LARGE BOWEL OBSTRUCTIONKatherine Jahnes MD

Colorectal Conference

St Luke’s Roosevelt Hospital Center

November 10, 2005

Case A

83 yo male presents with increasing abdominal distention s/p failed sigmoidoscopy/ colonoscopy

PMH: Alzheimer’s Disease, HTN, COPD, glaucoma

PSH: pacemaker placement (2001 for bradycardia) and left hip repair (2001)

PE: Lungs clear, Abdomen distended but soft with hyperactive BS, TTP diffusely, LLQ>LUQ, no rebound

Case A

20 year history of sigmoid volvulus Managed by sigmoidoscopy reduction as

outpatient three time a week On day of admission attempts at

reduction where unsuccessful Films were obtained

Case A

Case A

Pt underwent a sigmoid resection Findings:

Sigmoid volvulus with 3 360 degree turns around mesentery

No sigmoid ischemia Rectum, descending colon healthy and

viable Sigmoid resected with primary anastomosis

of descending colon to rectum

Case B

71 year old female with 2 week history of increasing abdominal distention and no bowel movements

PMH: HTN, DM, CVA- residual aphasia, hemiparesis

PSH: none PE: Abdomen:

(? Rectal- gas in vault?) NT, Bowel sounds present, tympanitic

Case B

Radiology:

Case B

Operative findings:

Large Bowel Obstruction:Causes

Obstruction- mechanical interruption of the flow of intestinal contents Volvulus Intussuception Neoplasia (60% of cases)

Colorectal CLL

Diverticular Strictures/ IBD

Pseudo-obstruction- dilation of the bowel in the absence of a causative anatomic lesion

Pseudoobstruction- Ogilvie’s syndrome Distention of colon with signs and symptoms of colonic

obstruction without a mechanical cause for the obstruction May be acute or chronic

Acute: usually involves only colon, and more commonly effects patients with chronic renal, respiratory, cerebral or cardiovascular disease

Chronic: can effect other parts of the GI tract and tends to recur Primary pseudoobstruction- a motility disorder

familial visceral myopathy Diffuse disorder involving autonomic innervation of intestinal wall

Secondary – more common. Associated with: neuroleptics, opiates, metabolic illness,

myxedema, DM, uremia, hyperPTH, lupus, scleroderma, Parkinson’s, traumatic retroperitoneal hematomas Associated with sympathetic overactivity suppressing

parasympathetics

Pseudoobstruction- Ogilvie’s syndrome Diagnosis

Water soluable contrast enema Can differentiate between mechanical and

pseudoobstruction Colonoscopy

Can also be used for treatment Initial treatment

NGT Resuscitation Neostigmine (parasympathomimetic)

2.5 mg IV over 3 minutes, with resolution in 10 minutes Bradycardia is a side effect- atropine must be available

Volvulus

Bowel is twisted on mesenteric axis resulting in complete or partial obstruction of the bowel lumen as well as possible vascular impairment

Represents about 5% of large bowel obstructions Associated factors-

chronic constipation Aging institutionalization (neuropyschiatric conditions treated

with pyschotrophic drugs) in the developing world- possible association with high

fiber diets Characteristically affected bowel is attached to

long floppy mesentery fixed to retroperitoneum with a narrow base

Volvulus Most commonly

sigmoid, also right colon and terminal ileum (cecal volvulus), cecum alone (due to a highly mobile cecum called a cecal bascule- mobile in caudad to cephalad direction), and rarely transverse colon

(photo: barium enema of cecal volvulus, contrast stops at hepatic flexure (arrowhead) and air filled cecum crosses midline of abdomen in LUQ)

Volvulus Presentation: may be

acute or subacute Sudden onset of severe

abdominal pain, vomiting, obstipation

Abdomen is distended and tympanitic, often dramatically

Radiographic findings- AXR: markedly dilated

colon with an air-fluid level, no gas in rectum

CT: mesenteric whirl (at right)

Contrast enema: bird’s beak

Volvulus

Treatment: Decompression with rectal tube placed via

proctoscope or colonoscopy, with rectal tube left in place for 1-2 days. Often a sudden gush of gas and fluid is released upon decompression

