Large Bowel Obstruction

1. Large Bowel Obstruction Katherine Jahnes MD Colorectal Conference St Luke’s Roosevelt Hospital Center November 10, 2005

2. Case A • 83 yo male presents with increasing abdominal distention s/p failed sigmoidoscopy/ colonoscopy • PMH: Alzheimer’s Disease, HTN, COPD, glaucoma • PSH: pacemaker placement (2001 for bradycardia) and left hip repair (2001) • PE: Lungs clear, Abdomen distended but soft with hyperactive BS, TTP diffusely, LLQ>LUQ, no rebound

3. Case A • 20 year history of sigmoid volvulus • Managed by sigmoidoscopy reduction as outpatient three time a week • On day of admission attempts at reduction where unsuccessful • Films were obtained

4. Case A

5. Case A • Pt underwent a sigmoid resection • Findings: • Sigmoid volvulus with 3 360 degree turns around mesentery • No sigmoid ischemia • Rectum, descending colon healthy and viable • Sigmoid resected with primary anastomosis of descending colon to rectum

6. Case B • 71 year old female with 2 week history of increasing abdominal distention and no bowel movements • PMH: HTN, DM, CVA- residual aphasia, hemiparesis • PSH: none • PE: Abdomen: • (? Rectal- gas in vault?) • NT, Bowel sounds present, tympanitic

7. Case B • Radiology:

8. Case B • Operative findings:

9. Large Bowel Obstruction:Causes • Obstruction- mechanical interruption of the flow of intestinal contents • Volvulus • Intussuception • Neoplasia (60% of cases) • Colorectal • CLL • Diverticular Strictures/ IBD • Pseudo-obstruction- dilation of the bowel in the absence of a causative anatomic lesion

10. Pseudoobstruction- Ogilvie’s syndrome • Distention of colon with signs and symptoms of colonic obstruction without a mechanical cause for the obstruction • May be acute or chronic • Acute: usually involves only colon, and more commonly effects patients with chronic renal, respiratory, cerebral or cardiovascular disease • Chronic: can effect other parts of the GI tract and tends to recur • Primary pseudoobstruction- a motility disorder • familial visceral myopathy • Diffuse disorder involving autonomic innervation of intestinal wall • Secondary – more common. • Associated with: neuroleptics, opiates, metabolic illness, myxedema, DM, uremia, hyperPTH, lupus, scleroderma, Parkinson’s, traumatic retroperitoneal hematomas • Associated with sympathetic overactivity suppressing parasympathetics

11. Pseudoobstruction- Ogilvie’s syndrome • Diagnosis • Water soluable contrast enema • Can differentiate between mechanical and pseudoobstruction • Colonoscopy • Can also be used for treatment • Initial treatment • NGT • Resuscitation • Neostigmine (parasympathomimetic) • 2.5 mg IV over 3 minutes, with resolution in 10 minutes • Bradycardia is a side effect- atropine must be available

12. Volvulus • Bowel is twisted on mesenteric axis resulting in complete or partial obstruction of the bowel lumen as well as possible vascular impairment • Represents about 5% of large bowel obstructions • Associated factors- • chronic constipation • Aging • institutionalization (neuropyschiatric conditions treated with pyschotrophic drugs) • in the developing world- possible association with high fiber diets • Characteristically affected bowel is attached to long floppy mesentery fixed to retroperitoneum with a narrow base

13. Volvulus • Most commonly sigmoid, also right colon and terminal ileum (cecal volvulus), cecum alone (due to a highly mobile cecum called a cecal bascule- mobile in caudad to cephalad direction), and rarely transverse colon • (photo: barium enema of cecal volvulus, contrast stops at hepatic flexure (arrowhead) and air filled cecum crosses midline of abdomen in LUQ)

14. Volvulus • Presentation: may be acute or subacute • Sudden onset of severe abdominal pain, vomiting, obstipation • Abdomen is distended and tympanitic, often dramatically • Radiographic findings- • AXR: markedly dilated colon with an air-fluid level, no gas in rectum • CT: mesenteric whirl (at right) • Contrast enema: bird’s beak

15. Volvulus • Treatment: • Decompression with rectal tube placed via proctoscope or colonoscopy, with rectal tube left in place for 1-2 days. Often a sudden gush of gas and fluid is released upon decompression • Detorsion with colonoscope • Sigmoid resection • Hartmann’s procedure- emergent if decompression not successful • If decompression is successful; redundant bowel may be removed laparoscopically with primary anastomosis electively (perform colonoscopy first to r/o neoplasm)

