Diagnostic and Management Approach of Intestinal

Obstruction

Danny A. Portes , M.D.Department of Medicine

Veterans Memorial Medical Center

GENERAL OBJECTIVE :

To discuss a case of Adenocarcinoma of the colon presenting as intestinal obstruction

SPECIFIC OBJECTIVES :

1. To discuss diagnostic approach on intestinal obstruction.

2. To present differential diagnoses on intestinal obstruction.

3. To discuss the management approach of intestinal obstruction.

General data

• 82 y/o , male • Married , RPV • Roman Catholic• Pangasinan• Admitted for the 1st time on May 23,

2005

Chief Complaint

Abdominal Pain

History of Present Illness

1 MONTH PTA abdominal pain consultation done

1 WEEK PTA still with abdominal pain(+) vomiting(+) loss of appetite(+) weight lossno consultation normedication taken

1 DAY PTA persistence of above s/sxconsultation donemedication: Cotrimoxazole 800mg/tab Ranitidine 150 mg/tab tid Hyoscine N Butyl Bromidetransferred to our institution

ADMISSION

Past Medical History (+) Hypertension x 20 years - on

Amlodipine 5mg/tab, OD Hemorrhoidectomy - 1969

Personal / Social History 47 pack year smoker – stopped in 1969 alcoholic beverage drinker – stopped in

1969

Family History Hypertension – paternal side

Review of Systems

(+) generalized body weakness (-) fever(-) cough, hemoptysis, DOB(-) chest pain, orthopnea, PND(-) palpitations, dyspnea(-) dysuria, frequency, urgency(-) bleeding episode(-) polyuria, polydipsia, polyphagia

Physical Examination Conscious , coherent , not in distress BP: 130/70 CR: 72bpm RR: 20 T:37 pale palpebral conjunctivae, anicteric

sclerae,no nasoaural discharge, moist lips and buccal mucosa

supple, no CLAD, no neck vein engorgement

SCE, no lagging, nor retractions, resonant, no adventitious sounds

Adynamic precordium, PMI at 5th ICS, LMCL NRRR, (-) murmur

• Flat, (-)scars, normoactive bowel sounds, (-) bruit, soft, tympanitic, with slight tenderness at the epigastric and hypogastric area on deep palpation, (-) hepatosplenomegaly, (-) palpable mass, (-) rebound tenderness

• Abdominal circumference= 34 inches

Genitalia: no lesions no scrotal enlargement

Extremities: grossly normal, full and equal pulses, no edema, no cyanosis

Skin: dry skin, poor skin turgor, no active dermatoses, no jaundice

DRE: no skin tags, no lesions, no fissures, good sphincteric tone, full rectal vault, (+) brownish hard stool on examining finger

Salient Features 82yo, male abdominal pain vomiting anorexia weight loss pallor slight tenderness on deep palpation at

epigastric area and hypogastrium

Admitting Impression

T/C BPUD, Anemia 2° Hypertension, Stage 2, controlled

Differential Diagnosis

Biliary tract disease Chronic diverticulitis Colonic CA

Biliary Tract Disease

nausea, vomiting and epigastric or RUQ abdominal pain that is steady or colicky

post-prandial fullness, flatulence and fatty food intolerance jaundice

Complete Blood Count

5-23 5-28 5-30 6-15 7-7

Hgb 81 116 148 115 112

Hct 27 37 46 37 36

WBC 4.2 15.7 8.4

seg .78 .96 .85 .78

lymp .22 .04 .15 .22

retic 16

platelet 264

protime 264

Pro act 120

control 12.9

MCV 66

MCH 20

MCHC 30

Blood Chemistries 5-23 5-25 5-28 6-1 7-10

BUN 5.2 3.2

Crea 82 73

Na 141 145 137

Cl 100 101 100

K 4.2 3.4 3.9

FBS 6.0

BUA 151

HDL 1.0

LDL 3.9

Mg

Ca 2.0

Phos

sgot 38

sgpt 20

TC 5.1

TG 0.5

amylse 51

glob 26 25

alb 28 15 27

TP 54

5-26 6-15 7-15

color yellow D. yellow yellow

transprency sl turbid sl turbid clear

sp gravity 1.010 1.015 1.015

pH 7.0 6.5 7.5

albumin neg neg neg

sugar neg neg neg

RBC 0-1 0-1 2-4

PUS 0-3 0-4 2-3

bacteria few mod

epith cells few occ

CEA: 6-241.18ng/ml ( 2.10-6.20)

