User:HamzahM71/Bowel obstruction

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Article Draft[edit]

Signs and symptoms[edit]

Depending on the level of obstruction, bowel obstruction can present with abdominal pain, abdominal distension, and constipation. Bowel obstruction may be complicated by dehydration and electrolyte abnormalities due to vomiting; respiratory compromise from pressure on the diaphragm by a distended abdomen, or aspiration of vomitus; bowel ischemia or perforation from prolonged distension or pressure from a foreign body and subsequently sepsis due to bowel flora.[1]

Tinkly bowel sounds
Tinkly bowel sounds as heard with a stethoscope in someone with a small bowel obstruction.
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In small bowel obstruction, the pain tends to be colicky (cramping and intermittent) in nature, with spasms lasting a few minutes. The pain tends to be central and mid-abdominal. Vomiting may occur before constipation.[2] Common physical exam findings may include signs of dehydration, abdominal distension with tympany, nonspecific abdominal tenderness, and high pitched tinkly bowel sounds. [3]

In large bowel obstruction, the pain is felt lower in the abdomen and the spasms last longer. Common symptoms include abdominal pain, distension, and severe constipation. Constipation occurs earlier and vomiting may be less prominent. Proximal obstruction of the large bowel may present as small bowel obstruction.[4] Patients may notice a history of bloating and narrowing of stools before the onset of more severe symptoms. Symptoms can present quickly in the cases of volvulus and can present over a longer period of time in the setting of cancer. Common physical exam findings may include a palpable hernia, abdominal distension with tympany, nonspecific lower abdominal tenderness, and a rectal mass. [5]

Diagnosis[edit]

Small bowel dilation on CT scan in adults[6]
Diameter Assessment
<2.5 cm Non-dilated
2.5-2.9 cm Mildly dilated
3-4 cm Moderately dilated
>4 cm Severely dilated
A small bowel obstruction as seen on CT
Average inner diameters and ranges of different sections of the large intestine.[7]

The main diagnostic tools are blood tests, X-rays of the abdomen, CT scanning, and ultrasound. If a mass is identified, biopsy may determine the nature of the mass.[citation needed]

Radiological signs of bowel obstruction include bowel distension (small bowel loops dilated >3 cm) and the presence of multiple (more than 2) air-fluid levels on supine and erect abdominal radiographs.[8] Ultrasounds may be as useful as CT scanning to make the diagnosis.[9]

Contrast enema or small bowel series or CT scan can be used to define the level of obstruction, whether the obstruction is partial or complete, and to help define the cause of the obstruction. The appearance of water-soluble contrast in the cecum on an abdominal radiograph within 24 hours of it being given by mouth predicts resolution of an adhesive small bowel obstruction with sensitivity of 97% and specificity of 96%.[10]

Colonoscopy, small bowel investigation with ingested camera or push endoscopy, and laparoscopy are other diagnostic options.

Treatment[edit]

Treatment of small and large bowel obstructions are initially similar and non-operative management is usually the initial management strategy as the majority of small bowel obstruction resolve spontaneously with non-operative management.[3][5] Patients are be monitored by the surgical team for signs of improvement and resolution of the obstruction on imaging; if the obstruction does not clear then surgical management is required for the treatment of the causative lesion are required.[11] In malignant large bowel obstruction, endoscopically placed self-expanding metal stents may be used to temporarily relieve the obstruction as a bridge to surgery,[12] or as palliation.[13] Diagnosis of the type of bowel obstruction is normally conducted through initial plain radiograph of the abdomen, luminal contrast studies, computed tomography scan, or ultrasonography prior to determining the best type of treatment.[14]

Further research is needed to find out if parenteral nutrition is of benefit to people with an inoperable blockage of the bowel caused by advanced cancer.[15]

Small bowel obstruction[edit]

In the management of small bowel obstructions, a commonly quoted surgical aphorism is: "never let the sun rise or set on small-bowel obstruction"[16] because about 5.5%[16] of small bowel obstructions are ultimately fatal if treatment is delayed. Improvements in radiological imaging of small bowel obstructions allow for confident distinction between simple obstructions, that can be treated conservatively, and obstructions that are surgical emergencies (volvulus, closed-loop obstructions, ischemic bowel, incarcerated hernias, etc.).[17] Exam findings of bowel compromise requiring immediate surgery include: severe abdominal pain, signs of peritonitis such as rebound tenderness, elevated heart rate, fever, and elevated inflammatory markers on lab work, such as lactic acid. [3][5]

A small flexible tube (nasogastric tube) may be inserted through the nose into the stomach to help decompress the dilated bowel. This tube is uncomfortable but relieves the abdominal cramps, distention, and vomiting. Intravenous therapy is utilized and the urine output may be monitored with a catheter in the bladder.[18][19]

Most people with SBO are initially managed conservatively because in many cases, the bowel will open up. Some adhesions loosen up and the obstruction resolves. The patient is examined several times a day, and X-ray images are made to ensure he or she is not getting clinically worse.[20]

Conservative treatment involves insertion of a nasogastric tube, correction of dehydration and electrolyte abnormalities. Opioid pain relievers may be used for patients with severe pain but alternate pain relievers are preferred as opioids can decrease bowel motility.[3] Antiemetics may be administered if the patient is vomiting. Adhesive obstructions often settle without surgery. If the obstruction is complete surgery is usually required.

