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Perspectives on large bowel obstruction

Article · January 2017

DOI: 10.4103/2468-7332.200556

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Review Article INTERNATIONAL

JOURNAL OF

Perspectives on Large Bowel Obstruction SURGERY

SHORT REPORTS

Elroy Patrick Weledji

IJS Publishing Group Ltd www.ijsshortreports.com

From the Department of Large bowel obstruction (LBO) is a serious and costly medical condition, indicating often
Surgery, University of Buea,

Abstract
emergency surgery. The main clinical issue is to determine whether the obstruction affects the
Buea, Cameroon small bowel or the colon since the causes and treatments are different. Delay in operative
intervention may lead to an unnecessary bowel resection, increased risk of perforation, and
overall worsening of patient morbidity and mortality. With the advent of colonic endoluminal
stent, the treatment of distal colonic obstruction should be individually tailored to each patient.
This article discussed LBO and emphasized the importance of history taking, examination, and
basic imaging in the early diagnosis of its cause, thus facilitating appropriate management.
Received: January, 2017.
Accepted: January, 2017. Key Words: Examination, history, large bowel, obstruction, resuscitation, treatment

toward the midline rather than being

Introduction
Intestinal obstruction remains a common and localized as the gut has a midline origin of
difficult problem encountered by the abdominal development. The visceral sensory fibers are
surgeon. Although large bowel obstruction (LBO) carried by the sympathetic nerves on their
presents less frequently (15%) than its small
bowel counterpart (85%), it remains nonetheless a way to the spinal cord. Thus, mid‑gut (mid
common surgical emergency.[1] Following second part of duodenum to proximal
resuscitation, a precise history may indicate the two‑thirds
pathology and physical examination supported by
basic imaging may indicate where the pathology Access this article online
is. These would determine which patient may
Quick Response Code:
require immediate surgery, urgent surgery,
semi‑elective surgery, or a trial of conservative Website:
management. The consequences of bowel www.ijsshortreports.c
obstruction are progressive dehydration, om
electrolyte imbalance, and systemic toxicity due
to migration of toxins and bacteria translocation
either through the intact but ischemic bowel or DOI: 10.4103/2468-
through a perforation. Appreciation of fluid 7332.200556
balance, acid–base–electrolyte disturbance, and
importance of preoperative resuscitation decrease
the morbidity and mortality
from intestinal obstruction.[2‑4]

Discussion
LBO may be mechanical (lumen partly or
completely blocked) or paralytic (no peristalsis).
It may be chronic, acute‑on‑chronic, acute, or
pseudo obstruction (nonmechanical). In fact, there
is a complete spectrum of clinical presentation
and patients may present with acute LBO without
a preexisting history of obstructive
symptoms.[5,6] The visceral pain of intestinal
obstruction is due to increased gut peristalsis
against the obstruction and is usually referred

of transverse colon) colicky pain is carried by the
lesser splanchnic nerve (T10–T11) and referred to the
umbilicus while hindgut (beyond the distal third of
transverse colon) colicky abdominal pain being carried
by the least splanchnic nerve (T12) is referred to the
suprapubic area. The other sources of pain are somatic
(localized) from abdominal distension and peritoneal
irritation when ischemia or perforation
supervenes.[7,8]
The main causes of LBO are malignancy and volvulus
of the sigmoid colon [Table 1]. The prevalence of both
is subject to a wide geographical variability.[5,6]
Colorectal cancer is particularly prevalent in the west,
accounting for at least 50% of LBO. This proportion
alters in Africa and Eastern Europe where sigmoid
volvulus is the cause of obstruction in up to 40% of
cases.[9,10] The most common site of LBO is the
sigmoid colon, accounting for 50% of all cases. This is
not only because the sigmoid colon is a common site
for colonic carcinoma but also because the lumen is
relatively narrow and the feces are firm rather than
liquid. The second most common site is the splenic
flexure (10%), where the combination of a sharp kink
in the colon together with luminal narrowing by the
tumor and relatively firm stools leads to blockage. The
© 2017 International Journal of Surgery Short Reports | Published by
Wolters Kluwer - Medknow
features of a right‑sided LBO may be less obvious
than those of left‑sided colonic lesions because
only a small proportion of the colon is distended.
However, an obstruction at the ileocecal valve
will produce features of a low small bowel
obstruction.[5,11] A closed loop obstruction may
follow an acute‑on‑chronic LBO from a distally
obstructing colonic
Address for
correspondence:
Dr. Elroy Patrick Weledji, E‑mail:
elroypat@yahoo.co.uk
This is an open access article distributed under the
terms of the Creative Commons Attribution-
NonCommercial-ShareAlike 3.0 License, which
allows others to remix, tweak, and build upon the
work non-commercially, as long as the author is
credited and the new creations are licensed under
the identical terms.
For reprints contact: reprints@medknow.com
How to cite this article: Weledji EP.
Perspectives on large bowel obstruction. IJS
Short Rep 2017;2:1-4.
1
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Weledji: Large bowel obstruction

