Large bowel obstruction

Definition

Bowel obstruction is a violation of the passage of contents through the intestine caused by obstruction of its lumen, compression, spasm, hemodynamic, or innervation disorders. Clinically, intestinal obstruction is manifested by pain in the abdomen, nausea, vomiting, delayed stool, and gas discharge. The diagnosis of intestinal obstruction takes into account the data of physical examination (palpation, percussion, auscultation of the abdomen), finger rectal examination, review abdomen radiography, contrast radiography, colonoscopy, and laparoscopy. In some types of intestinal obstruction, conservative tactics are possible; in other cases, surgical intervention is performed to restore the passage of contents through the intestine or its external diversion, resection of the non-viable part of the intestine.

General information

Intestinal obstruction (ileus) is not an independent nosologic form; in gastroenterology and coloproctology, this condition develops in various diseases. Intestinal obstruction accounts for about 3.8% of all emergency conditions in abdominal surgery. In intestinal obstruction, the passage of the contents (chyme), i.e., semi-digested food masses, through the digestive tract is impaired.

Intestinal obstruction is a polyetiologic syndrome that can have multiple causes and various forms. Timeliness and correct diagnosis are decisive factors in the outcome of this serious condition.

Causes of intestinal obstruction

The development of different forms of intestinal obstruction is due to their causes. Thus, spastic obstruction develops as a result of reflex spasm of the intestine, which may be due to mechanical and painful irritation in worm infestations, intestinal foreign bodies, abdominal bruises and hematomas, acute pancreatitis, nephrolithiasis and renal colic, biliary colic, basal pneumonia, pleuritis, hemo- and pneumothorax, rib fractures, acute myocardial infarction, etc., and other pathological conditions. pathologic conditions. In addition, the development of dynamic spastic intestinal obstruction may be associated with organic and functional lesions of the nervous system (traumatic brain injury, psychiatric trauma, spinal cord injury, ischemic stroke, etc.), as well as dyscirculatory disorders (thrombosis and embolism of mesenteric vessels, dysentery, vasculitis), Hirschsprung’s disease.

Paralytic intestinal obstruction is caused by paresis and paralysis of the intestine, which can develop due to peritonitis, abdominal surgery, hemoperitoneum, poisoning with morphine, heavy metal salts, food infections, etc.

Classification

Several variants of intestinal obstruction classification exist, taking into account different pathogenetic, anatomical, and clinical mechanisms. A differentiated approach to treating intestinal obstruction is applied depending on all these factors.

According to morphological causes are distinguished:

1. dynamic intestinal obstruction, which in turn can be spastic and paralytic.

2. mechanical intestinal obstruction, including forms of:

• Strangulation (ingestion, impingement, nodule formation)
• Obstruction (intraintestinal, extraintestinal)
• Mixed (adhesions, intussusception)

3. vascular intestinal obstruction due to intestinal infarction.

According to the location of the obstacle to the passage of food masses, distinguish high and low small intestinal obstruction (60-70%) and sizeable intestinal obstruction (30-40%). According to the degree of violation of the patency of the digestive tract, intestinal obstruction can be complete or partial, according to the clinical course – acute, subacute, and chronic. According to the time of formation of intestinal patency disorders, congenital intestinal obstruction is associated with embryonic malformations of the intestine and acquired (secondary) obstruction due to other causes.

Symptoms of intestinal obstruction

Regardless of the type and level of intestinal obstruction, there is a marked pain syndrome, vomiting, delayed stools, and failure to pass gas.

Abdominal pain has a contraction-like intolerable character. During the contraction, which coincides with the peristaltic wave, the patient’s face is distorted from pain; he groans and takes various forced positions (squatting, knee-locked). At the height of the pain attack, symptoms of shock appear pallor of the skin, cold sweat, hypotension, and tachycardia. Lowering pain can be a very insidious sign, indicating necrosis of the intestine and death of nerve endings. After an imaginary calm, on the second day from the beginning of the development of intestinal obstruction, peritonitis inevitably occurs.

