1. Timothy M. Farrell Department of Surgery UNC-Chapel Hill
Bowel Obstruction
Timothy M. Farrell
Department of Surgery
UNC-Chapel Hill

2. Small Bowel Obstruction

3. Small Bowel Obstruction Signs & Symptoms
Intermittent, Crampy Abdominal Pain
Nausea / Emesis
Distension
Obstipation
Peristaltic Rushes on Auscultation
Focal Tenderness
Diffuse Peritonitis

4. Small Bowel Obstruction Etiologies
Adhesions
Malignancy
External or Internal Hernia
Volvulus
Crohn’s Disease
Intra-abdominal Abscess

5. Small Bowel Obstruction Etiologies (Cont.)
Radiation Stricture
Foreign Body
Gallstone Ileus
Meckel’s Diverticulum
Intramural Hematoma
Mesenteric Ischemia
Intussusception

6. Intestinal Ileus Etiologies
Postoperative State
Sepsis
Electrolyte Imbalance
Drugs
Ureteral and Biliary Colic
Retroperitoneal Hemorrhage
Spinal Cord Injury
Myocardial Infarction
Pneumonia

7. Small Bowel Obstruction Partial vs. Total
Why Not Just Wait??
Potential for Closed Loop Obstruction
Risk of Ischemia / Perforation (4-6 hrs)

8. Small Bowel Obstruction Radiologic Evaluation
Xrays: ? AFLs, ? Free Air, ? Distal Gas
UGI / SBFT: Identify mechanical obstruction
Enteroclysis: Independent of gastric emptying
CT Scan: ? Free Air, ? Pneumatosis, ? Tumor

13. Small Bowel Obstruction Laboratory Evaluation
May see hypochloremic, hypokalemic metabolic alkalosis if having frequent emesis (proximal obstruction).
May see evidence of contraction alkalosis
Increased H/H, BUN.
WBC usually normal early.

14. Small Bowel Obstruction Treatment
Correct intravascular volume deficit
NGT vs. Miller-Abbott or Cantor Tubes
Serial Exams
Operation if no improvement or if signs of complete (closed loop) obstruction or incarceration.
Evaluation of Bowel Viability

16. Small Bowel Obstruction Special Cases
Early Postoperative SBO
<1% risk in first month
Must be considered after 7 days of “ileus” since adhesions become dense in 2-3 weeks.
Recurrent SBO (5-15%)
Malignant Obstruction
Radiation Fibrosis

17. Large Bowel Obstruction

18. Large Bowel Obstruction Etiologies
Colon Cancer
Diverticulitis
Extrinsic Cancer
Fecal Impaction
Intussusception
Volvulus
Incarcerated Hernias

19. Large Bowel Obstruction Colon Cancer
20% of colon cancers present with obstruction
Left-sided lesions are more prone to obstruct (more narrow lumen, more solid fecal stream)

20. Large Bowel Obstruction Diagnosis
Crampy Pain
Onset may be acute or insidious
Distension (50-60% have competent ileo-cecal valve and develop severe distension)
Xrays: cm cecum, perforation risk
Contrast enema: Obstruction vs Oglive’s
Consider rigid sigmoidoscopy to r/o and treat sigmoid volvulus

26. Large Bowel Obstruction Treatment
IVF
NGT
Operation
Emergently if signs of peritonitis / perforation
Prep bowel if possible
Is an ostomy necessary?
Right vs. Left-sided Lesions
Traditional vs. Newer Attitudes
right colon - can reanastamose
transverse colon - extended right hemi
left colon
3 stage (ostomy, resection, takedown)
2 stage (resect with protecting ostomy, takedown)
1 stage (resect, anastamose with or without colonic lavage)
leak rate 5%
1 stage (resect whole colon and do an ileoproctostomy to avoid fecal loading)

27. Oglive’s Syndrome (Colonic Pseudo-Obstruction)
May mimic mechanical obstruction
Associated Conditions
Treatment:
Rectal tube / enemas /exams (work in most)
Colonoscopic decompression (80-90% eff.)
Surgery (Cecostomy vs. Resection) - cecum >12 cm or peritoneal signs
Associated Conditions:
Amyloidosis
Blunt trauma
Cardiopulmonary Bypass
C-section
Chemotherapy
Dermatofibrosis
Diabetes
Electrolyte abnormalities
Hypothyroidism
Medications (anticholinergics, ganglionic blockers, narcotics, phenothiazines, tricyclic antidepressants)
Ortho or Neurologic Procedures
Renal Failure
RenalTransplantation
Scleroderma
Dementia / Stroke
SLE