Large BowelObstruction

M K Alam

Al Maarefa College

Anatomy

Distal end of Ileum anus (about 1.5 m)

Smallest diameter: Sigmoid colon

(diverticulosisis form here due to the high pressure)

Primary function of the large intestine

Completion of absorption, esp. final absorption of water

Normal flora manufacture certain vitamins- B complex, K

Formation, storage and expulsion of feces

Large bowel

General characteristics

larger internal diameter

Presence of epiploic appendices

Presence of taeniae coli

Presence of the haustra

Large bowel obstruction

An emergent condition requires early

identification and prompt surgical

intervention

Possibility of perforation of the distended

colon with risk of fecal peritonitis.

Pathophysiology of Mechanical LBO

A. Interruption of the flow of the intestinal contents

bowel dilatation above the obstruction mucosal

edema + impaired venous drainage and arterial blood

flow to the bowel (ischemia) :

Mucosal permeability bacterial translocation

+systemic toxicity + dehydration + electrolyte

abnormalities.

Perforation and fecal peritonitis

The process is accelerated in closed loop obstruction

Pseudo-obstruction (Ogilvie’s syndrome)

Colonic dilatation without anatomical lesion

Multiple medical and surgical illness

PSY and SY activity loss of peristalsis,

distention by gas and fluid

Maximum in the caecum

perforation and fecal peritonitis (3-15%)

Etiology of LBO

Prevalence increase with age as does its main causes

Neoplasm (benign or malignant) 60%

Stricture (diverticular or ischemic) 20%

Volvulus (colonic, sigmoid or coecal) 10%

Intussusceptions

Adynamic ileus, Ogilvie’s syndrome

Etiology

Fecal impaction, foreign body

Adhesions

Hernia

IBD

Ped: Hirschsprung’s, meconium ileus, imperforate anus

Etiology

Neoplasm and diverticular disease:

Tumor growth luminal narrowing gradual onset of obstruction.

Diverticular disease muscular hypertrophy of the colonic wall with repeated inflammation and fibrosis luminal narrowing

Colonic volvulus: Twisting of the bowel on its mesentery ischemia

perforation. 20% of the causes of LBO.

A. Sigmoid volvulus:• Common in elderly and frail with long h/ o

constipation and laxatives• Younger Pt- association with high fiber diet.• The twist is ante-clockwise

B. Coecal volvulus: Less common Clockwise twist

Intussusception

Primarily pediatric disease, usually with no leading point.

Two third of adult intussusception are caused by tumor

Entero-colic Or Colo-colic types

Acute colonic pseudo obstruction (Ogilvie’s syndrome):

Functional obstruction.

Elderly debilitated patients

Medical (infections, Cardiac disease)

Trauma (operative, non operative).

Clinical presentation

Complaints suggesting LBOCrampy abdominal painConstipationAbdominal distention Nausea and Vomiting Symptoms suggestive of peritonitis Fistula (passage of air, mucus or feces in

the urine)

Assessment of symptoms should attempt to distinguish the following:

Acute Vs acute on chronic obstructiononset, H/o bowel movement, stool caliber,

recurrent LLQ pain and weight loss

Complete Vs partial obstruction By symptoms and rectal examination

Mechanical Vs functional obstruction (illeus or Ogilvie’s syndrome)

In ACPO, symptoms develop over 1-2 days up to 1 week, distention is early sign, fever is a bad sign

Intussusception Recurrent, intermittent colicky pain relevied by

fetal position with weight loss and fatigability

Physical examination

Complete examination is necessary:

Abdomen: Distension, ? Asymmetrical,

tenderness, ↑ BS, mass

Inguinal and femoral region

Rectum: empty, blood, mass

Laboratory investigation

CBC

Serum chemistry

Serum lactate

Coagulation profile

Stool for Occult blood

Plain radiograph

Contrast radiography with enema

Contrast enhanced CT

Can distinguish between partial and

complete obstruction and site of obstruction

Gastrographine (water soluble contrast) is

used if bowel perforation is suspected.

