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Perspectives on large bowel obstruction

Article · January 2017

DOI: 10.4103/2468-7332.200556

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Elroy Patrick Weledji

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Review Article INTERNATIONAL

JOURNAL OF
SURGERY
Perspectives on Large Bowel Obstruction SHORT REPORTS

Elroy Patrick Weledji

IJS Publishing Group Ltd www.ijsshortreports.com

From the Department of Large bowel obstruction (LBO) is a serious and costly medical condition, indicating often

Abstract
Surgery, University of Buea,
Buea, Cameroon
Received: January, 2017.
Accepted: January, 2017.
emergency surgery. The main clinical issue is to determine whether the obstruction affects
the small bowel or the colon since the causes and treatments are different. Delay in operative
intervention may lead to an unnecessary bowel resection, increased risk of perforation, and
overall worsening of patient morbidity and mortality. With the advent of colonic endoluminal
stent, the treatment of distal colonic obstruction should be individually tailored to each patient.
This article discussed LBO and emphasized the importance of history taking, examination, and
basic imaging in the early diagnosis of its cause, thus facilitating appropriate management.
Key Words: Examination, history, large bowel, obstruction, resuscitation, treatment

Introduction of transverse colon) colicky pain is carried by the lesser

I ntestinal obstruction remains a common and difficult
problem encountered by the abdominal surgeon. Although
large bowel obstruction  (LBO) presents less frequently  (15%)
than its small bowel counterpart (85%), it remains nonetheless
a common surgical emergency.[1] Following resuscitation,
a precise history may indicate the pathology and physical
examination supported by basic imaging may indicate where
the pathology is. These would determine which patient may
require immediate surgery, urgent surgery, semi‑elective
surgery, or a trial of conservative management. The
consequences of bowel obstruction are progressive dehydration,
electrolyte imbalance, and systemic toxicity due to migration
of toxins and bacteria translocation either through the intact but
ischemic bowel or through a perforation. Appreciation of fluid
balance, acid–base–electrolyte disturbance, and importance of
preoperative resuscitation decrease the morbidity and mortality
from intestinal obstruction.[2‑4]
Discussion
LBO may be mechanical (lumen partly or completely blocked)
or paralytic (no peristalsis). It may be chronic, acute‑on‑chronic,
acute, or pseudo obstruction (nonmechanical). In fact, there
is a complete spectrum of clinical presentation and patients
may present with acute LBO without a preexisting history
of obstructive symptoms.[5,6] The visceral pain of intestinal
obstruction is due to increased gut peristalsis against the
obstruction and is usually referred toward the midline rather
than being localized as the gut has a midline origin of
development. The visceral sensory fibers are carried by the
sympathetic nerves on their way to the spinal cord. Thus,
mid‑gut (mid second part of duodenum to proximal two‑thirds
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splanchnic nerve (T10–T11) and referred to the umbilicus
while hindgut (beyond the distal third of transverse colon)
colicky abdominal pain being carried by the least splanchnic
nerve (T12) is referred to the suprapubic area. The other
sources of pain are somatic (localized) from abdominal
distension and peritoneal irritation when ischemia or
perforation supervenes.[7,8]
The main causes of LBO are malignancy and volvulus of the
sigmoid colon [Table 1]. The prevalence of both is subject
to a wide geographical variability.[5,6] Colorectal cancer is
particularly prevalent in the west, accounting for at least 50%
of LBO. This proportion alters in Africa and Eastern Europe
where sigmoid volvulus is the cause of obstruction in up
to 40% of cases.[9,10] The most common site of LBO is the
sigmoid colon, accounting for 50% of all cases. This is not
only because the sigmoid colon is a common site for colonic
carcinoma but also because the lumen is relatively narrow and
the feces are firm rather than liquid. The second most common
site is the splenic flexure  (10%), where the combination of a
sharp kink in the colon together with luminal narrowing by
the tumor and relatively firm stools leads to blockage. The
features of a right‑sided LBO may be less obvious than those
of left‑sided colonic lesions because only a small proportion
of the colon is distended. However, an obstruction at the
ileocecal valve will produce features of a low small bowel
obstruction.[5,11] A closed loop obstruction may follow an
acute‑on‑chronic LBO from a distally obstructing colonic
Address for correspondence:
Dr. Elroy Patrick Weledji, E‑mail: elroypat@yahoo.co.uk
This is an open access article distributed under the terms of the Creative Commons
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For reprints contact: reprints@medknow.com

DOI: 10.4103/2468-7332.200556 How to cite this article: Weledji EP. Perspectives on large bowel
obstruction. IJS Short Rep 2017;2:1-4.