12-L ECG Results:5-23-05

- 1st degree AV block

- CRBBB

6-5-05

- CRBBB

Radiographic Report

5-24 5-25 5-26 5-27

Gen adynamic ileus, OA thoraco lumbarspine

Gen ileus, partial int obstruction not ruled out, OA, TLS

Gen ileus, partial int obstruction not ruled out, OA TLS

Finding consistent with partial intestinal obstruction, OA, TLS

Chest ( A-P)

5-27-05

- No significant cardiopulmonary problems

findings except for atheromatous aorta, OA, thoracis spine

Lumbo-sacral - spurs on the bodies of the lumbar spine with intact disc space consistent with degenerative changes, lumbar instability

Ultrasound Report Abdominal Aorta:

5-23-05- no sonographic evidence of

abdominal aortic aneurysm HBT, LGBPS, AA:

5-24-05- normal liver, biliary tree, spleen- consider cholecystitis- non visualized pancreas and AA - minimal ascites noted

HBT, LGBPS, PAN:

6-17-05

- diffuse parenchymal liver disease

- dilated intrahepatic duct- sonographically normal gall bladder- non visualized pancreas- negative para-aortic node

enlargement- incident note of ascites and right basal pleural effusion

Whole Abdomen CT Scan

5-27-05

- Generalized ileus. Possibility of chronic partial intestinal

obstruction likewise considered.- dilated gall bladder- OA changes of lumbar spine

Histopathological Diagnosis

Adenocarcinoma, low grade (Moderately Differentiated), 5x4 cm extending to the muscular and subserosal layerASTLER COLLER STAGING, STAGE B2T3MOMx, AJCC

Remarks: all (0/8) lymph node and lines of resection are NEGATIVE for malignant cells.

Course in the ward

Admission

Venoclysis done • diet : low salt , low cholesterol Dx : CBC – anemia

12 L ECG – complete RBBB, 1st degree AV block

Tx : Famotidine 20 mg IV q 8°Metoclopramide 10 mg IV prnAlMgOH 45 cc prnAmlodipine 5 mg/tabISDN prnPRBC 2 “u” requested

1st hospital day Vital signs were normal • Occasional epigastric pain radiating to the

hypogastric area • 2 episodes of vomiting • IMPRESSION: T/C Cholecystitis

Dx: Ultrasound unremarkable Tx/Plan: Gastro service

Surgery service

2nd hospital day Still with crampy abdominal pain, vomiting• Normal vital signs, abdominal girth= 36 inches• IMPRESSION: T/C Acute Intestinal Obstruction

Dx: Flat Plate of abdomen

- Generalized adynamic ileus Serum amylase normalSerum electrolytes - normalUTZ of LGBPS normal

Tx: NPO NGT insertedBlood transfusion 1 unit PRBC

3rd hospital day Still with the same complaints • Normal vital signs, abdominal girth = 36

inches

Repeat flat plate done – Generalized ileus – Intestinal obstruction not ruled out

GI service - continue decompression and start Empiric antibiotic therapy • Cefuroxime 750 mg IV q8°• Metronidazole 500 mg IV q8°

Surgery service Non surgical abdomen and concurred

with the plan Suggestions :

Endoscopy serum TPAG determination liquid diet if tolerated

4th hospital day Still with crampy abdominal pain (+) nausea (-) vomiting Stable vital signs AC = 36 inches

