Large bowel obstruction

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

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INITIAL

acutely ill

1st line – supportive measures

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1st line –

supportive measures

When diffuse peritonitis occurs in perforation, the priority is to control the source of sepsis, and medical treatment should be started as soon as possible.[5] Supplemental oxygen may be needed.

Intravenous fluids should replace previous losses and any due to sepsis, and electrolyte imbalances should be corrected. Patients with sepsis may also require hemodynamic support with vasopressors. See Sepsis in adults.

Blood transfusion or blood products may be required to correct anemia or coagulopathy. Central venous pressure monitoring can be considered.

Urinary output should be monitored. Patients may require urinary catheterization.

Keep the patient nothing by mouth (npo) until the underlying cause is resolved.

Nasogastric decompression is part of the initial management of any cause, to decompress the intestinal tract and reduce flow of gastric contents or air toward the obstruction.

Antibiotics are given preoperatively routinely when surgery is required. [ ] If perforation is suspected, give antibiotics as soon as possible. If intra-abdominal infection is suspected, see Sepsis in adults. Consult your local guidelines and drug information source for more information on antibiotic suitability, contraindications, and precautions.

Where impending perforation is not suspected, and in the absence of any cause that mandates surgical intervention, a period of conservative management may be indicated with further workup and/or treatment of the underlying cause. However, patients with large bowel obstruction will more frequently require operative intervention compared with those with small bowel obstruction.[12]

suspected or impending perforation

Plus – emergency surgery

ACUTE

sigmoid volvulus

no peritonitis or mucosal gangrene

1st line – flexible or rigid sigmoidoscopy

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1st line –

flexible or rigid sigmoidoscopy

Urgent intervention is required due to risk of perforation from either ischemia of the affected segment or obstruction. Patients without hemodynamic instability, peritonitis, or evidence of perforation should typically undergo flexible sigmoidoscopy to assess sigmoid colon viability, detorse the anatomy, and decompress the colon.[3][8][13]

Endoscopic detorsion through flexible or rigid sigmoidoscopy is effective in 60% to 95% of patients.[3] It is considered first-line therapy in stable patients without colonic ischemia or perforation.[3] After successful detorsion of the sigmoid colon, a decompression tube may be left in place to allow for continued colonic decompression, to decrease the risk of recurrent volvulus, and to facilitate preoperative mechanical bowel preparation, as needed.[3][13] Any underlying medical conditions that could increase the morbidity and mortality of surgery (e.g., heart failure) should be evaluated and optimized as much as possible. A full colonoscopy should also be arranged to exclude more proximal pathology that could affect the extent of the surgery. Patients who undergo successful endoscopic detorsion should be considered for sigmoid colectomy during the same hospital admission to prevent recurrent volvulus.[3] Although minimally invasive and open approaches have been described in the management of volvulus, surgeon and patient factors influence the selection of the operative plan. The redundancy and mobility of the colon and the associated mesentery usually allow for colectomy via a minilaparotomy.[3]

2nd line – surgery

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2nd line –

surgery

Of the variety of elective and semi-elective operations that have been described for sigmoid volvulus, sigmoid colectomy (with or without colorectal anastomosis) is the most effective at preventing recurrent volvulus.[3][8] Stoma creation in the nonemergent setting is not usually necessary, and should be individualized based on the operative findings and unique patient factors.[3]

Alternative surgical strategies to resection include detorsion alone, sigmoidopexy, and mesosigmoidoplasty. However, these are inferior to sigmoid colectomy for the prevention of recurrent volvulus.[3][8] Endoscopic fixation of the sigmoid colon may be considered in selected patients in whom operative intervention presents a prohibitive risk.[3][8]