© 2017 International Journal of Surgery Short Reports | Published by Wolters Kluwer - Medknow 1
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Weledji: Large bowel obstruction
Table 1: Causes of large bowel obstruction
Cancer (primary or recurrent)
Volvulus
Diverticular disease
Hernia
Fecal impaction
Inflammatory bowel disease
Ischemic stricture
Anastomotic stricture
lesion. In cases where the ileocecal valve forms one end of
a closed loop strangulation obstruction is not a problem here,
but a similar problem to look for is intramural ischemia
of the cecum due to stretching causing patchy necrosis.
Right iliac fossa tenderness in a patient with LBO may
indicate cecal distension and imminent perforation which is
a disastrous complication of LBO. According to the law of
Laplace (2T = PR where P is the transmural pressure, T is the
wall tension and is the radius of a sphere), tension (in this case
in the wall of the colon) is proportional to the radius and is
therefore higher in the cecum which is the widest point of
the colon than elsewhere. Thus, the cecum takes the brunt of
the distension with imminent perforation if the cecal diameter
is >15 cm. When there is distal obstruction, the ileocecal valve
often becomes incompetent and both small and large bowel
become distended. If left untreated, the patient will start to
vomit, but ischemia or perforation of the bowel is unlikely.[5]
With regard to colonic intussusception in adults, the leading
point is invariable; a colonic pathology and laparotomy are
indicated.[12]
Sigmoid volvulus is the most common form of volvulus in
the gastrointestinal tract. The anatomic defect is the narrow
attachment of the root of the mesentery to the posterior
abdominal wall and a long mesenteric axis. Predisposed by
very high fiber diet and long redundant sigmoid colon in
Africans, chronic constipation and laxative abuse, psychiatric
and senile disorders, the sigmoid colon rotates around its
mesenteric pedicle usually more than 180° counterclockwise
resulting in partial or complete LBO. There is a palpable
tympanic mass and with the risk of ischemia from venous
obstruction.[9,11] Because of its high recurrence rate, sigmoid
colectomy is the definitive treatment as compared to
sigmoidoscopic decompression.[13,14] Less common causes of
LBO are diverticular disease, either as a result of stricture
or acute inflammation with edema, and obstructed groin
hernia. Inflammatory bowel disease is a very unusual cause
of obstruction, but strictures from any cause may precipitate
obstruction by proximal fecal impaction. Fecal impaction
alone rarely causes obstruction.[5]
The four cardinal clinical features of intestinal obstruction are
colicky abdominal pain, vomiting, constipation, and abdominal
distension. The clinical history may establish other features
indicative of the likely etiology of the obstruction. A thorough
history of the obstruction would include the patient’s age,
duration of symptoms, history and nature of the pain, history
of similar symptoms or surgery. A history of colorectal or
2 International Journal of Surgery Short Reports  ¦  Volume 2  ¦  Issue 1  ¦  January-March 2017
other intra‑abdominal malignancy, recent alteration in bowel
habit, or the passage of blood is suggestive of neoplasm.
Patients who are institutionalized and have cognitive
impairment have a high incidence of sigmoid volvulus and
severe constipation, and pseudo‑obstruction tends to occur in
patients with a history of recent nongastrointestinal surgery
or severe concurrent medical illness.[6,15] Chronic symptoms
will be associated with weight loss and anorexia, and the
general premorbid state (cardiovascular and respiratory)
is assessed for a patient with a known diagnosis and the
possibility of surgical intervention. Clinically, it is extremely
difficult to distinguish with any certainty between simple
obstruction and strangulation.[4] Simple obstruction presents
with colicky (visceral) pain, but there is mild generalized
abdominal tenderness from the distension with gas and fluid.
Strangulation (closed loop) obstruction usually has an acute
onset. The pain is most marked and the condition very serious
if overlooked. There is localized tenderness with pain on
coughing (rebound tenderness) as peritonism develops from
stimulation of pain receptors in the parietal peritoneum or
abdominal wall. The pain is constant rather than colicky and
abdominal rigidity is more marked. There is a tender mass
even with associated erythema of the skin. The patient is