Repeat flat plate – Partial Intestinal obstruction– Post BT H & H

Continue empiric antibiotic treatment and decompression

BT of 2nd unit of PRBC referred back to Gastro service

5th hospital day Still with abdominal pain localized in left

hypogastrium (+) vomiting (-) fever– Increasing abdominal girth (37 inches)– Tenderness on deep palpation

CT scan of abdomen – Generalized ileus – Consider Chronic partial intestinal

obstruction– Dilated gallbladder– Osteoarthritic changes of lumbar spine

6th hospital day Transfer of

service– Surgery

“E” lap done – Left

hemicolectomy with Devine’s colostomy and biopsy done

Intraoperative findings • 5 x 4 cms firm ,

constricting mass at the splenic flexure , markedly dilated bowels from LOT to mid transverse colon

• With serosal tears at

80 cm and 110 cm from LOT

Histopathologic report • Adenocarcinoma , low grade

( Moderately Differentiated ) extending to the muscular and subserosal layer

• ASTLER COLLER STAGING , STAGE B2 T3N0Mx , AJCC

• All (0/8)LN and lines of resection are NEGATIVE of malignant cells

Course in the ward:

• He stayed at surgery service for two weeks. Antimicrobial coverage, hydration and nutritional build-up were provided.

Course in the ward:

• He was subsequently transferred to ONCOLOGY service.

• On his 39th hospital day, he was discharged clinically improved and stable.

DISCUSSION

By location – small bowel (proximal/distal) - large bowel

By mechanism – mechanical or non-mechanical ( adynamic, paralytic ileus, pseudo-obstruction)

By pathophysiology – simple, closed loop, strangulated

Intestinal Obstruction

Colonic Obstruction

Neoplasm (60%)

Volvulus (20%)

Diverticular stricture (10%) Others (10%)

Volvulus 20-50% of all intestinal obstruction abnormal twisting of a segment of

bowel on itself along its longitudinal axis

closed loop obstruction is often produced

sigmoid and cecum are the most frequent sites

transverse colon, splenic flexure

colicky abdominal pain, obstipation and abdominal distention

“ bent-inner tube” ( sigmoid volvulus) or omega loop sign

“ kidney-bean shaped” ( cecum) these “classical” radiographic findings

are seen in 40%-60% of cases operative distortion/colonoscopic

distortion

Diverticulitis

diverticula are small mucosal pockets in the wall of the colon

obstruction of the neck of the diverticulum may result in the distention secondary to mucus secretion and overgrowth of normal colonic bacteria ultimately leading to perforation.

pain maybe intermittent or constant frequently associated with a change in

bowel habits hematochezia is rare anorexia, nausea and vomiting may

occur recurrent attacks can result in the

formation of scar tissue, leading to narrowing and obstruction of the colonic lumen.

Management ofIntestinal Obstruction

Evaluations

History and Physical Examination Laboratory Examinations Chest/Abdominal Radiographs

- flat, upright and decubitus Contrast studies (single, double) Endoscopy

Computed Tomography MRI CT colonoscopy/

Virtual colonography

Colonoscopy

Indications for colonoscopy: evaluation of potentially significant

barium enema evaluation of lower GI bleed IBD therapeutic indications surveilance studies

removal of colon polyp work up of iron deficiency anemia discretionary follow-up of colonic lesions

of unknown significance diagnosis and localization of lower GI

bleed prior to possible electrocauterization or surgery

“These indications are not all-inclusive and are subject to physician discretion in individual cases”.

Contraindications: toxic, fulminant colitis perforation of abdominal viscus severe coagulopathy acute diverticulitis acute or recent MI patient refusal

American College of Physician

“ Although colonoscopy maybe useful in patients with partial colonic obstruction, it has little role in the initial evaluation of patients suspected of having complete obstruction. The insufflation of air or CO2 through endoscope may exacerbate colonic distention and precipitate perforation”

Sleisenger and Fordtran’s 7TH Edition 2002

Contrast Studies

Perform if the diagnosis of large bowel obstruction is suspected but not proven

If differentiation b/w obstipation and obstruction is required

If localization is required for surgical intervention

Contrast Studies

The reflux of barium above an obstructing colon may promote the development of complete obstruction

The use of water soluble contrast media obviates the risk of barium impaction at the site of obstruction and barium peritonitis in the case of unrecognized perforation.

