrentially thickened loop High bowel wall attenuation target sign pneumatosis Retrospective analysis of CT diagnosed 8/19 with closed loop, 7/19 with strangulation (Radiology 185:769-775, 1992) Retrospective analysis shows CT no better than Plain film for detecting infarction (poorly controlled) (AJR 154:99-103, 1990)

SBO - CT Scan Incisional Hernia Diagnoses etiology of Obstruction in 78% (Rad Clin N America 32:5 1994) Incisional Hernia

SBO - CT Scan Crohn’s Disease with focal thickening of bowel wall

SBO - CT Scan Intussusception

SBO - Pathophysiology Three types of mechanical SBO: Obstruction of the lumen tumors, intussusception, gallstones, feces, bezoar Obstruction by intrinsic bowel wall lesions congenital, strictures, tumors Obstruction by extrinsic lesions adhesions, hernias, tumor

SBO - Pathophysiology Gas accumulates proximal to obstruction. 70% Swallowed Air (Nitrogen not absorbed) 30% Carbon Dioxide (Bacterial Fermentation)

SBO - Pathophysiology First 24 hours: After 24 hours: Distention decreases absorption of Na+ and H20 from lumen. After 24 hours: Active secretion of Na+ and H20 into lumen. Distention causes reflex vomiting. further loss of Na+, K+, Cl-, H+

SBO - Pathophysiology Luminal Pressure Rises: Normal 2-4 mmHg Rises to 8-10 mmHg Closed Loop Obstruction 30-60mmHg High Pressure causes rupture of small blood vessels, venous/arterial insufficiency. Intra-abdominal pressure rises, inhibiting respiration, venous return.

SBO Pathophysiology (Rosen) Relationship of Physiologic Changes to Clinical Manifestations in Patients with SBO

SBO - Pathophysiology Normally nearly sterile small bowel is rapidly overgrown by bacteria. Bacterial translocation occurs. (Am J Surgery 159:394, 1990) 70% Mortality from sepsis/shock.

SBO - Strangulation Occurs in 10% of cases (5-42%) (Surgery 89:407-13 1981) Blood supply to obstructed intestine is impaired Intraluminal Pressure > Central Venous Pressure Venous/lymphatic outflow obstructed (adhesive bands, hernial rings) Leads to hemorrhage, gangrene, sepsis, perforation - all of these are bad.

SBO - Treatment Aggressive Fluid Replacement Bowel Decompression Normal Saline/Lactated Ringers Bowel Decompression NG Tube Antibiotics Ampicillin/Levo or Gent/Flagyl or Clinda Surgical

SBO - Treatment Operative Planning: Minimal metabolic disturbance/co-morbidity Can go to OR immediately Marked metabolic disturbance/co-morbidity Correct these over several hours first

SBO - Treatment Immediate Surgery if: Fever Leukocytosis localized abdominal tenderness radiographic evidence of necrosis (tachycardia)

SBO - Treatment Conservative Management 75% of Partial SBO will resolve 16-36% of Complete SBO will resolve Most Likely: Early Post-Operative, Adhesions, Crohn’s Disease Least Likely: Intraluminal Cancer, Intussusception If no resolution in 24-48 hours - surgery

SBO - Treatment Operation Viability of bowel Resect 2nd look Empty bowel Pelvic loops Intestinal bypass

SBO - Treatment Intsussption with small bowel leiomyoma intsussuption with Small bowel lymphoma

SBO - Treatment Laparoscopy Laparoscopy advantage include lower adhesion formation and quicker post operative recovery. Safe and feasible Strickland Surg Endosc 1999 Controversy still exists in the use of laparascopy for acute obstruction. Some studies have demonstrated the safety and feasibility of lap treatment for SBO, but comparative data is still lacking.

