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E. Reitano et al.
admissions. Different predictors for LBOs have been described, and they include
prior abdominal surgery, colorectal cancer, inammatory bowel disease (IBD),
abdominal wall and inguinal hernias, irradiation, and foreign body ingestion [4].
There is no difference between the sex, and they can occur at any age. However,
LBO are more frequent in the elderly, as cancer constitutes its commonest cause [5].
1.2 Etiology
The etiopathology of LBOs is substantially different from SBOs. LBO can occur
secondary to a functional disorder or due to mechanical obstruction. The main
causes of LBOs are listed in Table1 [6–8]. Colorectal cancer (CRC) is the responsible of 60% of LBO cases [9]. In 3/4 of them, the obstruction is placed distally to the
splenic exure, with the commonest location being the sigmoid colon. According to
the National Institute for Clinical Excellence (NICE), up to 30% of cases of CRC
are diagnosed in the emergency setting, and approximately 15% of these patients
present with LBO [6, 7]. Mechanical LBOs are mainly produced by cancer, diverticulitis, volvulus, hernias, and adhesions. Endometriosis, bezoars, chronic ischemia,
inammatory bowel disease (IBD), intussusception, irradiation, post-anastomotic
stenosis, gallstones, foreign bodies, and tuberculosis have been also described [3].
Functional LBOs are characterized by the development of signs and symptoms
of mechanical obstruction, without appreciable anatomical condition altering the
normal ow of the intestinal content [6, 10]. Functional LBOs are often related to
Table 1 Common and uncommon causes of LBOs
Causes of mechanical LBO
Common (>95%) Uncommon (<5%)
• Primary colon carcinoma (60–80%)
• Volvulus (11–15%) of the sigmoid, cecum,
or transverse colon
• Complicated diverticulitis (4–10%)
Causes of functional LBO
Common Uncommon
• Narcotic/medication use (opiates,
anticholinergics, amphetamines, steroids)
• Ogilvie’s syndrome
• Intussusception
• Hernia
• Inammatory bowel disease
• Extrinsic compression (e.g., abscess)
• Fecal impaction
• Bezoars
• Lymphoma
• Peritoneal carcinomatosis
• Foreign body ingestion
• Endometriosis
• Stenosis (ischemia, radiation, anastomosis)
• Post-operative adhesions
• Gallstones
• Tuberculosis
• Trauma
• Neurobromatosis
• Autoimmune diseases
• Infection diseases
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narcotic use, medication intake (e.g., opiates, anticholinergics, amphetamines, steroids), systemic illnesses such as sepsis or toxic megacolon (e.g., Clostridium
Difcile infection), and severe acute colitis [1]. A particular form of functional
LBOs is the Ogilvie’s syndrome, which is an acute colonic pseudo-obstruction
characterized by a massive colonic dilatation. This syndrome is related to abnormalities involving the autonomic control system of the colonic motility [6, 7].
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1.3 Classification
Mechanical LBOs can be classied as a partial, complete, or closed loop occlusions.
In this latter type, there is a complete obstruction proximal and distal to a given
colonic segment [10]. LBO can be similarly classied in simple or complicated
forms. In complicated obstructions, the vascular supply of the colon is compromised, then implying a subsequent risk of ischemia, necrosis, and ultimately, colonic
perforation [7].
1.4 Pathophysiology
The presentation of LBO depends on the competency of the ileocecal valve [8].
When this valve is not competent, the large bowel is decompressed toward the small
bowel. A competent ileocecal valve is present in the 75% of cases, hampering the
colonic decompression and leading to a closed loop obstruction. This result in a
marked increase of the intraluminal pressure leading to wall distension and nally
to perforation [6, 8]. Following Laplace’s law, the intraluminal pressure required to
stretch the wall of a tube is inversely proportional to its radius. Given its larger
diameter, the cecum is the segment with the highest risk of perforation [3, 9, 10].
2 Diagnosis
2.1 Clinical Presentation
LBO may develop acutely or over a protracted period [2]. However, the clinical
presentation is most often sudden and associated with acute signs and symptoms,
such as abdominal pain and distension. Vomiting is relatively a late symptom of
LBO and is more common in SBO [1]. Patients with LBO may present with signs
of hypovolemia due to uid loss into the dilated bowel. They can be accompanied
by electrolyte imbalances and metabolic alkalosis as a consequence of vomiting and
dehydration [11]. Laboratory tests including blood cell count, renal function, and
electrolytes are of paramount importance to help the diagnosis. Marked leukocytosis and acidosis with low bicarbonate and high lactic levels could be reecting an
ongoing intestinal ischemia [1, 3]. A prompt diagnosis and establishing the cause of
LBO is of paramount important given the high associated morbidity and mortality.