Sleisenger & Fordtrans 7th Edition

Barium should be used cautiously or not at all because it may inspissate at the site of stricture and exacerbate the blockage

Cameron’s Current Surgical Therapy

7th Edition

“ CT scan has an overall sensitivity of 98 % and specificity of 87 % in detecting colon cancer “

Robinson P , Brunett H , Nicholson DA

Clinical Radiology Dec 2003

“ Overall sensitivity was 71.7% on plain film And 83.0% on CT.

Efficacy of abdominal plain film and CT in bowel obstruction

Nippon Igaku Hoshesen Gakkai Zasshi, Mar 2002Dept of Radiology, St Martin University

“ CT had high sensitivity (93%), specificity (99%) and accuracy (94%) in diagnosing

the presence of obstruction. The comparable

sensitivity, specificity and accuracy were, respectively, (83%), (98%), (84%) for US and (77%), (70%) and (80%) for plain radiography. The level of obstruction was correctly predicted in 93% on CT, 70% on US and 60% on plain films.

“Comparative evaluation of plain films, ultrasound and CTin the diagnosis of Intestinal obstruction”.

Suri, Gupta, Sudhakar, Venkataramu, Sood, WigDept of Radiodiagnosis, Post Grad Inst of Medical Education

And Research, Chandigarh, India ( 2001)

“ CT scan as a routine preoperative diagnostic exam could cause MISDIAGNOSIS due to the following :

Inadequate bowel preparation Flat lesions > 10 mm - misinterpreted

as feces Small polyps “

Barton JB , Langdale et alAm J of Surgey May 2004

“ MRI is superior to CT in staging Cancer and in differentiating between scarring tissue and recurrence “

“ It’s 91 % sensitive and 100 % specific ““ It has 100% positive predictive value

and 89% negative predictive value with an accuracy of 95 % “

Hock D. , Cancer Journal May 2003

“ MRI is superior in sensitivity , specificity and accuracy to CT scan in determining extent of tumor “

Pema PJ , Bennett WF Journal of Computer assisted Tomography March-April 2004

Treatment and Outcome

Resuscitation and Initial management

- restoration of intravascular volume- correction of electrolyte abnormalities- nasogastric decompression

Subsequent therapeutic decision depend primarily on the presence of complete or partial obstruction or evidenced of strangulation

Patients with partially obstructing benign or malignant strictures w/o evidenced of peritonitis may undergo semi-elective resection.

Complete colonic obstruction necessitates emergency operative decompression.

Self-expanding metallic endoprostheses or endoluminal colonic wall stents.

The goals of operative management in complete colonic obstruction are three-fold :(a) to quickly decompress the obstructed colon(b) to definitely treat the obstructing lesion(c) to re-established the intestinal continuity

“The competency of ileocecal valve is of great importance to the pathophysiology of colonic obstruction.

The necessity for emergency operation is dictated by the presence of complete colonic obstruction and not by the measurement of cecal diameter”.

Sleisenger & Fordtran’s GI and Liver Disease

7th Edition

“Operating in an urgent or emergent fashion is associated with high operative mortality/morbidity”. A thorough knowledge of the cause of colonic obstruction is important for optimal patient’s outcome”.

Cameron’s Current Surgical Therapy 7TH Edition

Current Concepts in Diagnoses and Management of Intestinal Obstruction

Virtual colonography/CT colonoscopy

•

Current concepts

“ CT colonography /Virtual colonoscopy promises to become a 1° screening method for colorectal Cancer “

“ New rapidly developing non invasive CT technique to detect polyps and cancers >/=10 mm in size “

Gluecher TM , Fletcher JG . Europe J Cancer Nov. 2003

“ CT colonography is 98 % sensitive and 96 % specificity in detecting Colorectal Cancer “

Neri E., Giusti P., Battolla L

Diagnostics and Interventional Radiology , Univ. Pisa , Rome June 2004

Angiography for diagnosis and treatment of colorectal

cancer Preoperative selective arterial

angiography can help the diagnosis and locate primary tumors and to detect liver metastasis. At the same time arterial chemotherapy can be an important form of preoperative therapy.