SBO - Treatment Stickland* found that if the operation could be performed then the laparoscopic approach was cost effective and reduced post operative morbidity and LOS. Wullstein et al** found that : treatment of acute adhesive SBO was feasible in half of their patients, who benefited from a low postoperative complication rate, a quicker recovery of bowel function and a shorter hospital stay. An attempt at laparoscopic management of acute SBO seems justified in patients with fewer than two previous laparotomies but should not be offered to other patients because of the unacceptably high risk of intraoperative bowel perforation. * Strickland Surg Endosc 1999 ** Wullstein, BJS 2003Laparoscopic

SBO - Treatment A case of band adhesion causing intestinal obstruction that is amenable to laparoscopic resection.

Adynamic Ileus The cessation of intestinal paralysis, in the absence of mechanical obstruction, which results in the dilatation of the entire gastrointestinal tract.

Adynamic Ileus - History Similar to SBO Abdominal distention Constant abdominal discomfort NO colicky waves of pain Vomiting (profuse, never feculent) Obstipation

Adynamic Ileus - Etiology Surgery Intestinal distention or ischemia Trauma (vertebral or rib fractures) Hemorrhage (especially retro-peritoneal hematoma) Perforation Peritonitis Infection (peritoneal, retro-peritoneal, pelvic, thoracic) Pancreatitis Renal/Biliary Colic Myocardial Infarction Electrolyte Abnormalities (hypokalemia)

Adynamic Ileus - KUB Dilated Loops Gas diffuse throughout small bowel and colon

Adynamic Ileus - Treatment Fluid Replacement Normal Saline/Lactated Ringers Bowel Decompression NG Tube Correct underlying etiology Symptomatic treatment Consider Surgical Consultation

Large Bowel Obstruction 53 % 17%

LBO - Etiology Causes of acute LBO requiring surgery (n=300) Arch Surg 108:470 1974

From: Cameron, Advances in Surgery LBO - Etiology From: Cameron, Advances in Surgery

LBO - History/Physical Exam Abdominal pain (may be sudden or insidious) Distention (competent ileocecal valve) Obstipation, change in bowel habits Vomiting Feculent smelling breath Medication use Altered bowel sounds (small bowel motility) Fever, tachycardia, peritonitis suggest strangulation

LBO - Pathophysiology Increased intraluminal pressure Transudate and decreased fluid absorption Hypovolemia Blood flow to other bowel segments increases Blood flow to cecum decreases Wall tension in cecum rises (Laplace’s Law) Bacterial overgrowth/translocation 39% node culture positive, 43% same organism causing sepsis (Br J Surg 63:721, 1976)

LBO - Radiology Plain Films: Contrast Enema: Dilated Peripheral loops (small and large bowel) Plain Films: 84% Sensitive 72% Specific Contrast Enema: 96% Sensitive 98% Specific Clin Rad 46:273, 1992

LBO - Radiology

LBO - Treatment Aggressive Fluid Replacement Bowel Decompression Normal Saline/Lactated Ringers Bowel Decompression NG Tube: does not decompress colon but may aid nausea/vomiting/distention Antibiotics Ampicillin/Levo or Gent/Flagyl or Clinda Surgical

LBO - Carcinoma Colorectal Cancer: large bowel decompression/lavage resection and primary anastomosis staged resection with colostomy/ileostomy laser ablation, endoscopic stenting, balloon dilation, tube decompression (palliative) Mortality 15%

LBO - Carcinoma

LBO - Carcinoma

LBO – Carcinoma Endoscopic Stenting

LBO - Volvulus Twisting or folding of a large bowel segment on its mesentery 5% of colonic obstructions Location: 65-72% sigmoid 21% cecal 2% transverse 40% Diagnosed on KUB High incidence of strangulation Coffee-Bean Sign

LBO - Volvulus Volvulus Risks: Bird’s Beak Sign Prior episodes (40-60%) Elongated mesentery with narrow base High fiber diet Chronic Constipation Institutionalization Laxative use Previous surgery Pregnancy African-American Hirshprung’s disease Bird’s Beak Sign

LBO - Volvulus Sigmoid Volvulus: Early decompression Colon/Sigmoidoscopy 55-85% successful (Ann Surg 206:1, 1987) Rectal Tube Recurrence in 60-90% (Surg Gyn Obs 124:5671967) Elective resection of prepped bowel Detorsion/colopexy Bent Inner-Tube Sign