Table 1: Causes of large bowel
obstruction
Cancer (primary or recurrent)
Volvulus
Diverticular disease
Hernia
Fecal impaction
Inflammatory bowel disease
Ischemic stricture
Anastomotic stricture
lesion. In cases where the ileocecal valve forms
one end of a closed loop strangulation obstruction
is not a problem here, but a similar problem to
look for is intramural ischemia of the cecum due
to stretching causing patchy necrosis. Right iliac
fossa tenderness in a patient with LBO may
indicate cecal distension and imminent perforation
which is a disastrous complication of LBO.
According to the law of Laplace (2T = PR where
P is the transmural pressure, T is the wall tension
and is the radius of a sphere), tension (in this case
in the wall of the colon) is proportional to the
radius and is therefore higher in the cecum which
is the widest point of the colon than elsewhere.
Thus, the cecum takes the brunt of the distension
with imminent perforation if the cecal diameter is
>15 cm. When there is distal obstruction, the
ileocecal valve often becomes incompetent and
both small and large bowel become distended. If
left untreated, the patient will start to vomit, but
ischemia or perforation of the bowel is
unlikely.[5] With regard to colonic
intussusception in adults, the leading point is
invariable; a colonic pathology and laparotomy
are indicated.[12]
Sigmoid volvulus is the most common form of
volvulus in the gastrointestinal tract. The
anatomic defect is the narrow attachment of the
root of the mesentery to the posterior abdominal
wall and a long mesenteric axis. Predisposed by
very high fiber diet and long redundant sigmoid
colon in Africans, chronic constipation and
laxative abuse, psychiatric and senile
disorders, the sigmoid colon rotates around
its mesenteric pedicle usually more than 180°
counterclockwise resulting in partial or
complete LBO. There is a palpable tympanic
mass and with the risk of ischemia from
venous obstruction.[9,11] Because of its high
recurrence rate, sigmoid colectomy is the
definitive treatment as compared to
sigmoidoscopic decompression.[13,14] Less
common causes of LBO are diverticular
disease, either as a result of stricture or acute
inflammation with edema, and obstructed
groin hernia. Inflammatory bowel disease is
a very unusual cause of obstruction, but
strictures from any cause may precipitate
obstruction by proximal fecal impaction.
Fecal impaction alone rarely causes
obstruction.[5]
The four cardinal clinical features of
intestinal obstruction are colicky abdominal
pain, vomiting, constipation, and abdominal
distension. The clinical history may establish
other features indicative of the likely
etiology of the obstruction. A thorough
history of the obstruction would include the
patient’s age, duration of symptoms, history
and nature of the pain, history of similar
symptoms or surgery. A history of colorectal
or

