Small Bowel Obstruction

Liane S. Feldman, MD, FRCSC October 25, 2000

Small Bowel Obstruction

One of the most common problems we face Partial or complete blockage of lumen Our Goal = intervene before gangrenous bowel develops

Bowel Obstruction

Classification of SBO
SBO

Paralytic (ileus)

Mechanical

Partial
Bowel Obstruction

Complete

Causes of Mechanical SBO

Extrinsic Intrinsic
Intraluminal Intramural

Bowel Obstruction

SBO: Extrinsic Causes

Adhesions
postop, congenital, postinflammatory

Hernias
external, internal

Volvulus Mass effect

abscess, carcinomatosis, endometriosis, pseudocyst

Bowel Obstruction

SBO: Intraluminal Causes

Gallstone Intussusception Polypoid lesion Bezoar Enteroliths Foreign body Meconium ileus Parasites Inspissated feces Inspissated barium

Bowel Obstruction

SBO: Intramural Causes

Congenital
atresia, stricture, web, duplication, Meckels

Inflammatory
Crohns, radiation, diverticulitis, postischemic stricture, meds (NSAID, KCl)

Neoplasm
primary, secondary

Traumatic
Bowel Obstruction

Etiology of SBO
Adhesions..60% Malignancy.20% Hernia.10% IBD.5% Volvulus..3% Miscellaneous2%

Bowel Obstruction

Approach to SBO
How can we recognize SBO? Is it partial or complete? Is it simple or strangulated?

Bowel Obstruction

Recognition of SBO: History

Previous surgery, esp. pelvic Abdominal pain Colicky early on Vomiting: the more distal, the later the onset Obstipation

Bowel Obstruction

Recognition of SBO: Exam

Distention: Varies with level Bowel sounds: may be hypoactive if late R/o incarcerated groin, femoral, obturator (on rectal) hernia !!! Rectal exam: masses, blood

Bowel Obstruction

Radiology: plain films

Supine and upright Distended loops of SB, air-fluid levels, paucity of colonic air But diagnostic only 50-80% of the time
Remember gasless abdomen with closed loop obstruction (air cant accumulate in loop)

Bowel Obstruction

Radiology: CT Scan
Discriminates mechanical vs ileus Fluid or air-filled loops proximally Transition zone Collapsed bowel distally Can look for extrinsic causes Note that obstructing ileocecal lesion can look like ileus

Bowel Obstruction

New modalities
Ultrasound
SB loop dilated > 3 cm Dilated loop > 10 cm Peristalsis of dilated loop Collapsed colon

MRI

Bowel Obstruction

Partial or Complete Obstruction?

Can be diagnostic challenge Important because risk of strangulation and thus initial management differs Partial: negligible risk of strangulation (except Richters), so nonoperative first Complete: 20-40% risk of strangulation, so early operation required

Bowel Obstruction

Partial or Complete Obstruction?

Partial suggested by:
Flatus 6-12 hrs after onset Colonic air 6-12 hrs after onset

Patients with complete obstruction may still pass gas early on due to distal peristalsis

Bowel Obstruction

Partial or Complete Obstruction?

Barium test: 50 ml of barium via NG
Clamp tube x 1 hour (unclamp if vomits, etc) Repeat x-rays over next 12-24 hrs See if get to colon Contraindicated if suspect LBO: inspissates

CT scan can also be useful

Degree of distention, amount of distal air

Bowel Obstruction

Simple vs Strangulated SBO

Presence of strangulation increases mortality to 20% and morbidity to 40% So why not just operate on the ones with strangulation? Problem: we cant diagnose strangulation on clinical grounds!!!

Bowel Obstruction

Classic signs of strangulation?

...Continuous pain ...Fever ...Tachycardia ...Peritoneal signs ...Leukocytosis ...Elevated K, amylase, alk phos, LDH, CK PREDICT NECROSIS, NOT ISCHEMIA

Bowel Obstruction

Predicting Reversible Ischemia

Unfortunately, reversible ischemia is not discernable clinically CT: thickened bowel wall, pneumatosis, PV air, bowel wall nonenhancement Most are signs of necrosis not ischemia

Bowel Obstruction

Management
Resuscitation Tube decompression Timing of surgery Operative strategy Specific examples

Bowel Obstruction

Resuscitation
All patients have intravascular depletion:
Decreased po intake Vomiting Fluid sequestration

Aggressive resuscitation with IV isotonic solution required

Urine output, pulse guide resuscitation CVP line in some cases

Bowel Obstruction

Tube decompression
NG tube: removes swallowed air and gastric fluid Symptomatic relief: vomiting, pain Can give barium down tube Prevent aspiration during induction Longer tubes not better than NG tubes

