How Do You Know if You Have a Bowel Obstruction?

Continuing Education Activeness

A bowel obstacle can either be a mechanical or functional obstacle of the pocket-size or large intestines. Obstacle frequently causes abdominal hurting, nausea, vomiting, constipation, obstipation, and distention. This activity explains the pathophysiology, nomenclature, evaluation, and direction in patients with bowel obstruction. Information technology highlights the part of the interprofessional team in treating and decreasing long term morbidity in patients with bowel obstruction.

Objectives:

• Draw the pathophysiology, epidemiology, and classification of bowel obstacle.

• Outline the evaluation in a patient with bowel obstruction.

• Explain the conservative and surgical management strategies in patients with bowel obstruction.

• Explicate the importance of a cohesive, interprofessional team approach to caring for patients with bowel obstruction.

Access gratis multiple choice questions on this topic.

Introduction

A bowel obstruction tin either exist a mechanical or functional obstacle of the modest or big intestines. The obstacle occurs when the lumen of the bowel becomes either partially or completely blocked. Obstruction frequently causes abdominal hurting, nausea, vomiting, constipation-to-obstipation, and distention. This, in turn, prevents the normal motility of digested products. Modest bowel obstructions (SBOs) are more common than large bowel obstructions (LBOs) and are the virtually frequent indication for surgery on the small intestines. Bowel obstructions are classified as a partial, complete, or closed loop. A airtight-loop obstruction refers to a type of obstacle in the small or big bowel in which there is consummate obstacle distally and proximally in the given segment of the intestine.[1][ii][3]

Etiology

In that location are many potential etiologies of pocket-size and big bowel obstructions that are classified as either extrinsic, intrinsic, or intraluminal. The almost common cause of SBOs in industrialized nations is from extrinsic sources, with post-surgical adhesions being the nigh mutual. Significant adhesions tin cause kinking of the bowel leading to obstruction. It is estimated that at least two-thirds of patients with previous intestinal surgery accept adhesions. Other common extrinsic sources include cancer, which causes compression of the modest bowel leading to obstruction. Less mutual just notwithstanding prevalent extrinsic causes are inguinal and umbilical hernias. Untreated or symptomatic hernias may eventually get kinked every bit the small bowel protrudes through the defect in the abdominal wall and becomes entrapped in the hernia sack. Hernias that are not identified or are non reducible may progress to obstacle of the bowel and are considered a surgical emergency with the strangulated or incarcerated bowel becoming ischemic over time. Other causes of SBO include intrinsic affliction, which tin create an insidious onset of bowel wall thickening. The bowel wall slowly becomes compromised, forming a stricture. Crohn disease is the most mutual cause of benign stricture seen in the adult population.  [4][5]

Intraluminal causes for SBOs are less common. This process occurs when there is an ingested strange trunk that causes impaction within the lumen of the bowel or navigates to the ileocecal valve and is unable to laissez passer, forming a barrier to the big intestine. However, it is noted that most foreign bodies that pass through the pyloric sphincter will be able to laissez passer through the residuum of the gastrointestinal tract. LBOs are less mutual and compromise just 10% to 15% of all abdominal obstructions. The most common cause of all LBOs is adenocarcinoma, followed by diverticulitis and volvulus. Colonic obstruction is most commonly seen in the sigmoid colon.

Epidemiology

Small-scale and big bowel obstructions are similar in incidence in both males and females. The overriding gene affecting incidence and distribution depends on patient risk factors, including but not limited to: prior abdominal surgery, colon or metastatic cancer, chronic abdominal inflammatory disease, existing abdominal wall and/or an inguinal hernia, previous irradiation, and foreign trunk ingestion. [half-dozen][seven]

Pathophysiology

The normal physiology of the small intestine consists of the digestion of food and the assimilation of nutrients. The big bowel continues to help in digestion and is responsible for vitamin synthesis, h2o absorption, and bilirubin breakdown. Any obstructive machinery will hinder these physiologic components. Obstruction causes dilation of the bowel proximal to the transition point and collapses distally. A result of fractional or complete blockage of digested products during obstruction is emesis. Frequent emesis tin lead to fluid deficits and electrolyte abnormalities. As the status is left untreated and worsens, a bowel wall edema forms, and 3rd-spacing begins. A serious and life-threatening complication of bowel obstruction is strangulation. Strangulation is more usually seen in closed-loop obstructions. If the strangulated bowel is not treated promptly, it somewhen becomes ischemic, and tissue infarction occurs. Tissue infarction progresses to bowel necrosis, perforation, and sepsis/septic shock.

History and Physical

Suspected bowel obstruction requires the practitioner to obtain a detailed medical history inquiring about pregnant risk factors related to bowel obstruction. Small and large bowel obstruction have many overlapping symptoms. However, quality, timing, and presentation differ. Commonly in SBO, intestinal pain is described every bit intermittent and colicky but improves with vomiting, while the pain associated with LBO is continuous. The vomiting in SBO tends to be more frequent, in larger volumes, and ailing, which is in dissimilarity to vomiting during an LBO, which typically presents equally intermittent and feculent when nowadays. Tenderness to palpation is nowadays in both weather condition, only with SBO, it is more focal, and with LBO, it is more lengthened.

Additionally, distention is marked in LBO with obstipation more than commonly present. It is important to note that in sure situations, an LBO volition mimic an SBO if the ileocecal valve is incompetent. An incompetent ileocecal valve tin allow for the insufflation of air from the large bowel into the small bowel producing symptoms of an SBO.