Ca right colon Intussusception

Management

Initial therapy include: Correction of fluid and electrolytes imbalance with

fluid monitoring Bowel rest NGT Appropriate preoperative antibiotic

Specific management:

Illeus: Tx of the underlying disorder Cessation of drugs slowing colonic motility

ACPO (Ogilvie’s syndrome) If no perforation conservative Tx, management of the

underlying disorder for 24hr. If failed, consider neostigmine or colonic decompression (success rate 80%)

If perforation or if conservative Tx failed surgical intervention with high mortality and morbidity.

Volvulus: Sigmoiod volvulus:

Sigmoidoscopy and deflation, flatus tube, later elective surgery.

Sig. failed, urgent laparotomy, un-twisting of the loop, per anal decompression followed by either fixation of the sigmoid loop “if viable” or sigmoid colectomy with anastomosis or Hartmann’s procedure.

Coecal or transverse colon volvulus:

Volvuls should be reduced followed by either fixation (caecopexy) and, or caecostomy.

If the cecum is ischemic or gangrenous right hemicolectomy.

Intussusception:

Children with no peritonitis contrast enema reduction. If failed or with signs of peritonitis surgery Surgery is indicated in adult intussusception why?Recurrence: 3% after contrast & 1%after surgery.

Hartmann's procedure

Hartmann's procedure is the surgical resection of the rectosigmoid colon with closure of the rectal stump and formation of an end colostomy.

Colonic masses and strictures: Endoscopic dilatation and stenting of obstructed colon:

Palliative- high risk patients with unresectable tumor preparation for surgery:

Relieve the acute obstruction. Allow time for resuscitation and bowel preparation

Surgery Right colon right hemicolectomy Left colon Hartmann procedure

Diverticular disease: Conservative followed by elective surgery If failed surgery (same principles of Ca tx)

Prognosis

Depends on:Patient’s factors Underlying disease Management timing and procedures Development of complications

Mortality:Mechanical obst.: 20%-40% (with perforation) ACPO 15%-36% (with ischemia, perforation)

Colostomies

Colostomy

Colostomy: a surgical procedure where a portion of the large intestine is brought through the abdominal wall to carry stool out of the body.

Permanent or temporary.

End or loop colostomy

Indications in Adults

Colorectal carcinoma Colonic Obstruction Traumatic perineal injury Colonic, High anal fistulae Protect a distal anastomosis Diverticular disease Ischemia IBD

Indications in children

Hirschsprung disease Meconium ileus Imperforate anus Complex hindgut anomalies Volvulus Trauma

End colostomy

The working end is brought through the abdomen to the skin surface after the damaged /diseased distal bowel is removed

End colostomy can be temporary to allow bowel rest or heal, following tumor resection, traumatic injury or inflammation of the bowel.

End colostomy can be permanent when the distal colon is resected or unresectable

Hartmann procedure involves leaving the distal portion of the colon in place,which is closed to create a Hartmann’s pouch.

Loop colostomy

A loop of the bowel is brought through the abdomen to the skin surface,

temporarily supported by a plastic bridge/ rod. A communicating wall

remains between the proximal and the distal bowel.

Created in transverse colon (transverse loop colostomy) or in sigmoid

colon (sigmoid loop colostomy)

Typically an emergency procedure to relieve an intestinal obstruction or

perforation.

Opened at the time of surgery or a few days later.

Has two openings through the stoma – the proximal end drains stool

while the distal portion drains mucus.

Loop colostomies are typically temporary.

Loop colostomy

Double-barrel colostomy

Both ends of the bowel are brought through the abdomen to the skin surface as two separate sections.

The proximal stoma (colostomy) , diverts feces through the abdominal wall.

The distal stoma (mucous fistula), expels mucus from the distal colon

A double-barrel colostomy may be created because of trauma, tumors, or inflammation, and it may be temporary or permanent.

Complications

Excessive bleeding

Ischemic stoma

Surgical wound infection

Retraction

Prolapse

Stenosis

Parastomal hernia

Thank You !