LBO - Volvulus Cecal Volvulus: Presents as SBO Incomplete fixation of right colon to peritoneum 90% - Ileocolic 10% - cecal bascule Endoscopy ineffective Resection/Colopexy

LBO Entero-colic intussusception 20% are colonic

Ogilvie’s Syndrome

Ogilvie’s Syndrome Colonic Dilation without mechanical obstruction Autonomic imbalance (parasympathetic inhibition/sympathetic excitation) Seriously ill/elderly patients Symptoms Abdominal Distention (100%) Abdominal Pain (83%) Constipation (51%) Diarrhea (41%) Fever (37%)

Ogilvie’s Syndrome Causes: Cardiovascular, trauma, post-operative, inflammatory, respiratory, metabolic, neurological, pharmacological Treatment: Bowel Rest Fluid Re-hydration Correction of underlying etiology Colonoscopic decompression (71-93% successful) (Am J Surg 147:243, 1984) (Ann Surg 197:416. 1983) Guanethadine/neostigmine/cisapride/erythromycin Risk of perforation correlated with duration

Pediatric Bowel Obstruction Atresia and stenosis Hypertrophic pyloric stenosis Meconium Ileus Meckel’s Diverticulum Intussusception Malrotation

Atresia and Stenosis Surgery to resect involved segment Neonatal Bowel Obstruction 95% Atretic 5% Stenotic 1:330 infants in USA Associated with Down’s syndrome Caused by an intrauterine vascular occlusion Polyhydraminos, bilious vomiting, distention, jaundice and failure to pass meconium on first day of life. Surgery to resect involved segment

Atresia and Stenosis Doudenal atresia oesphageal atresia

Hypertrophic pyloric stenosis

Meconium Ileus Neonatal SBO (typically ileum) 7-25% of Cystic Fibrosis (1:2000) Low water content and a gelatinous protein Distention, bilious vomiting, no stool passed by 24-48 hours after birth Soap Bubble appearance on KUB Hyperosmolar enema (gastrograffin) Meconium ileus “equivalent” in 10% of older CF patients (inadequate pancreatic enzyme dosage)

Meconium Ileus

Meconium Ileus

Meconium Ileus

Meconium Ileus

Malrotation Embryology: Intestine normally rotates 270 degrees counter-clockwise around the SMA Midgut Volvulus Duodenal Obstruction by Ladd’s Bands Double Bubble sign on KUB Internal Herniation (non -fixed colon created hernial pouches)

Malrotation

Malrotation and volvulus

Meckel’s Diverticulum Vittelline Duct remnant 2% of population 2 Years old (45%) 2 Feet from Cecum 2-4% symptomatic 44% Gastric Mucosa 35% asymptomatic 75% symptomatic 5% Pancreatic tissue

Meckel’s Diverticulum Obstruction (35%) Mechanism: Intussusception 47% Lead point of ileoileal obstruction with progress to ileocolic obstruction Duct Remnants 53% Herniation (Littre’s hernia) Bands Kinking Volvulus NG Tube, IVF, Antibiotics

Intussusception - History Well Nourished child with URI/OM symptoms (21%) <1 year old (65%) Colicky pain (100%) Vomiting (80-100%) Bloody stool (65-95%) Pallor/diaphoresis Apathy Stool - relief of symptoms Obstipation/diarrhea (7%) Prior Episodes (5-7%)

Intussusception

Intussusception Obstruction is complete from beginning 95% begin at ileocecal valve 2-8% have a lead point (polyp, Meckel’s, lymphoid patch) Edema produces lymph node enlargement Fluid, blood and mucus into the lumen Current Jelly Stool

Intussusception - Treatment NG Tube, IVF, Antibiotics, Surgical Consultation Hydrostatic Reduction (65%): Foley inserted into rectum, balloon inflated Barium run in from 3’6” above patient Fluoroscopy: meniscus lengthens, reduces If no free flow into ileum - surgery (Johns Hopkins series, 1965) Glucagon?

Hirshirprung disease

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