peritonitis or mucosal gangrene

1st line – surgery

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1st line –

surgery

Patients who present with colonic ischemia, colonic perforation, peritonitis, or septic shock, or in whom endoscopic detorsion fails, require urgent sigmoid resection.[3] After the volvulized segment has been resected, the decision to perform a primary colorectal anastomosis, end colostomy, or defunctionalized colorectal anastomosis with diverting ileostomy should be individualized after considering a patient's clinical status at the time of surgery, health of the remaining colon, and comorbidities.[3] The Hartmann procedure, the most commonly performed operation for patients who have sigmoid volvulus with a nonviable colon and peritonitis, has an associated mortality rate of around 12% but can be up to 57% in some cases, according to retrospective studies.[8][49][50][51] Resection with primary anastomosis had a leak rate of up to 12% and a mortality rate of 5% to 10% in international retrospective studies.[8][52] End colostomy may be the safest and most appropriate choice for higher-risk patients (e.g., patients with higher American Society of Anesthesiologists [ASA] class, acidosis, sepsis, coagulopathy).[3]

Frequently, the colostomy is on a permanent basis.

As proximal colonic obstruction occurs with sigmoid volvulus, rapid cecal dilation, and ischemia can place the cecum at risk of perforation, and the cecum must be carefully inspected at the time of surgery.

cecal volvulus

1st line – surgery

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1st line –

surgery

Nonviable or gangrenous cecum is present in 18% to 44% of patients with cecal volvulus and is associated with a significant mortality rate.[3] Segmental resection is the preferred treatment for cecal volvulus.[3] Attempts at endoscopic reduction of cecal volvulus are generally not recommended, given the low probability of success and the potential for procedure-related perforation.[3][13] End stoma creation should be considered in higher-risk patients and in patients with a nonviable bowel, although the data regarding this option are limited.[3]

For cecal volvulus with a viable bowel, the use of nonresectional operative procedures should be limited to patients who are considered unfit for resection.[3]

colorectal malignancy

1st line – surgery or endoscopic stenting

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1st line –

surgery or endoscopic stenting

Surgical care aims to relieve obstruction and resect the lesion in most cases.[53] In some patients, endoscopic stenting could be considered as a bridge before surgery.[54] The nature of the surgery depends on the anatomic position of the tumor.

For patients with an obstructing left-sided colon cancer and curable disease, the choice of endoscopic stent decompression, diverting colostomy with interval colectomy, or initial treatment with oncologic segmental colectomy should be individualized based on patient factors and available expertise.[55]

For patients with an obstructing right or transverse colon cancer and curable disease, initial colectomy or initial endoscopic stent decompression with subsequent interval colectomy may be performed.[55]

In the setting of perforation or impending perforation of the colon, resection following established oncologic principles with a low threshold for performing a staged procedure is recommended when feasible.[55]

In patients with an obstructing colon cancer and incurable metastatic disease, or in other scenarios in which palliation is preferred over an attempt at cure, endoscopic stent placement or fecal diversion is preferable to colectomy when life expectancy is <1 year.

See Colorectal cancer.

diverticular disease

1st line – surgery

Back

1st line –

surgery

A persistent obstruction due to diverticular disease will likely merit surgical intervention as outcomes with endoscopic stenting are poor.[56] In addition, it may be difficult to exclude a malignant etiology. The criteria for recommending elective colectomy for nonobstructing recurrent disease are not clear cut. Any judgment should be made on an individual basis depending on age, frequency and severity of recurrent symptoms, previous complications, comorbidities, and patient preferences and values.[57][58][59][60] See Diverticular disease.

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Large bowel obstruction

Treatment algorithm

acutely ill

supportive measures

suspected or impending perforation

emergency surgery

sigmoid volvulus

no peritonitis or mucosal gangrene

flexible or rigid sigmoidoscopy

surgery

peritonitis or mucosal gangrene

surgery

cecal volvulus

surgery

colorectal malignancy

surgery or endoscopic stenting

diverticular disease

surgery

foreign body ingestion

transluminal removal or laparotomy

benign strictures

treat underlying cause

pelvic abscess

percutaneous or transrectal drainage

resection

currently receiving palliative care

initial supportive care