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GS30 General Surgery and Thoracic Surgery Large Bowel Obstruction
Prognosis
• overallmortality:10%
• cecalperforation+feculentperitonitis:20%mortality
Toronto Notes 2019
Table 12. Bowel Obstruction vs. Paralytic Ileus
N/V
Abdominal Pain
Abdominal Distention
Constipation Bowel Sounds
AXR Findings
SBO
Early, may be bilious Colicky
+ (prox SBO), ++ (distal SBO)
+
Normal, increased Absent if secondary ileus (delayed presentation)
Air-fluid levels
“Ladder” pattern (plicae circularis)
Proximal distention (>3 cm) + no colonic gas
LBO
Late, may be feculent Colicky
++
+
Normal, increased (borborygmi) Absent if secondary ileus (delayed presentation)
Air-fluid levels
“Picture frame” appearance
Proximal distention + distal decompression
No small bowel air if competent ileocecal valve
Coffee bean sign (sigmoid volvulus)
Paralytic Ileus
Present
Minimal or absent +
+
Decreased, absent
Air throughout small bowel and colon
Functional LBO: Colonic Pseudo-Obstruction (Ogilvie’s Syndrome)
Definition
• acutepseudo-obstruction
• distentionofcolonwithoutmechanicalobstructionindistalcolon
• exactmechanismunknown,likelyautonomicmotordysregulation→possiblysympatheticdeprivation
to colon, unopposed parasympathetic tone, and interruption of sacral parasympathetic tone to distal bowel
Associations
• mostcommon:trauma,infection,andcardiac(MI,CHF)
• disability(long-termdebilitation,chronicdisease,bed-boundnursinghomepatients,andparaplegia),
drugs (narcotic use, laxative abuse, and polypharmacy), other (recent orthopedic or neurosurgery, post-partum, electrolyte abnormalities including hypokalemia, retroperitoneal hematoma, and diffuse carcinomatosis)
Clinical Features
• mostprominentisabdominaldistention(acuteorgraduateover3-7days) • abdominalpain,nauseaandvomiting,constipation/diarrhea
• watchoutforfever,leukocytosis,andpresenceofperitonealsigns
Investigations
• AXR:cecaldilatation–ifdiameter≥12cm,increasedriskofperforation
Treatment
• treatunderlyingcause
• NPO, NGT
• decompression:rectaltube,colonoscopy,neostigmine(cholinergicdrug),surgicaldecompression
(ostomy/resection) uncommon
• surgery(extremelyrare):ifperforation,ischemia,orfailureofconservativemanagement
Prognosis
• mostresolvewithconservativemanagement