Large bowel obstruction

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

Initial management includes correction of biochemical, hematologic, and physiologic parameters.

Surgical consultation is required, as surgical intervention is frequently indicated.[13] The type of surgery chosen depends on the site and cause of obstruction. Perforation or impending perforation requires emergency surgical intervention. The nature of the intervention depends on the cause and the patient's premorbid state and clinical status. Treatment recommendations regarding colorectal surgery should consider the patient’s degree of frailty (i.e., physiologic age) rather than chronologic age.[49] Minimally invasive techniques should be considered for frail older adults.[49]

Initial management

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] See Sepsis in adults. All patients, including those with perforation/impending perforation, should be fasted until the underlying cause is resolved. Supplemental oxygen is also given. Most patients are fluid depleted, so intravenous fluids replace previous losses, and any electrolyte imbalances should be corrected. Losses are increased in patients with sepsis and should be taken into consideration when addressing the fluid balance. Patients with sepsis may also require hemodynamic support with vasopressors.

Blood transfusion or blood products may be required to correct anemia or coagulopathy. Patients require urinary catheterization and monitoring of urinary output. Central venous pressure monitoring can be considered.

Nasogastric decompression should be 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. [ ] [Evidence A] Broad-spectrum antibiotics that cover likely pathogens, including amoxicillin, metronidazole, and gentamicin, or a penicillin/beta-lactamase inhibitor combination are recommended.

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]

Perforation or impending perforation

Emergency surgery is mandatory in patients with colonic perforation or impending perforation due to obstruction, unless there are additional factors (e.g., limitations on goals of care or the patient not expected to survive surgery).[4] The objectives of surgical intervention are to deal with any intra-abdominal contamination by thorough irrigation, resect the perforated segment, and ideally address the underlying cause.

Sigmoid volvulus

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]

Flexible or rigid sigmoidoscopy

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] Underlying medical conditions should be addressed and a later colonoscopy arranged to exclude more proximal pathology. 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]

Emergent surgery

Patients who present with colonic ischemia or perforation, peritonitis, or septic shock, or in whom endoscopic detorsion fails, all require urgent sigmoid resection.[3][8] 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 patients’ 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][50][51][52] Resection with primary anastomosis has a leak rate of up to 12% and a mortality rate of 5% to 10% in international retrospective studies.[8][53] 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.

Elective 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] 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]

Cecal volvulus

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

Surgical care aims to relieve obstruction and resect the lesion in most cases.[54] The nature of the surgery depends on the anatomic position of the tumor.

The American Society of Colon and Rectal Surgeons has issued the following recommendations:[55]

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.
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.
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.
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.

Large bowel obstruction in people receiving palliative care

Bowel obstruction may occur in patients already receiving palliative care.

In these situations, management decisions should be made with the appropriate multidisciplinary team and the patient and/or their caregivers should be involved where possible.

Careful consideration as to whether or not surgery is indicated for the individual patient receiving palliative care is needed; take into account the patient’s condition and their preferences, as well as the benefits and risks when considering surgery.

Diverticular disease

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.

Foreign body ingestion

Management of a foreign body should be handled on a case-by-case basis and may be done with endoscopy. However, emergency surgery is mandatory in patients with perforation due to obstruction. Objectives of surgical intervention are to deal with intra-abdominal contamination by thorough irrigation, resect the perforated segment, and ideally address the underlying cause.

See Foreign body ingestion.

Benign strictures

Benign strictures should be treated based on the severity of symptoms, the underlying disease process, and the patient's general condition.

Endometriosis

Endometriosis may require the diseased segment to be resected if there is an obstruction and, depending on the severity of the endometriosis, medical therapy may need to be initiated by a gynecologist.

See Endometriosis.

Pelvic abscess

Pelvic abscess may be due to complicated diverticular disease, or have a gynecologic cause in females.

Percutaneous or transrectal drainage may be performed, though there is a risk that an underlying malignancy will be missed. Resection of the diseased segment may be considered at a later date depending on the patient's progress.

Central venous catheter insertion: animated demonstration

Ultrasound-guided insertion of a non-tunnelled central venous catheter (CVC) into the right internal jugular vein using the Seldinger insertion technique.