Bowel/intestinal obstruction is mechanical/functional obstruction of the intestine, preventing normal transit of feces.
SBO is shorthand for Small bowel obstruction.
Patient information
What is bowel obstruction?
Bowel is just another word for intestine. So it's just anything that's obstructing the intestine from what it normally does, which is carry feces.
Sx
Sx depends on the level of obstruction
Abdominal pain, which tends to be:
In small bowel obstruction:
Colicky (cramping and intermittent) in nature, w/ spasms lasting a few minutes
Pain tends to be central and mid-abdominal
In large bowel obstruction:
Pain felt lower in the abdomen, w/ spasms lasting longer
Constipation occurs earlier
Proximal obstruction of the large bowel may present as small bowel obstruction
Swollen abdomen
Abdominal distension
Vomiting, including fecal vomiting
In small bowel obstruction, vomiting may occur before constipation
In large bowel obstruction, vomiting may be less prominent
Constipation, absence of normal stool/flatus
Increased bowel sounds
Patient information
What is it like if you get an intestinal obstruction?
Constipation happens, because feces can't get through. The tummy can be enlarged, because feces is building up. If feces keeps building out, it can come out the mouth, as fecal vomiting.
Is there any tummy pain?
Tummy pain, is seen in both obstruction of the small and large intestine. But whereas the pain is more central and colicky in the small intestine... when it gets to the later large intestine, the pain is lower, and the spasms last longer.
Pathophysiology
Can occur at any level distal to the duodenum (of the small intestine)
Cause
Small intestine obstruction, including:
Adhesions from previous abdominal surgery, most commonly
Pseudoobstruction
hernias containing bowel
Crohn's disease, causing adhesions or inflammatory strictures
Neoplasms, benign or malignant
Intussusception in children
Volvulus
Superior mesenteric artery syndrome, a compression of the duodenum by the superior mesenteric artery and abdominal aorta
Ischemic strictures
Foreign bodies, e.g. gallstones in gallstone ileus, swallowed objects
Narcotic induced, especially w/ the large doses given to cancer or palliative care Pt's
Dx
Blood tests
Imaging, including:
Abdo x-ray, which may show bowel distension, and presence of multiple (>6) gas fluid levels on supine and erect abdominal radiographs. The appearance of water-soluble contrast in the cecum on abdo x-ray w/in 24 hours of oral administration predicts resolution of an adhesive small bowel obstruction
Luminal contrast studies, including contrast enema, small bowel series, or CT, can define the level of obstruction, whether the obstruction is partial or complete, and define the cause of obstruction
U/S
Biopsy, to determine the nature of the mass, if a mass is identified
Colonoscopy, small bowel investigation w/ ingested camera or push endoscopy, and laparoscopy
Patient information
What can you do to look further into an obstruction in the intestine?
You can start with bloods. You can also take images, including an x-ray of the tummy. Because x-rays aren't that good to see soft tissue, you can use contrast to outline the inside of the GI tract. Or you can use ultrasound or CT, which is better for soft tissue. You can also put a camera down the throat, to look inside, and pinch a bit of the thing that's causing the blockage.
DDx
Ileus
Pseudo-obstruction or Ogilvie's syndrome
Intra-abdominal sepsis
Pneumonia, or other systemic illness
Tx
Mostly Tx conservatively over 2-5 days (e.g. in Crohn's disease, peritoneal carcinomatosis, sclerosing peritonitis, radiation enteritis, and postpartum bowel obstruction), because in many cases, the bowel will open up. Some adhesions loosen up, and the obstruction resolves. However, this requires close monitoring, examined several times a day, and x-rays taken to ensure the Pt is not clinically getting worse. It includes:
Insertion of an NG tube, to correct dehydration and electrolyte abnormalities
Opioid pain drugs, can be used for Pt's w/ severe pain
Antiemetics, if the Pt is vomiting
Surgical intervention to Tx the causative lesion, in surgical emergencies (e.g. volvulus, closed-loop obstructions, ischemic bowel, incarcerated hernias, fully lodged foreign object, malignant tumor), including bowel resection or lysis of adhesions
Endoscopically placed self-expanding metal stents, may be used to temproarily relieve the obstruction as a bridge to surgery, or as palliation, in malignant large bowel obstruction
NG tube inserted from the nose into the stomach, to help decompress the dilated bowel. The tube is uncomfortable but does relieve the abdominal cramps, distension and vomiting
IV therapy
Catheter in the bladder, to monitor urine output
Patient information
What can you do about an obstruction in the intestine?
If the patient isn't eating, you can put a tube down their nose and feed them that way. If they're in pain or vomiting, you can also fix that. You can do open surgery. Or you may be able to use a stent to relieve any obstruction that you find.
Complications
Dehydration
Electrolyte abnormalities, due to vomting
Respiratory compromise, from pressure on the diaphragm by a distended abdomen, or aspiration of vomitus
Bowel ischemia or perforation from prolonged distension or pressure from a foreign body
Patient information
What are the things you're worried about, in an obstruction in the intestines?
All the vomiting can cause a patient to become dehydrated, and affect electrolytes. The expanding mass in the tummy, can also put pressure on the diaphragm, even affecting the patient's breathing. A blockage can also cause the tummy system to blow up, or put pressure against it's blood supply, and kill parts of it.
Prognosis
It is a medical emergency
Some causes of bowel obstruction may resolve spontaneously
6% of small bowel obstruction, are ultimately fatal if Tx is delayed
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