Evaluation

Although bowel obstruction alone can be suspected with an accurate patient history and presentation, the electric current standard of care to confirm the diagnosis in small and large bowel obstruction is an abdominal CT with oral dissimilarity. CT allows for visualization of the transition point, the severity of obstruction, potential etiology, and assessment of whatever life-threatening complications. This information enables the provider to exist more effective in identifying patients who will require surgical intervention.  Laboratory evaluation is essential to evaluate for any leukocytosis, electrolyte derangements that may be present equally a result of the emesis. Labs too evaluate for elevated lactic acrid that may be suggestive of sepsis or perforation, which at times may not exist visible on CT if information technology is a microperforation and early in the class, claret cultures, or other signs of sepsis/septic shock. Although the lactic acid is oftentimes looked to in order to determine if there is a sign of perforation or ischemic gut, it should be noted this can exist normal even with a microperforation present, initially. Physical examination of the patient remains an essential diagnostic tool regarding the patient's severity and the need for emergent surgery vs. medical direction.[8]

Treatment / Management

Initial management should e'er include an assessment of the patient'due south airway, breathing, and circulation. If resuscitation is required, information technology should be performed with isotonic saline and electrolyte replacement. A Foley catheter should be inserted to monitor the patient's urine output if the patient is unstable or septic. Nasogastric tube insertion will allow for bowel decompression to save distention proximal to the obstruction. Nasogastric tube insertion will also help control emesis, let for authentic assessment of intake and output, and lower the risk of aspiration.

Management ultimately depends on the etiology and severity of the obstruction. Stable patients with partial or low-grade obstruction resolve with nasogastric tube decompression and supportive measures. Patients who present with reducible hernias volition require non-emergent surgical intervention to forbid future recurrence. Non-reducible or strangulated hernias require emergency surgical intervention. Consummate or loftier-class obstructions often require urgent or emergent surgical intervention equally the hazard of ischemia increases. Chronic affliction states such as Crohn illness and malignancy require initial supportive measures and longer periods of nonoperative direction. Treatment will ultimately depend on the patient's disposition and surgeon's acumen.

Differential Diagnosis

• Abdominal hernias

• Intestinal pain in elderly people

• Appendicitis

• Chronic megacolon

• Colonic polyps

• Diverticulitis

• Diverticulitis empiric therapy

• Pseudomembranous colitis surgery

• Small bowel obstruction

• Toxic megacolon

Prognosis

When bowel obstacle is managed promptly, the outcome is practiced. In general, when bowel obstacle is managed non surgically the recurrence rate is much college than those treated surgically.

Complications

• Intraabdominal abscess

• Sepsis

• Disability

• Wound dehiscence

• Aspiration

• Short bowel syndrome

• Pneumonia

• Bowel perforation

• Respiratory failure

• Anastomotic leak

• Renal failure

• Death

Postoperative and Rehabilitation Care

The postoperative recovery, in nearly cases of bowel obstacle, is slow. These patients need prophylaxis against deep venous thrombosis and prevention of atelectasis. Ambulation is necessary. Time to feeding tin vary depending on the ileus.

Consultations

• General surgeon

• Radiologist for drainage of any abscess

• Stoma nurse

• Infectious disease

Pearls and Other Bug

Most bowel obstructions will crave hospital admission and surgical consultation. Prompt recognition and diagnosis are critical in improving morbidity and mortality. The well-nigh important step in the initial management of bowel obstruction is identifying the type, severity, and cause. Agreement the departure betwixt emergent and not-emergent surgical intervention is essential in improving outcomes and preventing sequelae of complications, including bowel necrosis, perforation, and sepsis. Disposition ultimately depends on the type and etiology of the obstruction, too as the patient'due south past medical history, current wellness status, and risk factors.

Enhancing Healthcare Team Outcomes

The key to preventing the high mortality following a bowel obstruction is the early diagnosis, resuscitation, and operative intervention. An interprofessional squad is vital to ensure that the patient receives prompt attention. The triage nurse must be fully aware of the signs of bowel obstruction and expedite the admission. The emergency physician, nurse practitioner, or doc assistant must examine the patient and become the appropriate radiological examination. The surgeon must be consulted even if no intervention is planned. While awaiting surgery, the bowel may demand to be decompressed with a nasogastric tube, and the nurse is essential for monitoring of vital signs and worsening of the obstruction. Communication betwixt healthcare workers is critical. [nine][4] [Level V]

Outcomes

The morbidity and mortality of bowel obstruction are dependent on early diagnosis and management. If any strangulated bowel is left untreated, there is a mortality rate of shut to 100%. However, if surgery is undertaken within 24-48 hours, the mortality rates are less than 10%. Factors that determine the morbidity include the age of patient, comorbidity, and delay in treatment. Today, the overall mortality of bowel obstacle is nevertheless about 5%-8%.[3][10] [Level 3]

Review Questions

Figure

Ultrasound of a pocket-sized bowel obstruction with dilated bowel, thick bowel wall, adjacent intra-peritoneal fluid, and back and along peristalsis. Contributed past Michael Schick DO, MA

Figure

Figure 5: Coronal CT abdomen reveals cecal volvulus. Ordinarily a patient with a cecal volvulus will present with minor and large bowel obstructions, with plummet of the distal big bowel, and with extensive dilation of the proximal small bowel. Contributed (more...)

Effigy

Sigmoid vulvulus. Contributed by Sunil Munakomi, MD

Figure

adhesive intestinal obstruction. Contributed past Sunil Munakomi, Md

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Source: https://www.ncbi.nlm.nih.gov/books/NBK441975/

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