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E. Reitano et al.
Indeed, the nature of the obstruction will inuence the treatment choice, which
ranges from medical and endoscopic therapies to surgical resections or bowel
decompressions via an ostomy formation [9].
2.2 Tests
2.2.1 Abdominal Plain Radiography andUltrasound
Abdominal plain X-ray represents the rst imaging evaluation when LBBO is suspected. The examination should include supine and upright or left-lateral decubitus
projections to diagnose LBO and its possible complications such as pneumatosis
and pneumoperitoneum [6]. Abdominal radiography has shown a sensitivity of 84%
and a specicity of 72% in the diagnosis of LBO [3, 6]. Normal colonic caliber
ranges from 3 to 8cm, with the largest diameter in the cecum. Colonic dilatation is
diagnosed when the caliber is >9cm in the cecum or >6cm in any other segment.
In the setting of an LBO, abdominal radiography usually shows the dilation of the
colon proximally to the site of the obstruction and the absence of distal gas [6, 7].
The presence of air-uid levels in the dilated colon suggests an acute obstruction
since the colonic uid has not been present enough time to be absorbed [6]
(Figs.1 and 2).
The main disadvantage of plain radiology is that it usually does not provide an
etiological diagnosis [3]. Administration of water-soluble contrasts increases the
sensitivity to 96% and the specicity to 98% but obtaining the etiological diagnosis
is usually unfeasible [12]. This exploration has been widely used in the diagnosis
Fig. 1 Anteroposterior
supine abdominal
radiograph in a 72-year-old
man with LBO showing
dilated transverse and
descending colon due to an
ascending colon carcinoma
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Fig. 2 Right lateral
decubitus radiograph in
LBO due to an ascending
colon carcinoma
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and management of adhesive SBO.The inability of the contrast agent to reach the
colon during 24 h at a plain X-ray is highly indicative of the failure of a nonoperative management for SBO [12, 13]. Abdominal ultrasound, conversely, allows
to establish an etiological diagnosis of LBO.However, the success of the exploration highly depends on the experience of the radiologist and on the physical characteristics of the patient [14].
2.2.2 Computed Tomography andMagnetic Resonance Imaging
Computed tomography (CT) with intravenous contrast administration is superior to both plain X-ray and ultrasound to provide an etiological diagnosis of
LBO, allowing for a more accurate preoperative management [6, 15]. The
administration of water-soluble rectal contrast may be useful if diagnostic
doubts persist after the CT [15]. Moreover, CT allows to perform an accurate
staging of the neoplastic bowel obstructions and identify possible complications, such as a perforation [16]. Despite the disadvantage of an increased irradiation compared to the previously described techniques, CT is the gold
standard imaging exploration for LBO having a high sensitivity (96%) and
specificity (93%) [17]. Intravenous contrast agent is recommended to identify
the presence of masses, signs of inflammation, and bowel wall ischemia.
Iodinated intravenous contrast agent can be administrated following a weightbased protocol, or in a routine volume (e.g., 150mL) and 3mL/s rate with a
delay of 70s, to allow portal venous phase imaging [6, 16, 17].
Beyond the risk linked to radiation exposure, allergic reactions to intravascular
iodinated contrasts and renal failure in patients with underlying kidney diseases
must be considered. According to the current guidelines, prophylaxis with corticosteroid and antihistamine should be administered in patients with a history of moderate/severe allergic reactions to iodinated contrast or when the reaction severity is
unknown [18]. Hydration therapy should be administered in patients with kidney
diseases due to the risk of contrast induced nephropathy [19]. In children and during
pregnancy, magnetic resonance imaging (MRI) should be preferred over CT to
avoid the exposure to ionizing radiations [20]. MRI had a sensitivity of 95% and
specicity of 100% for LBO diagnosis [20] (Fig.3).
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Fig. 3 CT scan showing a
LBO with dilated
transverse, descending, and
ascending colon due to a
rectal carcinoma
E. Reitano et al.
2.2.3 Colonoscopy
CRC may present with LBO in 15–20% of cases [17]. According to the American
Society for Gastrointestinal Endoscopy (ASGE), the colonoscopy is contraindicated
in patients with severe unremitting pain or peritoneal signs with a complete colonic
obstruction or presenting with bowel ischemia [21]. Patients with partial colonic
obstruction may undergo endoscopy after IV hydration, electrolytes correction, and
nasogastric tube placement. Endoscopic evaluation of a left-side colonic obstruction
by exible sigmoidoscopy or a limited colonoscopy allows to conrm the site of
obstruction, to apply anal tubes, stents, or endoscope decompression with no bowel
preparation [21]. Endoscopic evaluation of the right side of the colon is challenging
and requires an adequate bowel preparation with a higher risk of perforation [21]. If
contrast enemas are used, water-soluble are of choice, to avoid barium peritonitis in
patients with an unrecognized perforation. Colonoscopy facilitates a histological
diagnosis of the bowel occlusion providing tissue biopsy for analysis [3]. Moreover,
tattooing of the pathologic segment could guide the surgeon during further surgical
procedure.
