Large Bowel Obstruction
Management of large bowel obstruction (LBO) is challenging and complex. Colorectal cancer and diverticular stricture are the most common mechanical causes of LBO. Nonmechanical causes, including pseudo-obstruction, have also been described. Regardless, in
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Key Concepts • Initial management of large bowel obstruction should include early correction of fluid and electrolyte abnormalities and surgical or endoscopic decompression. • The current indications of endoluminal colonic stents include palliation in cancer and in patients who are medically unfit. • Following correction of fluid and electrolyte abnormalities in patients with acute colonic pseudo-obstruction, intravenous neostigmine should be attempted as the next step in management. • Following successful endoscopic decompression of a sigmoid volvulus, given the high recurrence rates, the next step in management should be a segmental resection during the same hospitalization. • CT scan is the imaging modality of choice for the diagnosis and subsequent management of large bowel obstruction.
Introduction Large bowel obstruction (LBO) is a common surgical emergency encountered in a colon and rectal surgical practice [1]. It is caused by the blockage of fecal flow. While most causes are mechanical, nonmechanical causes (pseudo-obstruction) have also been described. LBO is a complex problem that will challenge even the most seasoned clinicians. The surgeon must not only manage the immediate emergency (i.e., the obstruction) but also consider the treatment of the underlying etiology and consider the long-term outcomes of any particular intervention. Therefore, no one strategy will be adequate for all patients. Surgeons must be familiar with all the causes of LBO and understand the myriad of treatment options so that therapeutic plans can be tailored to a variety of clinical presentations.
Etiology Most LBOs are due to progressive narrowing of the bowel lumen caused by intrinsic lesions of the bowel wall (Table 40-1). The most common example of an intrinsic lesion is colorectal cancer, which accounts for nearly 50% of all LBOs. In fact, approximately 10% of all colorectal cancer will present with evidence of a LBO [1]. Diverticular disease also causes intrinsic compression of the lumen and is generally considered the second most common cause of LBO (≈10–20%). Other less common examples of intrinsic narrowing include Crohn’s disease, ischemia, endometriosis, and radiation, all of which cause progressive thickening of the bowel wall and obliteration of the lumen and can often be difficult to distinguish from colorectal cancer. Extrinsic lesions can also impinge the bowel lumen. Most commonly extrinsic compression is caused by non-colorectal malignancy, such as ovarian cancer. Other less common causes of extrinsic compression are hernias and adhesions, the most likely causes of small bowel obstructions but rare for LBO. Because both intrinsic and extrinsic compressions are slowly progressive, the clinical presentation of LBO is often insidious. Even when patients seemingly present with an acute LBO, the astute physician can elicit a history of progressive constipation and narrowed stools for left-sided obstruction or crampy abdominal pain for right-sided disease. Depending on when patients seek care, the clinical presenta
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