other intra‑abdominal malignancy, recent alteration in
bowel habit, or the passage of blood is suggestive of
neoplasm. Patients who are institutionalized and have
cognitive impairment have a high incidence of sigmoid
volvulus and severe constipation, and
pseudo‑obstruction tends to occur in patients with a
history of recent nongastrointestinal surgery or severe
concurrent medical illness.[6,15] Chronic symptoms
will be associated with weight loss and anorexia, and
the general premorbid state (cardiovascular and
respiratory) is assessed for a patient with a known
diagnosis and the possibility of surgical intervention.
Clinically, it is extremely difficult to distinguish with
any certainty between simple obstruction and
strangulation.[4] Simple obstruction presents with
colicky (visceral) pain, but there is mild generalized
abdominal tenderness from the distension with gas and
fluid. Strangulation (closed loop) obstruction usually
has an acute onset. The pain is most marked and the
condition very serious if overlooked. There is localized
tenderness with pain on coughing (rebound tenderness)
as peritonism develops from stimulation of pain
receptors in the parietal peritoneum or abdominal wall.
The pain is constant rather than colicky and abdominal
rigidity is more marked. There is a tender mass even
with associated erythema of the skin. The patient is
obviously ill, toxic and may have a leukocytosis. Thus
a tense, tender, irreducible lump with no cough
impulse, especially over hernia orifice, for example,
femoral or inguinal, is a strangulation until proven
otherwise. Occasionally, hernia is internal and not
palpable.[1,4,5] In colon obstruction, vomiting occurs
much later if at all especially if the ileocecal valve
remains competent and implies a state of severe
volume depletion. In LBO, the lesion is very distal
within the intestine and constipation and distension are
the earliest and most predominant symptoms. Absolute
2 International Journal of Surgery Short Reports ¦ Volume 2 ¦ Issue 1 ¦ January-
March 2017
constipation occurs when there is complete
luminal obstruction and the patient is unable to
pass either feces or flatus. Patients with partial
obstruction may develop spurious diarrhea
because fluid feces are all that can pass through a
stenosed segment.
The physical findings include dehydration,
abdominal distension, and sometimes, visible
peristalsis. Dehydration assessed by examination
of the mucous membranes and skin turgor is an
indication of severe fluid depletion. In colonic
obstruction, distension is mainly in the flanks and
upper abdomen. Abdominal distension is usually
evident and more marked the more distal the
obstruction, but it is more an indication of the site
than the extent of obstruction.[5] Swallowed air,
gas from bacterial fermentation, and nitrogen
diffusion from the congested mucosa are all
responsible for the increased intestinal gas. The
cause of the obstruction may be may be evident
(e.g., scars from previous surgery, tender
irreducible hernia, abdominal mass, e.g.,
intussusception or carcinoma of the bowel).
Percussion produces a tympanic note and
auscultation high‑pitched tinkling bowel sounds.
If the obstruction is advanced, there may be signs
of bowel strangulation (worsening constant pain,
toxic patient, tachycardia, hypotension, and
pyrexia) with absent bowel sounds (paralytic
ileus).[1,5,16] The examination findings will
depend on the stage at which the patient presents.
The patients with complete obstruction are at
substantial risk
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Weledji: Large bowel obstruction
of strangulation (20%–40%), but a patient with
chronic obstruction may appear generally quite
well with normal vital signs.[4] On the other
hand, the patient who has an acute large bowel
volvulus or an acute closed loop small bowel
obstruction may be profoundly ill at the time of
presentation. Abdominal distension may be so
marked as to render further assessment of the
intra‑abdominal contents impossible. Rarely a
mass be felt, or an irregularly enlarged liver may
suggest a malignant lesion as the cause of
obstruction. Hernia orifices must be examined in
all cases of intestinal obstruction although hernias
are unusual cause of LBO.[5,16] Although rectal
examination will rarely provide a diagnosis as a
true rectal lesion rarely causes LBO, it must
always be performed in bowel obstruction.
Symptoms such as rectal bleeding and Tenesmus
herald its discovery before obstruction ensues.
The rectum will be empty unless the cause of the
problem is impacted feces. A pelvic mass may be
palpable, and the presence of blood and mucus on
the glove is suggestive of a distal neoplasm.
Assessment of the cardiovascular and respiratory
systems is necessary as most of these patients will
require surgery.[5,16]
A plain abdominal X‑ray (AXR) will show the
distribution of gas and its distal limits, and it can
thus distinguish small from LBO. AXR features
of LBO include distended colon (over 5 cm)
proximal to the obstructing lesion, collapsed colon
distally (“cutoff” sign). Distended large bowel
tends to lie peripherally and to show the
haustrations of the taenia coli, which does not
extend across the whole width of the bowel.
Distended small bowel may also be seen if the
ileocecal valve is incompetent.[17] Only rarely is
the cause of obstruction detectable on plain films
of the abdomen. The advent of modern, fast
multidetector computed tomography (MDCT)
scanners has changed management strategies for
acute abdominal conditions including
suspected LBO in all groups of patients,
especially the elderly infirm, and those on
intensive care/high dependency unit
(ITU/HDU). MDCT was shown to be more
accurate in the diagnosis of LBO. It is
usually available on a 24‑h basis, and in
many institutions, it has replaced the urgent
water‑soluble contrast enema X‑ray indicated
in all cases of apparent LBO but
contraindicated in the presence of peritonitis
and in toxic megacolon.[18] It also has the
advantage of excluding incidental findings
and in staging malignant disease.
The management of LBO depends on its
presentation. If intervention is not
forthcoming following progressive
symptoms of chronic obstruction over a
period, acute‑on‑chronic obstruction may
supervene. These acute presentations are
managed as an emergency to prevent
imminent perforation and fecal
peritonitis.[6,16,18] Following resuscitation,
a water‑soluble gastrografin contrast enema
X‑ray may show the level of obstruction and
importantly exclude a pseudo‑obstruction if a
CT scan is not available.[16] The penalty of
misdiag nosis in pseudo‑obstruction is an
unnecessary laparotomy in a poor‑risk
patient.[15] Obstructing carcinomas of right
colon are treated by right hemicolectomy and
of splenic flexure by extended right
hemicolectomy. This removes cancer and
obstructed right colon and results in a
well‑vascularized ileocolic anastomosis.
Postoperative diarrhea is rarely problematic
as the sigmoid and rectum

