Bowel obstruction

Obstruction occurs when digested food is unable to pass through the intestine due to tumor, impacted
feaces,oedema or motility disorders. It is commonly associated with intestinal and gynecological cancers.

Causes:

Oedema cause by tumor.

Fecal impaction.

Intestinal muscle paralysis.

Lumen occlusion – due to primary tumer enlargement, recurrence of abdominal mass, fibrosis, adhesion.

Carcinomatosis with concurrent infiltration of the mesentery or bowel muscle and nerves by the tumer.

Small bowel Net also often infiltrate the mesentery.

Symptoms:

The obstruction can be partial or complete. Presenting symptoms commonly include :

Nausea and vomiting, include occasionally

Core:

Overview
I. Definition: cessation of forward movement of bowel contents
II. Pathophysiology :
A. Mechanical obstruction—most common in end-stage cancer, may be partial or complete, and may becaused by
extrinsic or intrinsic factors.
B. Functional obstructions—caused by changes to peristalsis such as by infiltration of bowel muscle by tumor;
includes fecal impaction.
C. Small-intestine obstructions are more common.
D. Large-bowel obstructions (about 25% of bowel obstructions) most often at or distal to the transverse colon.
E. Bowel dilation occurs proximal to the obstruction to due intestinal stasis that increases gas from bacterial
proliferation and fermentation of ingested food. Mural edema occurs, and the bowel loses its absorptive
ability, leading to accumulation of fluids. This leads to bowel distention because of the stationary
solids, intestinal fluids, and gas. Tension increases in the intestinal wall, and an increased risk for bowel
perforation exists (see section on bowel perforation later). Transudative fluid leakage from the intestinal
lumen to the peritoneal cavity may occur. Loss of fluids in addition to emesis secondary to the obstruction may lead
to hypovolemia and electrolyte disturbance. If obstruction is not relieved, bowel ischemia and necrosis may result.
F. Colorectal obstruction may lead to perforation, colonic necrosis, and septic shock.
G. Causes of obstructions:
1. Cancer, most often colorectal cancer, and may be the presenting symptom
a. Malignant obstruction occurs in 8% to 29% of colorectal cancers and 10% to 50% of ovarian cancers.
b. Cholangiocarcinoma, pancreatic, and gallbladder carcinoma are the most common tumors causing duodenal
obstruction.
c. Intraluminal tumors that may occlude the lumen or act as a point of intussusception.
d. Intramural tumors that may extend to the mucosa and obstruct the lumen or impair peristalsis.
e. Mesenteric and omental masses or malignant adhesions that may kink or angulate the bowel, creating an
extramural obstruction.
f. Tumors that infiltrate into the mesentery bowel muscle or the enteric or celiac plexus and cause dysmotility.
2. Postoperative intra-abdominal adhesions—entrap a loopof intestine andcontract, causing anobstruction and
possibly strangulation; may develop a few days after surgery or many years later
3. Nonsurgical adhesions after an infection such as peritonitis or after RT; may occur at any time after the infection
or completion of RT
4. Hernias with colonic incarceration
5. Miscellaneous conditions such as inflammatory bowel disease
6. Volvulus: twisting of the intestine that may cut off blood flow; most common benign cause of bowel obstruction
7. Diverticulitis—repetitive bouts causing strictures
8. Pseudo-obstruction from paraneoplastic destruction of enteric neurons in rare cases
9. Severe ileus caused by:
a. Pharmacologic agents: anticholinergic drugs, opioids, certain antineoplastic agents and antihypertensive agents,
antidiarrheals/ antispasmodics
b. Medical conditions: pancreatitis, gastroenteritis, spinal cord injury, hypokalemia, diabetic ketoacidosis,
myocardial infarction, stroke, and other comorbid conditions
10. Objects blocking the intestinal lumen—for example, foreign bodies and fecal or barium impaction
III. Poor prognostic factor in colorectal cancer
Assessment
I. Identification of patients at risk.
A. Disease related: cancers such as colorectal, ovarian, pancreatic most common
B. Treatment related
1. Prior abdominal surgery due to adhesive bowel disease (more common in small-bowel
obstructions)
2. Stricture formation from prior colorectal resection
3. Surgical trauma to neurogenic pathways to intestines, rectum, or both
4. RT to abdominal area
C. Previous intestinal obstruction
D. Frequent intestinal inflammation from diseases such as diverticulitis, colitis, inflammatory bowel disease
E. Abdominal wall hernia
F. Chronic constipation, fecal impaction
G. Peritoneal carcinomatosis
II. History (Yeh & Bordeianou, 2017)
A. Abdominal pain and intestinal colic from intestinal
stretching and pressure of peristalsis as the bowel
tries to push its contents past the obstruction.
1. Assess characteristics of pa
2. in (description, timing, duration, location, intensity, associated
symptoms)
2. May describe as cramping and spasmodic in
mechanical obstructions (every 20–30 minutes)
or as diffuse, constant, and less intense pain
(may be described as pressure or fullness) in functional
obstructions
3. In partial obstructions, pain may be described as
cramping pain after eating
4. In complete obstructions, pain intensifies and
comes in waves or spasms as the bowel tries to
push intestinal contents past the obstruction
5. With strangulation pain is constant and severe
pain intensified with movement
6. A sudden relief of pain followed by more severe
pain may indicate bowel perforation (see section
on bowel perforation later)
B. Nausea and vomiting
1. Small-bowel obstructions—more severe nausea
and vomiting
2. Gastric outlet obstruction—sour emesis that is not
bile-colored and often contains undigested food
3. Proximal small-intestine obstruction—rapidonset,