Another characteristic of intestinal obstruction is vomiting. Particularly abundant and repeated vomiting, which does not bring relief, develops in small intestinal obstruction. Initially, vomiting masses contain remnants of food, then bile, and in the late period – intestinal contents with a putrid odor. In low intestinal obstruction, vomiting is usually repeated 1-2 times.

A typical symptom of low bowel obstruction is delayed stool and gas discharge. A finger rectal examination reveals the absence of feces in the rectum, distension of the ampulla, and gaping of the sphincter. In high small bowel obstruction, there may be no stool retention; emptying of the lower intestine occurs independently or after enema.

Diagnosis

Auscultation in the early phase reveals increased intestinal peristalsis, “splashing noise,” and weakening of peristalsis in the late phase. A distended intestinal loop can be palpated in intestinal obstruction, and in late terms, stiffness of the anterior abdominal wall can also be seen.

An essential diagnostic value is rectal and vaginal examination, which can be used to detect rectal obstruction and pelvic tumors. The objectivity of the presence of intestinal obstruction is confirmed by instrumental studies.

In the overview, radiography of the abdominal cavity, characteristic intestinal arches (gas-expanded intestine with fluid levels), and Kloiber’s cups (dome-shaped lucencies above the horizontal fluid level) are determined. X-ray contrast examination of the GI tract is used in challenging diagnostic cases. Depending on the level of intestinal obstruction, barium passage radiography of the intestine or irrigoscopy may be used. Colonoscopy allows the examination of the distal parts of the large intestine to identify the cause of intestinal obstruction and, in some cases, resolve the phenomena of acute intestinal obstruction.

Ultrasound of the abdominal cavity in intestinal obstruction is difficult because of the pronounced pneumatization of the intestine, but the study can help detect tumors or inflammatory infiltrates in some cases. During diagnosis, acute intestinal obstruction should be differentiated from acute appendicitis, perforated ulcer of the stomach and duodenum, acute pancreatitis and cholecystitis, renal colic, and ectopic pregnancy.

Treatment of intestinal obstruction

If intestinal obstruction is suspected, the patient must be urgently hospitalized in a surgical hospital. Until a doctor’s examination, enemas, painkillers, laxatives, and gastric lavage are strictly forbidden.

In the absence of peritonitis in the hospital, decompression of the GI tract is performed by aspiration of gastrointestinal contents through a thin nasogastric tube and siphon enema. In cases of contraction-like pain and marked peristalsis, antispasmodics are administered. In intestinal paresis, stimulating intestinal motility drugs are used; novocaine paranephral blockade is performed. To correct the water-electrolyte balance, intravenous administration of saline solutions is prescribed.

If intestinal obstruction is not resolved despite the measures taken, we should consider mechanical ileus, which requires urgent surgical intervention. Surgery for intestinal obstruction aims to remove the mechanical obstruction, resection the non-viable part of the intestine, and prevent recurrent obstruction.

In small intestinal obstruction, small intestinal resection with enteroenteroanastomosis or enterocolonastomosis, deinvagination, untwisting of the intestinal loop, dissection of adhesions, etc., may be performed. In intestinal obstruction caused by colorectal tumors, hemicolectomy, and temporary colostomy are performed. In case of inoperable colon tumors, a bypass anastomosis is performed; if peritonitis develops, a transversostomy is performed.

All these treatment options are available in more than 690 hospitals worldwide (https://doctor.global/results/diseases/large-bowel-obstruction). For example, Hartmann’s operation can be done in these countries for following approximate prices:

Turkey $6.8 K in 25 clinics

China $15.4 K in 6 clinics

Germany $22.4 K in 43 clinics

Israel $25.8 K in 11 clinics

United States $36.2 K in 15 clinics.

Prognosis and prevention

The prognosis of intestinal obstruction depends on the time of onset and the completeness of treatment. An unfavorable outcome occurs in late-recognized intestinal obstruction, in weakened and elderly patients, and in inoperable tumors. Recurrence of intestinal obstruction is possible in severe adhesions in the abdominal cavity.

The prevention of intestinal obstruction includes timely screening and removal of intestinal tumors, prevention of adhesions, elimination of worm infestation, proper nutrition, and avoidance of trauma. If intestinal obstruction is suspected, immediate medical attention should be sought.