Jin Gu, Ming Li, Guang Xu, Dept of Sx, Oncology School of Peking University, Beijing, Beijing China.

Zhai-Li Dept of Surgery, Beijing Chaoyang Hospital

Carcinoma of the Colon

•

Colonic Cancer• 5-year survival is 90%

when colorectal Ca is diagnosed at an early stage, less than 40% of cases are diagnosed when the cancer is still localized.

• 3rd most common Ca in men and women.

• about 60% present with obstructive symptoms

How is colon cancer diagnosed?

RISK FACTORS

• > 40 y/o• High fat and low

fiber diet• Sedentary lifestyle• Smoking • Alcohol use • Family history• IBD

SIGNS/SYMPTOMS • No obvious signs but

could include – Change in bowel

frequency– Change in consistency– Rectal bleeding/

bloody stool– Unexplained weight

loss– Fatigue– Persistent abdominal

discomfort – Unexplained anemia

Environmental Factors Potentially Influencing

Carcinogenesis in the Colon and Rectum

Probably Related- high fat and low fiber consumption

Possibly Related- beer and ale consumption (esp Rectal Ca)- environmental carcinogen and mutagens

Fecapentaenes ( from colonic bacteria )

Heterocyclic amines ( from charbroiled and fried meat and fish )

Probably Protective- high fiber consumption- physical activity and low body mass- Aspirin and NSAIDs- Calcium

Possibly Protective- yellow green cruciferous vegetable- Vitamin A, C, E- HRT ( estrogen )

Average-Risk Sreening Guidelines

FOBT Flexible sigmoidoscopy Colonoscopy Double-contrast enema CEA and Serologic Tumor Markers Genetic Testing

High-Risk Groups

IBD Previous colorectal cancer Previous adenomas Female genital cancer Familial polyposis HNPCC Familial colon cancer

Treatment

Surgery Chemotherapy Immunotargeted therapy and

Immunotherapy Radiation therapy

Summary

History & Physical Examination Symptomatology Diagnostics Management and Intervention Prognosis

Conclusion

“Prompt investigation of the cause of abdominal pain, watchful monitoring of the patient’s clinical status with adequate history and physical examination as well as collaboration with different specialties are of prime importance to the diagnosis and appropriate management of our patient”.

THANK YOU! &

GOOD MORNING

THANK YOU

Small Intestinal Disease

Periumbilical region crampy and maybe associated

with vomiting and changes in bowel movement

constipation and inability to pass flatus

high –pitched or musical bowel sounds

What is the most likely etiology of

his abdominal pain?

ABDOMINAL PAIN

A. PARIETAL

B. VISCERAL

A. ACUTE

B. CHRONIC

What happens after treatment ?Follow up care

Follow up care 1st year after treatment

2nd-3rd year after treatment

4th – 5th year

after treatment

Doctor’s visit Every 3- 6 mos

Every 3-6 mos

Every 6 mos

Tumor markers

Every 3 mos Every 3 mos determined by doctor

CT colonography

Yearly Yearly determined by doctor

Proctosigmoi-doscopy

Yearly yearly determined by doctor

What could have caused the misdiagnosis preoperatively ?

Differential Diagnosis of Colonic Obstruction

Acute Obstruction

- cecal volvulus- sigmoid volvulus- transverse volvulus

Subacute/Chronic onset- colon ca

- Rectal ca- Metastatic or extracolonic malignancy- IBD- Diverticulitis- Ischemic bowel

Others- colonic pseudo-obstruction- Imperforate anus