3 Therapy
3.1 Medical Treatment
In hemodynamically stable patients without signs of sepsis or peritonitis, the initial
treatment consists of uid resuscitation with correction of electrolyte imbalances,
gastrointestinal decompression through a nasogastric tube, and close monitoring of
the diuresis [3]. The conservative treatment is not indicated in patients with mechanical LBO with severe pain or in those with signs of peritonitis: in these cases, surgery should be considered as the rst therapeutic option [3]. Patients with malignant
LBO could undergo surgery or endoscopic/interventional radiology treatment, after
restoring the electrolyte unbalance (Fig.4). Non-operative management could be
the denitive treatment in cases of inammatory LBO (e.g., IBD or acute diverticulitis without peritonitis) [22]. Complicated abdominal hernias without signs of
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Evidence of
inguinal/abdominal hernia?
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Suspected LBO
Physical examinaon, laboratory test,
ultrasound/abdominal X-Ray
Yes
Manual
reducon
Signs of ischemia/perforaon.
Hemodinamic instability/shock
No
Fig. 4 Flowchart of diagnosis and treatment of LBO
Emergency Surgery
No
CT-SCAN
LBO
Yes
Funconal LBO
Infiammatory
disease/others
Volvulus
Cancer
Conservave
treatment
Endoscopic
SEMS
Conservave treatment or
endoscopic failure/not
possible
ischemia/perforation can be reduced manually, reserving surgery for unsuccessful
cases [23].
In Ogilvie’s syndrome, the treatment aims to relieve the patient’s discomfort and
to prevent colonic complications, consisting in supportive care for 24–48h. If failure occurs, different options may be considered such as neostigmine and erythromycin use, endoscopic decompression, or surgery, which is mandatory in patients
who develop signs of peritonitis [6].
3.1.1 Endoscopy
The endoscopic management has a role in selected patients presenting with LBO
secondary to malignant or benign conditions. Endoscopic placement of a transanal
tube for decompression in malignant colonic obstructions represents an alternative
to diverting decompressive stoma, allowing for 78–100% of patients to undergo
one-stage surgery [21]. However, it is noteworthy to recognize that these tubes are
not routinely used because of different limitations such as tube malfunction, expulsion, or severe patient discomfort.
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Sigmoid volvulus can be treated with endoscopic derotation, while surgery is
indicated in cases of endoscopic failure, or in patients with cecal volvulus [24].
Patients with IBD, diverticulitis, previous colonic surgery, or radiation therapy may
develop colon stenosis. They can be treated by endoscopic dilation or stent placement [21, 24]. The endoscopic stenting constitutes an alternative strategy to manage
colonic obstructions, especially in case of CRC. Colonic stent for malignancies
were rst used in the early 1990s, and they have been used as a bridge to surgery or
with palliative intention [25]. Self-expandable metal stents (SEMS) allow for the
decompression of the proximal colon, making possible to administrate a standard
bowel preparation and to further perform an endoscopic evaluation of the proximal
colon. This can be useful to detect synchronous lesions and to perform a quasielective surgery [25]. Elective resections are associated with lower morbidity and
mortality compared with emergency procedures [3]. The main complications of
SEMS placement are perforation followed by stent migration, and cancer regrowth
into the stent causing obstruction [26]. According to the European Society of
Gastrointestinal Endoscopy (ESGE) guidelines, given the high risk of perforation
with cancer cell dissemination, SEMS placement as a bridge to surgery should
always be discussed within a multidisciplinary team as a treatment option in patients
with potentially curable left-sided obstructing CRC as an alternative to emergency
surgery [26]. SEMS, however, are the preferred palliative treatment in malignant
left-colon obstructions [25]. SEMS cannot be considered as a long-term solution in
benign obstructions, but they could be helpful as a bridge to surgery [25, 26].