bitter, bile-stained emesis that may be
projectile
4. Distal small-intestine obstruction or colonic
obstruction with an incompetent ileocecal valve—
orange-brown, malodorous, feculent emesis
C. Anorexia, appetite changes
D. Change in bowel habits—constipation to obstipation
1. May experience lack of bowel movements and flatus
or may have paradoxical diarrhea (if partial
blockage exists)
2. Bowel may evacuate below an obstruction
E. Bloating, abdominal distention
F. Assess current medications
G. Note endocrine and immunologic history
H. Dietary history
III. Physical examination :
A. Immediate assessment for signs of dehydration,
shock, or abdominal compartment syndrome
B. Presentation will vary according to severity, location,
duration, and etiology of the bowel obstruction
C. Abdominal
1. Distention: baseline measurement of abdominal
girth should be obtained and section of measurement
marked. Serial exams are needed.
2. Abnormal bowel sounds:
a. Mechanical obstruction: intermittent borborygmi
(loud prolonged gurgles of hyperperistalsis)
b. Nonmechanical:
(1) Proximal to obstruction—high-pitched,
tinkling, or hyperactive bowel sounds that
may be heard in clusters or rushes
(2) Distal to the obstruction—bowel sounds
hypoactive or absent
(3) Hypoactive, low-pitched gurgles or weak
tinkles
(4) Absent bowel sounds indicating a paralytic
ileus
3. Abdominal palpation:
a. Boardlike abdomen may indicate peritonitis
b. Abdominal tympany noted over air-filled bowel
c. Abdominal dullness noted over fluidfilled
bowel
d. Abdominal tenderness often present but does
not correlate well with location of obstruction
e. Note surgical scars
f. Assess for abdominal hernia, abdominal mass,
hepatomegaly, lymphadenopathy
g. Rebound tenderness, guarding may indicate
ischemia or bowel perforation
4. Rectal examination may note fecal impaction or
rectal mass
D. Vital signs:
1. Pyrexia may indicate mucosal ischemia and sepsis
2. Tachycardia, hypotension, and orthostasis could
indicate dehydration
E. Dry mucous membranes and poor skin turgor may
indicate dehydration
F. May appear restless and acutely ill IV. Diagnostic testing (Ramanathan, Ojili, Vassa, & Nagar,
2017; Rami Reddy & Cappell, 2017; Yeh & Bordeianou,
2017)
A. Abdominal radiography: less sensitive than CT
B. CT of the abdomen: highly sensitive and specific
1. Can identify multifocal disease, metastatic disease,
ascites, or carcinomatosis
2. Can identify ischemia, necrosis, or perforation
C. Lower endoscopy may assist in patients with chronic
symptoms or with nondiagnostic CT
D. MRI:
1. More time consuming and expensive
2. Useful in persons with Crohn disease and when
radiation is a concern, such as pregnant patients
E. Abdominal ultrasound
1. Useful in pregnancy and in children
2. Poor diagnostic ability in early obstruction
F. Laboratory studies: CBC with differential, electrolyte
panel; carcinoembryonic antigen (CEA) if
imaging shows mass consistent with colorectal
malignancy
Management
I. Medical management (Lambert & Wiseman, 2018; Obita
et al., 2016; Shimura & Joh, 2016; Yeh & Bordeianou,
2017)
A. Initial management is supportive care, and subsequent
management depends on etiology, location, comorbidities,
prognosis, and goals of treatment (Obita
et al., 2016; Rami Reddy & Cappell, 2017; Shimura
& Joh, 2016; Yeh & Bordeianou, 2017)
B. Chemotherapy/targeted therapy
1. If surgery cannot be performed, or before surgery as
neoadjuvant treatment, or after surgery as adjuvant
treatment
2. After a stent placement
C. IV fluid therapy for dehydration and correction of
electrolyte abnormalities
D. Pharmacologic management
1. Low-dose steroids to decreased bowel wall edema
and to decrease nausea
2. Antiemetic agents
3. Octreotide to decrease intestinal secretions and
stretching of bowel wall, thus decreasing pain
4. Hyoscine butylbromide or scopolamine butylbromide
5. Metoclopramide
E. Flexible sigmoidoscopy to initially decompress colon
allowing time for planning surgical intervention
F. GI stenting allows time to plan surgical intervention or
for palliation in advanced disease
G. Surgical management:
1. Ostomy alone for fecal diversion
2. Colectomy with primary anastomosis with or without
ostomy
3. Hartmann procedure: resection of the rectosigmoid
colon with closure of the rectal stump and formation
of an end colostomy
4. Emergent surgery has worse outcomes than elective
surgery with more complications (such as sepsis
and organ failure) and higher rates of local recurrence,
as well as metastatic disease and lower 5-year
survival rates
II. Nursing management
A. Obtain dietary consultation for possible total parenteral
nutrition
B. Provide patient comfort measures
1. Ensure a relaxing environment
2. Position patient on side and support with pillows
3. Provide frequent oral care; use of moistened sponge
sticks; avoidance of lemon or glycerin swabs
C. Provide nasogastric tube care:
1. Assess pressure around nostrils every shift
2. Apply a water-soluble lubricant to nasal mucosa
3. Irrigate the tube with normal saline
4. Elevate HOB to 45 degrees to improve ventilation
and prevent aspiration
D. Monitor for complications related to bowel obstruction
1. Assess for signs and symptoms of dehydration—
dry mouth and lips, poor skin turgor, decreased urinary
output
2. Assess for interference with deep breathing related
to abdominal distention
3. Assess for signs and symptoms of peritonitis—
boardlike abdomen, increased pain on movement,
shallow respirations, tachycardia
4. Measure of abdominal girth during every shift
5. Monitor intake and output ratio, including gastric
output
Expected Patient Outcomes
I. Patient will have adequate pain control.
II. Patient has adequate fluid volume and electrolyte balance.
III. Patient receives adequate nutrition while bowel is
obstructed.