are preserved. The surgical treatment of sigmoid and
rectosigmoid junction lesions depends on the general
status of the patient, findings at operation, and
preference of the operating surgeon. Perhaps, the most
common procedure performed for acutely obstructed
left‑sided colonic cancer is Hartmann’s operation
(left‑sided segmental resection without primary
anastomosis). The advantages have no anastomosis,
limited mobilization required, resection of obstructing
lesion, and preservation of proximal colon. The
disadvantages are stoma formation, high morbidity of
reversal, and up to 50% are not reversed. More
recently, surgical practice has moved toward one‑stage
procedures for LBO. The advantages are avoiding
stoma, resecting the lesion, and preserving the
proximal colon. The disadvantages are the potential for
anastomotic leakage and the possibility of a
synchronous proximal lesion. A subtotal colectomy
with ileosigmoid or ileorectal anastomosis is indicated
if, in the obstructed colon, the quality of the proximal
bowel is poor with respect to anastomosis because of
edema, fecal loading, shutdown of the splanchnic
blood supply, and an inconsistent marginal vessel. The
anastomosis has a good blood supply from the ileum
and proximal diversion is unnecessary. As the whole of
the proximal colon is removed, undetected
synchronous lesions, which may be missed in the
absence of preoperative imaging, are removed and
subsequent colonoscopic surveillance can be avoided.
The main perceived disadvantage is postoperative
bowel frequency of twice per day with ileosigmoid
anastomosis increasing to three per day after ileorectal
anastomosis. Subtotal colectomy is of course
inadvisable in patients with sphincter dysfunction or
fecal incontinence.[5,6,11,16] On‑table lavage is most
appropriate for obstructing rectal lesions amenable to
International Journal of Surgery Short Reports ¦ Volume 2 ¦ Issue 1 ¦
January-March 2017
primary resection, where preservation of colon
above a low anastomosis is desirable.[17] A
chronic LBO can be admitted electively for
colonoscopic investigations before definitive
elective surgery.[4‑6,16] Self‑expandable metal
stents are now being used more widely in the
management of malignant low (distal to the
splenic flexure) left‑sided LBO. These stents are
placed endoscopically under fluoroscopic control
through the obstructing lesion and can remain in
place for a prolonged period where the stent is
definitive palliative treatment or alternatively can
decompress the colon, and after staging and a
complete workup, a definitive one‑stage resection
and anastomosis may be possible.[19] The stents
are expensive, but they appear to be
cost‑effective. Colonic stenting as a bridge to
surgery provides surgical advantages, as higher
primary anastomosis rate and a lower overall
stoma rate, without increasing the risk of
anastomotic leak or intra‑abdominal abscess.[20]
However, these results should be interpreted with
caution because of few studies reported data on
these outcomes.[21] Further randomized
controlled trials are needed including a larger
number of patients and evaluating long‑term
results (overall survival and quality of life) and
cost‑effectiveness.[22] Optimal treatment in
advanced disease remains controversial.
Complications of perforation and bleeding are
possible but uncommon, and it is likely this
technique will be used more widely in the future.
At present, the treatment of distal colonic
obstruction is individually tailored to each
patient.[20,21]
3
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Weledji: Large bowel obstruction

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Conclusions pseudo‑obstruction.
LBO remains a common and difficult problem Gastroenterol Clin North Am
encountered by the abdominal surgeon. It is 2003;32:1229‑47.
important to distinguish simple from strangulation 7. Irvin TT. Abdominal pain: A surgical
obstruction, following resuscitation. A precise
audit of 1190 emergency admissions. Br J
history may indicate the pathology and physical
examination supported by basic imaging may Surg 1989;76:1121‑5.
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fluid balance, acid–base–electrolyte disturbance, Parietal or visceral? J R Soc Med
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decrease the morbidity and mortality from 1992;85:379.
intestinal obstruction. In distal obstruction,
optimal treatment in advanced disease remains
controversial, particularly after the appearance
and use of colonic endoluminal stents.

Financial support and sponsorship

Nil.
Conflicts of interests
There are no conflicts of interest.
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