Large BowelObstruction M K Alam Al Maarefa College

Anatomy Distal end of Ileum  anus (about 1.5 m) Smallest diameter: Sigmoid colon (diverticulosisis form here due to the high pressure) Primary function of the large intestine Completion of absorption, esp. final absorption of water Normal flora manufacture certain vitamins- B complex, K Formation, storage and expulsion of feces

Large bowel General characteristics larger internal diameter Presence of epiploic appendices Presence of taeniae coli Presence of the haustra

Large bowel obstruction An emergent condition requires early identification and prompt surgical intervention Possibility of perforation of the distended colon with risk of fecal peritonitis.

Pathophysiology of Mechanical LBO A. Interruption of the flow of the intestinal contents  bowel dilatation above the obstruction  mucosal edema + impaired venous drainage and arterial blood flow to the bowel (ischemia) :  Mucosal permeability  bacterial translocation +systemic toxicity + dehydration + electrolyte abnormalities. Perforation and fecal peritonitis The process is accelerated in closed loop obstruction

Pseudo-obstruction (Ogilvie’s syndrome) Colonic dilatation without anatomical lesion Multiple medical and surgical illness PSY and SY activity  loss of peristalsis, distention by gas and fluid Maximum in the caecum  perforation and fecal peritonitis (3-15%)

Etiology of LBO Prevalence increase with age as does its main causes Neoplasm (benign or malignant) 60% Stricture (diverticular or ischemic) 20% Volvulus (colonic, sigmoid or coecal) 10% Intussusceptions Adynamic ileus, Ogilvie’s syndrome

Etiology Fecal impaction, foreign body Adhesions Hernia IBD Ped: Hirschsprung’s, meconium ileus, imperforate anus

Etiology

Neoplasm and diverticular disease: Tumor growth  luminal narrowing  gradual onset of obstruction. Diverticular disease  muscular hypertrophy of the colonic wall with repeated inflammation and fibrosis  luminal narrowing

Colonic volvulus: Twisting of the bowel on its mesentery  ischemia  perforation. 20% of the causes of LBO. A. Sigmoid volvulus: Common in elderly and frail with long h/ o constipation and laxatives Younger Pt- association with high fiber diet. The twist is ante-clockwise B. Coecal volvulus: Less common Clockwise twist

Intussusception Primarily pediatric disease, usually with no leading point. Two third of adult intussusception are caused by tumor Entero-colic Or Colo-colic types

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

Clinical presentation Complaints suggesting LBO Crampy abdominal pain Constipation Abdominal distention Nausea and Vomiting Symptoms suggestive of peritonitis Fistula (passage of air, mucus or feces in the urine)

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

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

Physical examination Complete examination is necessary: Abdomen: Distension, ? Asymmetrical, tenderness, ↑ BS, mass Inguinal and femoral region Rectum: empty, blood, mass

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

Plain radiograph

Contrast radiography with enema

Contrast enhanced CT Can distinguish between partial and complete obstruction and site of obstruction Gastrographine (water soluble contrast) is used if bowel perforation is suspected.

Ca right colon Intussusception

Management Initial therapy include: Correction of fluid and electrolytes imbalance with fluid monitoring Bowel rest NGT Appropriate preoperative antibiotic Specific management: Illeus: Tx of the underlying disorder Cessation of drugs slowing colonic motility

ACPO (Ogilvie’s syndrome) If no perforation  conservative Tx, management of the underlying disorder for 24hr. If failed, consider neostigmine or colonic decompression (success rate 80%) If perforation or if conservative Tx failed  surgical intervention with high mortality and morbidity. Volvulus: Sigmoiod volvulus: Sigmoidoscopy and deflation, flatus tube, later elective surgery. Sig. failed, urgent laparotomy, un-twisting of the loop, per anal decompression followed by either fixation of the sigmoid loop “if viable” or sigmoid colectomy with anastomosis or Hartmann’s procedure.

Coecal or transverse colon volvulus: Volvuls should be reduced followed by either fixation (caecopexy) and, or caecostomy. If the cecum is ischemic or gangrenous  right hemicolectomy. Intussusception: Children with no peritonitis  contrast enema reduction. If failed or with signs of peritonitis  surgery Surgery is indicated in adult intussusception  why? Recurrence: 3% after contrast & 1%after surgery.

Hartmann's procedure Hartmann's procedure is the surgical resection of the rectosigmoid colon with closure of the rectal stump and formation of an end colostomy.

Colonic masses and strictures: Endoscopic dilatation and stenting of obstructed colon: Palliative- high risk patients with unresectable tumor preparation for surgery: Relieve the acute obstruction. Allow time for resuscitation and bowel preparation Surgery Right colon  right hemicolectomy Left colon  Hartmann procedure Diverticular disease: Conservative followed by elective surgery If failed  surgery (same principles of Ca tx)

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

Colostomies

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

Indications in Adults Colorectal carcinoma Colonic Obstruction Traumatic perineal injury Colonic, High anal fistulae Protect a distal anastomosis Diverticular disease Ischemia IBD

Indications in children Hirschsprung disease Meconium ileus Imperforate anus Complex hindgut anomalies Volvulus Trauma

End colostomy The working end is brought through the abdomen to the skin surface after the damaged /diseased distal bowel is removed End colostomy can be temporary to allow bowel rest or heal, following tumor resection, traumatic injury or inflammation of the bowel. End colostomy can be permanent when the 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.

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 and the distal bowel. Created in transverse colon (transverse loop colostomy) or in sigmoid colon (sigmoid loop colostomy) Typically an emergency procedure to relieve an intestinal obstruction or perforation. Opened at the time of surgery or a few days later. Has two openings through the stoma – the proximal end drains stool while the distal portion drains mucus. Loop colostomies are typically temporary.

Loop colostomy

Double-barrel colostomy Both ends of the bowel are brought through the abdomen to the skin surface as two separate sections. The proximal stoma (colostomy), diverts feces through the abdominal wall. The distal stoma (mucous fistula), expels mucus from the distal colon A double-barrel colostomy may be created because of trauma, tumors, or inflammation, and it may be temporary or permanent.

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

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