Treatment

A strangulated obstruction is a surgical emergency. In patients with a complete SBO, the risk of strangulation is high and early surgical intervention is warranted. Patients with simple complete obstructions in whom nonoperative trials fail also need surgical treatment but experience no apparent disadvantage to delayed surgery.

Adhesions. Decreasing intraoperative trauma to the peritoneal surfaces can prevent adhesion formation.

Malignant tumor. Obstruction by tumor is usually caused by metastasis. Initial treatment should be nonoperative; surgical resection is recommended when feasible.

Inflammatory bowel disease. To reduce the inflammatory process, treatment generally is nonoperative in combination with high-dose steroids. Consider parenteral treatment for prolonged periods of bowel rest. Undertake surgical treatment, bowel resection, and/or stricturoplasty if nonoperative treatment fails.

Intra-abdominal abscess. CT-guided drainage is usually sufficient to relieve obstruction.

Radiation enteritis. If obstruction follows radiation therapy acutely, nonoperative treatment accompanied by steroids is usually sufficient. If obstruction is a chronic sequel of radiation therapy, surgical treatment is indicated.

Acute postoperative obstruction. This is difficult to diagnose because symptoms often are attributed to incisional pain and postoperative ileus. Treatment should be nonoperative. If nonoperative treatment fails, surgical treatment is indicated.

Prognosis

With proper diagnosis and treatment of the obstruction, prognosis is good. Complete obstructions treated successfully nonoperatively have higher incidence of recurrence than those treated surgically.

A large-bowel obstruction (lbo)

LBO may be caused by neoplasms or anatomic abnormalities such as volvulus, incarcerated hernia, stricture or constipation.

LBO from an anatomic abnormality leads to colonic distention, abdominal pain, anorexia, and, late in the course, feculent vomiting. Persistent vomiting may result in dehydration and electrolyte disturbances.

LBO is a surgical entity. The morbidity and mortality often are related to the surgical procedure used to relieve the colonic obstruction and, in the long term, to the underlying disease that caused the obstruction.

Colonic obstruction is most common in elderly individuals because the incidence of neoplasms and other causative diseases is higher in this population.

Hirschsprung’s disease resembles colonic obstruction in the pediatric population.

History

History focuses initially on the failure to pass stools or gas. One should attempt to distinguish complete bowel obstruction from partial obstruction, which is associated with passage of some gas or stools, and from ileus. Further historical questioning may be directed at the patient’s current and past history in an attempt to determine the most likely cause.

Complete obstruction is characterized by the failure to pass either stools or flatus and the presence of an empty rectal vault upon rectal examination, unless the obstruction is in the rectum.

Partial obstruction, in which the patient appears obstipated but continues to pass some gas or stools, is a less urgent condition. Distinguishing colonic ileus from organic obstruction is important. Ileus may be suggested by abdominal pain as a dominant feature of the clinical presentation, by peritoneal signs, or by the presence of pronounced fever and leukocytosis.

History of chronic weight loss and passage of maelanotic bloody stool suggests neoplastic obstruction.

Conversely, a history of recurrent left lower quadrant abdominal pain over several years is more consistent with diverticulitis, a diverticular stricture, or similar problems.

A history of aortic surgery suggests the possibility of an ischaemic stricture.