Most patients improve with conservative care in 2–5 days. When the obstruction is cancer, surgery is the only treatment. Those with bowel resection or lysis of adhesions usually stay in the hospital a few more days until they can eat and walk.[21]

Small bowel obstruction caused by Crohn's disease, peritoneal carcinomatosis, sclerosing peritonitis, radiation enteritis, and postpartum bowel obstruction are typically treated conservatively, i.e. without surgery.

Prognosis[edit]

The prognosis for non-ischemic cases of SBO is good with mortality rates of 3–5%, while prognosis for SBO with ischemia is fair with mortality rates as high as 30%.[22]

Cases of SBO related to cancer are more complicated and require additional intervention to address the malignancy, recurrence, and metastasis, and thus are associated with a more poor prognosis.[23] Surgical options in patients with malignant bowel obstruction need to be considered carefully as while it may provide relief of symptoms in the short term, there is a high risk of mortality and re-obstruction.[24]

All cases of abdominal surgical intervention are associated with increased risk of future small-bowel obstructions. Statistics from U.S. healthcare report 18.1% re-admittance rate within 30 days for patients who undergo SBO surgery.[25] More than 90% of patients also form adhesions after major abdominal surgery.[26] Common consequences of these adhesions include small-bowel obstruction, chronic abdominal pain, pelvic pain, and infertility.[26] The majority of small bowel obstructions cases are caused by post-operative adhesions. [27]

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References[edit]