obviously ill, toxic and may have a leukocytosis. Thus a tense,
tender, irreducible lump with no cough impulse, especially
over hernia orifice, for example, femoral or inguinal, is a
strangulation until proven otherwise. Occasionally, hernia is
internal and not palpable.[1,4,5] In colon obstruction, vomiting
occurs much later if at all especially if the ileocecal valve
remains competent and implies a state of severe volume
depletion. In LBO, the lesion is very distal within the intestine
and constipation and distension are the earliest and most
predominant symptoms. Absolute constipation occurs when
there is complete luminal obstruction and the patient is unable
to pass either feces or flatus. Patients with partial obstruction
may develop spurious diarrhea because fluid feces are all that
can pass through a stenosed segment.
The physical findings include dehydration, abdominal
distension, and sometimes, visible peristalsis. Dehydration
assessed by examination of the mucous membranes and
skin turgor is an indication of severe fluid depletion. In
colonic obstruction, distension is mainly in the flanks and
upper abdomen. Abdominal distension is usually evident and
more marked the more distal the obstruction, but it is more
an indication of the site than the extent of obstruction.[5]
Swallowed air, gas from bacterial fermentation, and nitrogen
diffusion from the congested mucosa are all responsible for
the increased intestinal gas. The cause of the obstruction may
be may be evident (e.g., scars from previous surgery, tender
irreducible hernia, abdominal mass, e.g., intussusception or
carcinoma of the bowel). Percussion produces a tympanic
note and auscultation high‑pitched tinkling bowel sounds.
If the obstruction is advanced, there may be signs of bowel
strangulation (worsening constant pain, toxic patient,
tachycardia, hypotension, and pyrexia) with absent bowel
sounds (paralytic ileus).[1,5,16] The examination findings
will depend on the stage at which the patient presents. The
patients with complete obstruction are at substantial risk
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Weledji: Large bowel obstruction
of strangulation (20%–40%), but a patient with chronic
obstruction may appear generally quite well with normal vital
signs.[4] On the other hand, the patient who has an acute large
bowel volvulus or an acute closed loop small bowel obstruction
may be profoundly ill at the time of presentation. Abdominal
distension may be so marked as to render further assessment of
the intra‑abdominal contents impossible. Rarely a mass be felt,
or an irregularly enlarged liver may suggest a malignant lesion
as the cause of obstruction. Hernia orifices must be examined
in all cases of intestinal obstruction although hernias are
unusual cause of LBO.[5,16] Although rectal examination will
rarely provide a diagnosis as a true rectal lesion rarely causes
LBO, it must always be performed in bowel obstruction.
Symptoms such as rectal bleeding and Tenesmus herald its
discovery before obstruction ensues. The rectum will be empty
unless the cause of the problem is impacted feces. A pelvic
mass may be palpable, and the presence of blood and mucus
on the glove is suggestive of a distal neoplasm. Assessment
of the cardiovascular and respiratory systems is necessary as
most of these patients will require surgery.[5,16]
A plain abdominal X‑ray (AXR) will show the distribution
of gas and its distal limits, and it can thus distinguish
small from LBO. AXR features of LBO include distended
colon (over 5 cm) proximal to the obstructing lesion,
collapsed colon distally (“cutoff” sign). Distended large
bowel tends to lie peripherally and to show the haustrations
of the taenia coli, which does not extend across the whole
width of the bowel. Distended small bowel may also be
seen if the ileocecal valve is incompetent.[17] Only rarely
is the cause of obstruction detectable on plain films of the
abdomen. The advent of modern, fast multidetector computed
tomography (MDCT) scanners has changed management
strategies for acute abdominal conditions including suspected
LBO in all groups of patients, especially the elderly
infirm, and those on intensive care/high dependency unit
(ITU/HDU). MDCT was shown to be more accurate in the
diagnosis of LBO. It is usually available on a 24‑h basis, and
in many institutions, it has replaced the urgent water‑soluble
contrast enema X‑ray indicated in all cases of apparent LBO
but contraindicated in the presence of peritonitis and in