Detorsion with colonoscope Sigmoid resection

Hartmann’s procedure- emergent if decompression not successful

If decompression is successful; redundant bowel may be removed laparoscopically with primary anastomosis electively (perform colonoscopy first to r/o neoplasm)

Neoplasm

Presentation, treatment, and multivariate anaysis of risk factors for obstructive and perforative colorectal carcinoma Alvarez et al, American Journal of Surgery

190(3): Sept 2005 A high proportion of colon cancers

present as surgical emergencies Acute obstruction, perforation or both Associated with high morbidity and

mortality

Retrospective study 936 consecutive pts underwent surgery for

primary colorectal carcinoma 107 (11.4%) underwent emergency surgery

Indications: history and physical consistent with peritonitis Intrabdominal abscess with systemic signs of sepsis Clinical signs of obstruction and radiographic evidence

thereof not responding to conservative measures within 4 days of hospitalization

Study excluded pts with crohn’s, UC, other types of neoplasm, FAP, h/o operations at outside hospitals, and those not requiring surgery

Of 107 pts, 83 (78%) had complete obstruction and 24 (22%) had perforation Sigmoid was most common location Comorbid conditions were present in 70% of pts- HTN,

CV, COPD, DM. Males predominated in the obstruction group Advance tumor stage was seen in 70% of the obstructing

pts and in 54% of the perforated pts Overall/ curative resection rate for obstructed pts was

85/ 83% respectively Mean OR time was 145.7 minutes (SD 57.1) 37% required a blood transfusion

Tables Table 2 . Surgical procedures in patients with complicated colorectal

carcinoma Obstruction (n = 83)Perforation (n = 24)Total n (%)Right colon nLeft colon nRight colon nLeft colon nNo resection16 (14.9)†Colostomy only7411Colostomy only with intention for staged resection22Bypass anastomosis only22Laparotomy only11Resection91 (85.1)†Resection + anastomosis1921⁎4347Resection + stoma3111244⁎  Two patients had proximal diverting colostomy and primary anastomosis. †  The comparison between the obstructing and perforating groups was not significant.

Major postop complications in 33%- most frequently GI and pulmonary

Factors associated with major complications or mortality included: Older age, female sex, perioperative blood

transfusion, high ASA or APACHE II score Not associated: location of lesion

Diverticular Strictures/ IBD

Crohn’s disease Obstruction most commonly in terminal

ileum

Intussusception

A segment of bowel and its associated mesentery (intussusceptum) invaginates into the lumen of an adjacent bowel segment (intussuscipiens)

Leading cause of bowel obstruction in children May be caused by intramural, mural, or extramural

process- intraluminal mass pulled forward by peristalsis and drags

bowel wall with it Ie pedunculated tumors, inverted meckel’s diverticulum or

appendix Segment of bowel wall that does not contract normally and

the opposite wall rotates the abnormal segment inward causing a kink that acts as a lead point Ie sessile malignancies, local inflammation, suture lines,

lymphoid hyperplasia Adhesion causes focal area of abnormal peristalsis and

kinking

Intussusception

In the colon, most frequently are colocolic or sigmoidrectal, and comprise 38% of adult intussusceptions

Neoplasia causes 2/3 of cases in adults Adenocarcinoma, leiomyosarcoma, reticular cell sarcoma, mets

Association with AIDS- secondary to lymphoma, Kaposi’s sarcoma, reative lymphoid hyperplasia, atypical mycobacteria infection, CMV, Camphylobacter enteritis

Childhood presenting symptoms: acute presentation with episodic crampy abdominal pain and bloody currant jelly stool

Adult presentation: often nonspecific chronic or subacute symptoms- crampy abdominal pain, nausea and vomiting, constipation or diarrhea, rarely bleeding or presence of a palpable mass

Intussusception

Radiology: Abdominal plain film

Air crescent sign- intraluminal air between the walls of the the intussusceptum and the intussuscipiens

Barium enema Coiled spring appearance (fig 12)- a thin central barium stream with or

without a leading mass US

More useful in childhood intussusceptions Target or doughnut mass with outer hypoechoic rim

Ct Target lesion, whirling pattern of mesenteric vessels May see air bubble between opposed layers of bowel Underlying etiology may be difficult to determine

Treatment Surgery

Reduce or not?