E. Reitano et al.
3.1.2 Interventional Radiology
In the last years, several studies suggested the placement of colonic self-expanded
stent under uoroscopic guide as a palliative treatment in oncologic patients not t
for surgery [26]. This minimal-invasive technique allows the stent placement without the need of colonic preparation [27]. Moreover, angiographic catheters with
variable head shapes and easily shapeable guidewires can overcome the angulated
obstructions, allowing the placement of stents otherwise not possible to place endoscopically [27, 28]. A hybrid approach with combined endoscopy and uoroscopy
could be used in technically challenging cases. Indeed, most of the malignant strictures are located distal to the splenic exure. In this segment, endoscopy allows an
easier negotiation of tortuous bowel loops and SEMS delivery to other locations
such as the ascending or transverse colon [28].
Finally, some authors suggested the possibility to perform cecostomy or colostomy under image-guidance, with high technical success [29]. Despite the data is
still limited, interventional radiology could represent a relevant tool for decompressive or palliative purposes in selected patients.
3.2 Surgery
Surgery is the treatment of choice of mechanical LBO.The type of surgery depends
on the underlying disease. Non-reducible abdominal and inguinal hernias must
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undergo prosthetic repair. In some cases with associated perforation and highly contaminated surgical eld, a direct suture can be considered to avoid mesh infection
[30]. Explorative laparoscopy can be performed to assess the vitality of the bowel
after the reduction of complicated hernias [30].
CRC determining bowel occlusion and benign obstruction irresponsive to medical therapy may require surgery and bowel resection as well. The type of surgery to
performed depend on the patient’s and disease characteristics, which are
detailed below.
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3.2.1 Right-Sided Obstruction
Right-sided obstruction can be treated with right-hemicolectomy with ileocolic
anastomosis. It is considered the treatment of choice with low rates of anastomotic
leak (AL) [1]. When a primary anastomosis is judged unsafe, a terminal ileostomy or
an ileo-colostomy can be performed [31]. In the event of unresectable cancers causing obstruction, a loop ileostomy, or an ileocolic bypass (i.e., between the terminal
ileum and the transverse colon), is the treatment of choice [32, 33]. Cecostomy with
decompressive purpose is no longer performed due to the high complications rate
[31]. Endoscopic stent placement is not recommended in right colic occlusions due
to its technical difculty, and the high migration and complications rates [26–28].
3.2.2 Left-Sided Obstruction
Left-sided obstruction can be treated with resection and primary anastomosis [33].
The current literature shows no evidence that a diverting stoma decreases the risk of
AL [33–35]. However, in patients with high surgical risk, the Hartmann procedure
(HP) should be preferentially considered. It consists in the resection of the primary
lesion and the creation of a left colostomy [36]. A HP avoids the risk of AL while
insuring an oncologic resection during the rst operation [36]. However, HP reversal surgery is associated with high morbidity and mortality rates, and the effective
stoma reversion rate after HP for CRC is limited (approximately 20%) [37, 38].
Patients unt to major surgery or with unresectable lesions can be treated with loop
colostomy as a bridge to surgery or with palliative purposes (when endoscopic stent
placement is unfeasible) [35, 36]. Subtotal colectomy (SC) with ileo-sigmoid or
ileo-rectal anastomosis is an alternative to stoma creation in patients with left-sided
obstructions with the advantage to remove any possible compromised and dilated
segment of the colon and any possible synchronous colonic neoplasms [39].
However, SC is burdened by a strong impact on the quality of life, a risk of dehydration, the need for dietary restrictions, and a reduction in the daily activity [40].
Therefore, it should be reserved to selected patients. Figure4 reported the owchart
of LBO diagnosis and treatment.
3.3 Prognosis
LBO are usually an abdominal emergency, with relevant morbidity and mortality
rates, if left untreated, due to the high risk of perforation and subsequent peritonitis
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E. Reitano et al.
[6]. Recent studies reported a morbidity rate of 42–46% and a mortality rate of
13–19% following surgery for LBO [6].
The prognosis the LBO patients depends on the cause of the obstruction, with a
life expectancy of 1–9months for patients with malignant LBO [2, 3]. However,
different factors (e.g., previous surgery, age≥75years old, male sex, comorbidities) may impact on the prognosis [6]. Recognizing the cause of LBO and providing
a timely and appropriate treatment are pivotal for the patient’s prognosis.
Take Home Messages
• LBO remain as one of the most frequent abdominal emergency conditions, with
several different underlying causes.
• CT scan is the gold standard radiologic exploration to diagnose an LBO, provid-
ing etiological and anatomical information to choose the best treatment strategy.
• Endoscopic or interventional radiology are treatments which can be applied in
selected patients. Surgery is required in the majority of the cases.
• The best strategy to adopt should be discussed in a multidisciplinary staff.
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