toxic megacolon.[18] It also has the advantage of excluding
incidental findings and in staging malignant disease.
The management of LBO depends on its presentation.
If intervention is not forthcoming following progressive
symptoms of chronic obstruction over a period,
acute‑on‑chronic obstruction may supervene. These acute
presentations are managed as an emergency to prevent
imminent perforation and fecal peritonitis.[6,16,18] Following
resuscitation, a water‑soluble gastrografin contrast enema
X‑ray may show the level of obstruction and importantly
exclude a pseudo‑obstruction if a CT scan is not available.[16]
The penalty of misdiag nosis in pseudo‑obstruction is an
unnecessary laparotomy in a poor‑risk patient.[15] Obstructing
carcinomas of right colon are treated by right hemicolectomy
and of splenic flexure by extended right hemicolectomy.
This removes cancer and obstructed right colon and results
in a well‑vascularized ileocolic anastomosis. Postoperative
diarrhea is rarely problematic as the sigmoid and rectum
International Journal of Surgery Short Reports  ¦  Volume 2  ¦  Issue 1  ¦  January-March 2017
are preserved. The surgical treatment of sigmoid and
rectosigmoid junction lesions depends on the general status
of the patient, findings at operation, and preference of the
operating surgeon. Perhaps, the most common procedure
performed for acutely obstructed left‑sided colonic cancer
is Hartmann’s operation (left‑sided segmental resection
without primary anastomosis). The advantages have no
anastomosis, limited mobilization required, resection of
obstructing lesion, and preservation of proximal colon.
The disadvantages are stoma formation, high morbidity of
reversal, and up to 50% are not reversed. More recently,
surgical practice has moved toward one‑stage procedures
for LBO. The advantages are avoiding stoma, resecting the
lesion, and preserving the proximal colon. The disadvantages
are the potential for anastomotic leakage and the possibility
of a synchronous proximal lesion. A subtotal colectomy with
ileosigmoid or ileorectal anastomosis is indicated if, in the
obstructed colon, the quality of the proximal bowel is poor
with respect to anastomosis because of edema, fecal loading,
shutdown of the splanchnic blood supply, and an inconsistent
marginal vessel. The anastomosis has a good blood supply
from the ileum and proximal diversion is unnecessary. As
the whole of the proximal colon is removed, undetected
synchronous lesions, which may be missed in the absence
of preoperative imaging, are removed and subsequent
colonoscopic surveillance can be avoided. The main
perceived disadvantage is postoperative bowel frequency
of twice per day with ileosigmoid anastomosis increasing
to three per day after ileorectal anastomosis. Subtotal
colectomy is of course inadvisable in patients with sphincter
dysfunction or fecal incontinence.[5,6,11,16] On‑table lavage is
most appropriate for obstructing rectal lesions amenable to
primary resection, where preservation of colon above a low
anastomosis is desirable.[17] A chronic LBO can be admitted
electively for colonoscopic investigations before definitive
elective surgery.[4‑6,16] Self‑expandable metal stents are now
being used more widely in the management of malignant
low  (distal to the splenic flexure) left‑sided LBO. These
stents are placed endoscopically under fluoroscopic control
through the obstructing lesion and can remain in place for
a prolonged period where the stent is definitive palliative
treatment or alternatively can decompress the colon, and
after staging and a complete workup, a definitive one‑stage
resection and anastomosis may be possible.[19] The stents
are expensive, but they appear to be cost‑effective. Colonic
stenting as a bridge to surgery provides surgical advantages,
as higher primary anastomosis rate and a lower overall
stoma rate, without increasing the risk of anastomotic leak
or intra‑abdominal abscess.[20] However, these results should
be interpreted with caution because of few studies reported
data on these outcomes.[21] Further randomized controlled
trials are needed including a larger number of patients and
evaluating long‑term results  (overall survival and quality
of life) and cost‑effectiveness.[22] Optimal treatment in
advanced disease remains controversial. Complications of
perforation and bleeding are possible but uncommon, and
it is likely this technique will be used more widely in the
future. At present, the treatment of distal colonic obstruction
is individually tailored to each patient.[20,21]