Bowel Obstruction

Timing of surgery: Partial SBO

Usually patients suspected of adhesions from previous surgery Initial nonoperative treatment for few days 60-85% will resolve without operation Repeat physical exam and AXR q12 hours Reassess decision to operate or not q12 hours
Worsening status or failure to improve are indications for OR
Bowel Obstruction

Timing of surgery: Complete SBO

The issue 20-40% incidence of strangulation Cannot predict reversible ischemia clinically The Strategy Operation after initial 12 - 24 hours of resuscitation

Bowel Obstruction

Operative Strategy
May involve:
Lysis of adhesions Resection of obstructing lesion with anastomosis Intestinal bypass Rarely, stoma placement

Bowel Obstruction

Operative Technique
1. Clear adhesions to anterior abdominal wall
Avoid blind finger dissection and excessive countertraction; careful, sharp dissection best

2. Inspect region of cecum

If distended, is this really a LBO?

3. Work back from collapsed bowel to point of obstruction

Dont need to free adhesions proximal to point of obstruction
Bowel Obstruction

Assessing viability of intestine

Place back in abdomen with warm towel Conventional clinical criteria: normal color, peristalsis, marginal arterial pulsations
Doppler probe does not improve this impression

IV fluorescein dye (1 amp) with Wood lamp more reliable than clinical judgement alone for borderline bowel (Bulkley, Ann Surg, 1981) Rarely, second look in 24 hours
Bowel Obstruction

Adhesions
Pathophysiology
Transudated fibrinogen activated by tissue factor Forms fibrin clot which initiates adhesion formation

Peritoneal trauma and ischemia promote adhesion formation by release of tissue factor

Bowel Obstruction

Prevention of Adhesions
Avoid serosal trauma Avoid lysis of nonobstructing adhesions Avoid spillage in peritoneal cavity Aggressive irrigation of debris Adjuvent agent: bioresorbable membrane of hyaluronic acid and carboxymethylcellulose
Reduced adhesions to anterior abdominal wall in RCT (Becker, JACS, 1996)
Bowel Obstruction

Incarcerated hernia
Acutely incarcerated nonreducible hernia = early operative management
Site of incarceration is external ring make sure bowel does not reduce prior to direct examination

If suspect strangulation, consider midline incision

Bowel Obstruction

Intraabdominal abscess
Severe localized ileus near abscess mimics SBO Drainage of abscess often sufficient to relieve SBO
May be amenable to CT-guided drainage

Bowel Obstruction

Malignant tumor
Primary or secondary neoplasm with SBO - in general, treat like any other obstruction History of cancer or suspected carcinomatosis- may be challenge
Dont assume the worst: up to 40% due to benign causes (adhesions, radiation, stricture) Individualize treatment

Bowel Obstruction

Radiation enteritis
Acute enteritis (within few wks of radiation):
Try tube decompression, steroids

Chronic
Laparotomy usually required
Bowel looks fibrotic, gray-white, thick adhesions

Local resection or bypass if resection difficult

To ascending colon - outside of pelvic radiation field

Avoid anastomosis of radiated bowel

Bowel Obstruction

Acute postoperative obstruction

Risk of obstruction 1% within 4 weeks
Causes: adhesions (90%); internal hernia, abscess, volvulus, intussusception (10%)

Challenge is to differentiate ileus and SBO CT with oral contrast very useful
R/o abscess Delineate degree, site of obstruction

Bowel Obstruction

Acute postoperative obstruction

Management: like late obstructions
Partial: initially nonoperative, NG decompression Complete: early surgery

Laparotomy required in up to 50% As interval from first operation approaches 2-3 weeks, character of adhesions worsens and operation is much harder

Bowel Obstruction

Recurrent Obstruction
Risk of SBO after surgery is about 5%
Recurrence rates vary from 5-30%

Initial nonoperative trial usually safe

Bowel less mobile and apt to twist due to dense adhesions

Evaluate each patient to formulate plan Bowel fixation procedures largely abandoned

Bowel Obstruction

Role of laparoscopy in SBO

Key is careful selection:
(1) mild distention (2) proximal obstruction (3) partial obstruction (4) single band anticipated

Best chance of cure: recurrent abdominal pain in localized area with adhesions at same site

Bowel Obstruction

Take Home Messages

How to diagnose SBO
History, physical, radiology

Classify it as partial or complete Operate early in complete SBO (12-24 hrs) because we cannot diagnose strangulation clinically

Bowel Obstruction

Proximal or Distal?
Symptom Pain Vomiting Tenderness Distention Obstipation Proximal (open loop)
Intermittent, colicky, relieved by vomiting Large volumes, bilious Epigastric, mild unless strangulated Absent May not be present

Distal Closed loop (open loop)

Intermittent to constant Low volume, feculent over time Diffuse and progressive Moderate to marked Present Progressive, rapidly worsens May be prominent (reflex) Diffuse, progressive Often absent May not be present

Bowel Obstruction