  1. ^ "Large Bowel Obstruction". The Lecturio Medical Concept Library. Retrieved 10 July 2021.
  2. ^ "Large Bowel Obstruction". The Lecturio Medical Concept Library. Retrieved 10 July 2021.
  3. ^ a b c d Vercruysse, Gary; Busch, Rebecca; Dimcheff, Derek; Al-Hawary, Mahmoud; Saad, Richard; Seagull, F. Jacob; Somand, David; Cherry-Bukowiec, Jill; Wanacata, Lauren (2021). Evaluation and Management of Mechanical Small Bowel Obstruction in Adults. Michigan Medicine Clinical Care Guidelines. Ann Arbor (MI): Michigan Medicine University of Michigan. PMID 34314126.
  4. ^ "Large Bowel Obstruction". The Lecturio Medical Concept Library. Retrieved 10 July 2021.
  5. ^ a b c Ferri, Fred (12 Jul 2023). Ferri's Clinical Advisor 2024 (1st ed.). Elsevier. ISBN 9780323755764.{{cite book}}: CS1 maint: date and year (link)
  6. ^ Jacobs SL, Rozenblit A, Ricci Z, Roberts J, Milikow D, Chernyak V, Wolf E (April 2007). "Small bowel faeces sign in patients without small bowel obstruction". Clinical Radiology. 62 (4): 353–7. doi:10.1016/j.crad.2006.11.007. PMID 17331829.
  7. ^ Nguyen H, Loustaunau C, Facista A, Ramsey L, Hassounah N, Taylor H, et al. (July 2010). "Deficient Pms2, ERCC1, Ku86, CcOI in field defects during progression to colon cancer". Journal of Visualized Experiments (41). doi:10.3791/1931. PMC 3149991. PMID 20689513.
  8. ^ Singh, Ajay; Mansouri, Mohammad (2018), Singh, Ajay (ed.), "Imaging of Bowel Obstruction", Emergency Radiology: Imaging of Acute Pathologies, Cham: Springer International Publishing, pp. 67–75, doi:10.1007/978-3-319-65397-6_5, ISBN 978-3-319-65397-6, retrieved 2024-02-12
  9. ^ Gottlieb M, Peksa GD, Pandurangadu AV, Nakitende D, Takhar S, Seethala RR (February 2018). "Utilization of ultrasound for the evaluation of small bowel obstruction: A systematic review and meta-analysis". The American Journal of Emergency Medicine. 36 (2): 234–242. doi:10.1016/j.ajem.2017.07.085. PMID 28797559. S2CID 24769945.
  10. ^ Abbas S, Bissett IP, Parry BR (July 2007). "Oral water soluble contrast for the management of adhesive small bowel obstruction". The Cochrane Database of Systematic Reviews. 2010 (3): CD004651. doi:10.1002/14651858.CD004651.pub3. PMC 6465054. PMID 17636770.
  11. ^ Bower, Katie Love; Lollar, Daniel I.; Williams, Sharon L.; Adkins, Farrell C.; Luyimbazi, David T.; Bower, Curtis E. (2018-10-01). "Small Bowel Obstruction". Surgical Clinics of North America. Emergency General Surgery. 98 (5): 945–971. doi:10.1016/j.suc.2018.05.007. ISSN 0039-6109.
  12. ^ Young CJ, Suen MK, Young J, Solomon MJ (October 2011). "Stenting large bowel obstruction avoids a stoma: consecutive series of 100 patients". Colorectal Disease. 13 (10): 1138–41. doi:10.1111/j.1463-1318.2010.02432.x. PMID 20874797. S2CID 12724976.
  13. ^ Mosler P, Mergener KD, Brandabur JJ, Schembre DB, Kozarek RA (February 2005). "Palliation of gastric outlet obstruction and proximal small bowel obstruction with self-expandable metal stents: a single center series". Journal of Clinical Gastroenterology. 39 (2): 124–8. PMID 15681907.
  14. ^ Holzheimer, Rene G. (2001). Surgical Treatment. NCBI Bookshelf. ISBN 3-88603-714-2. Archived from the original on August 27, 2011.
  15. ^ Sowerbutts AM, Lal S, Sremanakova J, Clamp A, Todd C, Jayson GC, et al. (August 2018). "Home parenteral nutrition for people with inoperable malignant bowel obstruction". The Cochrane Database of Systematic Reviews. 8 (8): CD012812. doi:10.1002/14651858.cd012812.pub2. PMC 6513201. PMID 30095168.
  16. ^ a b Maglinte DD, Kelvin FM, Rowe MG, Bender GN, Rouch DM (January 2001). "Small-bowel obstruction: optimizing radiologic investigation and nonsurgical management". Radiology. 218 (1): 39–46. doi:10.1148/radiology.218.1.r01ja5439. PMID 11152777. Archived from the original on April 18, 2008. Retrieved June 6, 2008.
  17. ^ Fitzgerald JE (2010). "Small Bowel Obstruction". Emergency Surgery. Oxford: Wiley-Blackwell. pp. 74–79. doi:10.1002/9781444315172.ch14. ISBN 9781405170253. Archived from the original on September 8, 2017.
  18. ^ Small Bowel Obstruction overview Archived February 12, 2010, at the Wayback Machine. Retrieved February 19, 2010.
  19. ^ Vercruysse, Gary; Busch, Rebecca; Dimcheff, Derek; Al-Hawary, Mahmoud; Saad, Richard; Seagull, F. Jacob; Somand, David; Cherry-Bukowiec, Jill; Wanacata, Lauren (2021). Evaluation and Management of Mechanical Small Bowel Obstruction in Adults. Michigan Medicine Clinical Care Guidelines. Ann Arbor (MI): Michigan Medicine University of Michigan. PMID 34314126.
  20. ^ Small Bowel Obstruction: Treating Bowel Adhesions Non-Surgically Archived February 27, 2010, at the Wayback Machine. Clear Passage treatment center online portal Retrieved February 19, 2010
  21. ^ Small Bowel Obstruction Archived July 5, 2010, at the Wayback Machine The Eastern Association for the Surgery of Trauma. February 19, 2010
  22. ^ Kakoza R, Lieberman G (May 2006). "Mechanical Small Bowel Obstruction" (PDF). Archived from the original (PDF) on May 7, 2013. Retrieved October 9, 2012. {{cite journal}}: Cite journal requires |journal= (help)
  23. ^ "Small Bowel Obstruction". The Lecturio Medical Concept Library. Retrieved 10 July 2021.
  24. ^ Song, Yun; Metzger, Daniel Aryeh; Bruce, Adrienne N.; Krouse, Robert S.; Roses, Robert E.; Fraker, Douglas L.; Kelz, Rachel R.; Karakousis, Giorgos C. (2022-01). "Surgical Outcomes in Patients With Malignant Small Bowel Obstruction: A National Cohort Study". Annals of Surgery. 275 (1): e198–e205. doi:10.1097/SLA.0000000000003890. ISSN 0003-4932. {{cite journal}}: Check date values in: |date= (help)
  25. ^ "Readmissions to U.S. Hospitals by Procedure" (PDF). Agency for Healthcare Research and Quality. April 2013. Archived (PDF) from the original on October 20, 2013. Retrieved August 27, 2013.
  26. ^ a b Liakakos T, Thomakos N, Fine PM, Dervenis C, Young RL (2001). "Peritoneal adhesions: etiology, pathophysiology, and clinical significance. Recent advances in prevention and management". Digestive Surgery. 18 (4): 260–73. doi:10.1159/000050149. PMID 11528133. S2CID 30816909.
  27. ^ Song, Yun; Metzger, Daniel Aryeh; Bruce, Adrienne N.; Krouse, Robert S.; Roses, Robert E.; Fraker, Douglas L.; Kelz, Rachel R.; Karakousis, Giorgos C. (2022-01). "Surgical Outcomes in Patients With Malignant Small Bowel Obstruction: A National Cohort Study". Annals of Surgery. 275 (1): e198–e205. doi:10.1097/SLA.0000000000003890. ISSN 0003-4932. {{cite journal}}: Check date values in: |date= (help)
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