3
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Weledji: Large bowel obstruction
Conclusions
LBO remains a common and difficult problem encountered
by the abdominal surgeon. It is important to distinguish
simple from strangulation obstruction, following
resuscitation. A precise history may indicate the pathology
and physical examination supported by basic imaging
may indicate where the pathology is. Appreciation of fluid
balance, acid–base–electrolyte disturbance, and importance
of preoperative resuscitation decrease the morbidity and
mortality from intestinal obstruction. In distal obstruction,
optimal treatment in advanced disease remains controversial,
particularly after the appearance and use of colonic
endoluminal stents.
Financial support and sponsorship
Nil.
Conflicts of interests
There are no conflicts of interest.
References
1. Jackson PG, Raiji MT. Evaluation and management of intestinal
obstruction. Am Fam Physician 2011;83:159‑65.
2. Campling EA, Devlin HB, Hoile RW, Ingram GS, LunnJN.
The Report of National Confidential Enquiry into Perioperative
Deaths (NCEPOD) 1991/1992. United Kingdom. London:
Lincoln's Inn fields; 1993.
3. Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A,
Knoblich B, et al. Early goal‑directed therapy in the treatment of
severe sepsis and septic shock. N Engl J Med 2001;345:1368‑77.
4. Sarr MG, Bulkley GB, Zuidema GD. Preoperative recognition
of intestinal strangulation obstruction. Prospective evaluation of
diagnostic capability. Am J Surg 1983;145:176‑82.
5. Dexter SP, Monson JR. Large bowel obstruction. In: Monson J,
Duthie  G, O’Malley  K, editors. Surgical Emergencies. Osney
Mead, Oxford: Blackwell Science; 1999.
6. Kahi  CJ, Rex  DK. Bowel obstruction and pseudo‑obstruction.
Gastroenterol Clin North Am 2003;32:1229‑47.
7. Irvin TT. Abdominal pain: A surgical audit of 1190 emergency
admissions. Br J Surg 1989;76:1121‑5.
8. Gallegos N, Hobsley M. Abdominal pain: Parietal or visceral? J
R Soc Med 1992;85:379.
4 International Journal of Surgery Short Reports  ¦  Volume 2  ¦  Issue 1  ¦  January-March 2017
View publication stats
9. Chiedozi LC, Aboh IO, Piserchia NE. Mechanical bowel
obstruction. Review of 316 cases in Benin City. Am J Surg
1980;139:389‑93.
10. Soressa U, Mamo A, Hiko D, Fentahun N. Prevalence, causes
and management outcome of intestinal obstruction in Adama
Hospital, Ethiopia. BMC Surg 2016;16:38.
11. Frago  R, Ramirez  E, Millan  M, Kreisler  E, del Valle  E,
Biondo S. Current management of acute malignant large bowel
obstruction: A systematic review. Am J Surg 2014;207:127‑38.
12. Weledji EP, Aminde LN, Teno DN, Bonko NM, Cholong TB,
Fon AT. Adult intussusception in a rural setting: A report of
two cases and brief review of literature. Afr J Integr Health
2014;1.
13. Perrot L, Fohlen A, Alves A, Lubrano J. Management of the
colonic volvulus in 2016. J Visc Surg 2016;153:183‑92.
14. De U, Ghosh S. Single stage primary anastomosis without
colonic lavage for left‑sided colonic obstruction due to acute
sigmoid volvulus: A prospective study of one hundred and
ninety‑seven cases. ANZ J Surg 2003;73:390‑2.
15. Yazar FM, Kanat BH, Emir S, Bozan MB, Bilgiç Y, Sahin A, et al.
An obstruction not to forget: Pseudo‑obstruction (Ogilvie syndrome):
Single center experience. Indian J Crit Care Med 2016;20:164‑8.
16. Goyal A, Schein M. Current practices in left‑sided colonic
emergencies: A survey of US gastrointestinal surgeons. Dig Surg
2001;18:399‑402.
17. Lim  JH, Ko  YT, Lee  DH, Lee  HW, Lim  JW. Determining the
site and causes of colonic obstruction with sonography. AJR Am
J Roentgenol 1994;163:1113‑7.
18. Jacob  SE, Lee  SH, Hill  J. The demise of the instant/unprepared
contrast enema in large bowel obstruction. Colorectal Dis
2008;10:729‑31.
19. Keymling M. Colorectal stenting. Endoscopy 2003;35:234‑8.
20. Cirocchi R, Farinella E, Trastulli S, Desiderio J, Listorti C,
Boselli C, et al. Safety and efficacy of endoscopic colonic
stenting as a bridge to surgery in the management of intestinal
obstruction due to left colon and rectal cancer: A systematic
review and meta‑analysis. Surg Oncol 2013;22:14‑21.
21. Heriot AG. Colonic stenting in malignant large bowel obstruction:
An unanswered question. ANZ J Surg 2016;86:742‑3.
22. Arezzo A, Balague C, Targarona E, Borghi F, Giraudo G,
Ghezzo L, et al. Colonic stenting as a bridge to surgery versus
emergency surgery for malignant colonic obstruction: Results
of a multicentre randomised controlled trial (ESCO trial). Surg
Endosc 2016;6. [Epub ahead of print].