16. Neoplasm • Presentation, treatment, and multivariate anaysis of risk factors for obstructive and perforative colorectal carcinoma • Alvarez et al, American Journal of Surgery 190(3): Sept 2005 • A high proportion of colon cancers present as surgical emergencies • Acute obstruction, perforation or both • Associated with high morbidity and mortality

17. Retrospective study • 936 consecutive pts underwent surgery for primary colorectal carcinoma • 107 (11.4%) underwent emergency surgery • Indications: • history and physical consistent with peritonitis • Intrabdominal abscess with systemic signs of sepsis • Clinical signs of obstruction and radiographic evidence thereof not responding to conservative measures within 4 days of hospitalization • Study excluded pts with crohn’s, UC, other types of neoplasm, FAP, h/o operations at outside hospitals, and those not requiring surgery

18. Of 107 pts, 83 (78%) had complete obstruction and 24 (22%) had perforation • Sigmoid was most common location • Comorbid conditions were present in 70% of pts- HTN, CV, COPD, DM. • Males predominated in the obstruction group • Advance tumor stage was seen in 70% of the obstructing pts and in 54% of the perforated pts • Overall/ curative resection rate for obstructed pts was 85/ 83% respectively • Mean OR time was 145.7 minutes (SD 57.1) • 37% required a blood transfusion

19. Tables • Table 2 . Surgical procedures in patients with complicated colorectal carcinomaObstruction (n = 83)Perforation (n = 24)Total n (%)Right colon nLeft colon nRight colon nLeft colon nNo resection16 (14.9)†Colostomy only7411Colostomy only with intention for staged resection22Bypass anastomosis only22Laparotomy only11Resection91 (85.1)†Resection + anastomosis1921⁎4347Resection + stoma3111244⁎  Two patients had proximal diverting colostomy and primary anastomosis. †  The comparison between the obstructing and perforating groups was not significant.

20. Major postop complications in 33%- most frequently GI and pulmonary • Factors associated with major complications or mortality included: • Older age, female sex, perioperative blood transfusion, high ASA or APACHE II score • Not associated: location of lesion

21. Diverticular Strictures/ IBD • Crohn’s disease • Obstruction most commonly in terminal ileum

22. Intussusception • A segment of bowel and its associated mesentery (intussusceptum) invaginates into the lumen of an adjacent bowel segment (intussuscipiens) • Leading cause of bowel obstruction in children • May be caused by intramural, mural, or extramural process- • intraluminal mass pulled forward by peristalsis and drags bowel wall with it • Ie pedunculated tumors, inverted meckel’s diverticulum or appendix • Segment of bowel wall that does not contract normally and the opposite wall rotates the abnormal segment inward causing a kink that acts as a lead point • Ie sessile malignancies, local inflammation, suture lines, lymphoid hyperplasia • Adhesion causes focal area of abnormal peristalsis and kinking

23. Intussusception • In the colon, most frequently are colocolic or sigmoidrectal, and comprise 38% of adult intussusceptions • Neoplasia causes 2/3 of cases in adults • Adenocarcinoma, leiomyosarcoma, reticular cell sarcoma, mets • Association with AIDS- secondary to lymphoma, Kaposi’s sarcoma, reative lymphoid hyperplasia, atypical mycobacteria infection, CMV, Camphylobacter enteritis • Childhood presenting symptoms: acute presentation with episodic crampy abdominal pain and bloody currant jelly stool • Adult presentation: often nonspecific chronic or subacute symptoms- crampy abdominal pain, nausea and vomiting, constipation or diarrhea, rarely bleeding or presence of a palpable mass

24. Intussusception • Radiology: • Abdominal plain film • Air crescent sign- intraluminal air between the walls of the the intussusceptum and the intussuscipiens • Barium enema • Coiled spring appearance (fig 12)- a thin central barium stream with or without a leading mass • US • More useful in childhood intussusceptions • Target or doughnut mass with outer hypoechoic rim • Ct • Target lesion, whirling pattern of mesenteric vessels • May see air bubble between opposed layers of bowel • Underlying etiology may be difficult to determine • Treatment • Surgery • Reduce or not?