intestinal obstruction (2023)

continuing education activity

A bowel obstruction can be a mechanical or functional obstruction of the small or large intestine. Obstruction often causes abdominal pain, nausea, vomiting, constipation, constipation, and bloating. This activity explains the pathophysiology, classification, evaluation and treatment of patients with intestinal obstruction. Highlights the role of the interprofessional team in treating and reducing long-term morbidity in patients with intestinal obstruction.

Goals.

• Describe the pathophysiology, epidemiology and classification of intestinal obstruction.

• Description of the evaluation in a patient with intestinal obstruction.

• Explanation of conservative and surgical treatment strategies in patients with intestinal obstruction.

• Explain the importance of a coherent, interprofessional team approach to the care of patients with intestinal obstruction.

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introduction

A bowel obstruction can be a mechanical or functional obstruction of the small or large intestine. Obstruction occurs when the lumen of the intestine becomes partially or completely blocked. Obstruction often causes abdominal pain, nausea, vomiting, constipation, and bloating. This in turn impedes the normal movement of the digested products. Small bowel obstructions (SBOs) are more common than large bowel obstructions (LBOs) and are the most common indication for small bowel surgery. Bowel obstructions are classified as partial, complete, or closed. A closed-loop obstruction refers to a type of obstruction in the small or large bowel in which there is complete obstruction in a specific segment of the bowel distally and proximally.[1][2][3]

etiology

There are many possible etiologies of small and large bowel obstructions, classified as extrinsic, intrinsic, or intraluminal. The most common cause of SBOs in industrialized nations are extrinsic sources, with postoperative adhesions being the most common. Significant adhesions can cause torsion of the bowel, leading to obstruction. It is estimated that at least two-thirds of patients who have had prior abdominal surgery have adhesions. Other common extrinsic sources are cancer, which causes compression of the small bowel leading to obstruction. Less common but still widespread external causes are inguinal and umbilical hernias. Untreated or symptomatic hernias can eventually twist as the small bowel protrudes through the defect in the abdominal wall and becomes trapped in the hernial sac. Unidentified or unretractable hernias can progress to bowel obstruction and are considered a surgical emergency if the strangulated or herniated bowel becomes ischemic over time. Other causes of SBO are intrinsic diseases that can lead to insidious thickening of the intestinal wall. The intestinal wall is slowly affected and forms a stricture. Crohn's disease is the most common cause of benign stenosis in the adult population.[4][5]

Intraluminal causes of SBOs are less common. This process occurs when an ingested foreign body impacts the intestinal lumen or navigates to the ileocecal valve and cannot pass through, creating a barrier to the colon. However, it is cautioned that most foreign bodies that pass through the pyloric sphincter can pass through the rest of the GI tract. LBOs are rarer, accounting for only 10% to 15% of all bowel obstructions. The most common cause of all LBOs is adenocarcinoma, followed by diverticulitis and volvulus. Colonic obstruction is most commonly seen in the sigmoid colon.

Epidemiology

Small and large bowel obstructions are similar in both men and women. The overriding factor affecting incidence and distribution depends on the patient's risk factors, including but not limited to: prior abdominal surgery, colon or metastatic carcinoma, inflammatory bowel disease, existing abdominal wall and/or inguinal hernia, anterior radiation exposure, and ingestion of foreign bodies.[6][7]

pathophysiology

The normal physiology of the small intestine is to digest food and absorb nutrients. The large intestine continues to aid in digestion and is responsible for vitamin synthesis, water absorption and bilirubin breakdown. Any obstructive mechanism will impede these physiological components. The obstruction causes the bowel to expand proximal to the transition point and collapse distally. A result of the partial or complete blockage of digestive products during obstruction is vomiting. Frequent vomiting can lead to dehydration and electrolyte abnormalities. If the condition is left untreated and worsens, swelling of the intestinal wall forms and the third clearance begins. A serious and life-threatening complication of intestinal obstruction is strangulation. Throttling is most common with closed loop obstacles. If the strangulated bowel is not treated promptly, it will eventually become ischemic and tissue infarction will occur. Tissue infarction progresses to intestinal necrosis, perforation, and sepsis/septic shock.

story and body

If intestinal obstruction is suspected, the doctor must take a detailed medical history and inquire about significant risk factors associated with intestinal obstruction. Small and large bowel obstruction have many overlapping symptoms. However, quality, timing and presentation differ. Typically, in SBO, the abdominal pain is described as intermittent and colicky but improves with vomiting, while the pain associated with DCL is continuous. Vomiting in SBO tends to be more frequent, more voluminous, and bilious, in contrast to emesis during LBO, which typically presents as intermittent and feculent when present. Tenderness is present in both conditions, but is more focal in SBO and more diffuse in LBO.

In addition, bloating is characterized in LBO, with constipation being more common. It is important to note that in certain situations an LBO mimics an SBO when the ileocecal valve is incompetent. An incompetent ileocecal valve can allow air to bleed from the colon into the small intestine and cause symptoms of SBO.

Evaluation

Although intestinal obstruction can be suspected even with an accurate history and patient presentation, the current standard of care to confirm the diagnosis of small and large bowel obstruction is an abdominal CT scan with oral contrast. CT allows visualization of the transition point, severity of obstruction, possible etiology, and assessment of life-threatening complications. This information allows the provider to more effectively identify patients who require surgical intervention. A laboratory test is essential to assess leukocytosis, electrolyte disorders that can occur as a result of vomiting. Laboratory tests also look for elevated lactic acid, which can indicate sepsis or perforation, sometimes not visible on CT if microperforation is involved, and early in the course, blood cultures or other signs of sepsis/septic shock. Although lactic acid is commonly tested to determine if signs of intestinal perforation or ischemia are present, it should be noted that this can be normal even when microperforation is initially present. The physical examination of the patient remains an essential diagnostic tool in view of the patient's severity and the need for emergency surgery versus medical treatment.[8]

Treatment / Management

Initial treatment should always include an assessment of the patient's airway, breathing, and circulation. If resuscitation is required, it should be performed with isotonic saline and electrolyte replacement. A Foley catheter should be inserted to monitor the patient's urinary output if the patient is unstable or septic. Insertion of the nasogastric tube allows for decompression of the bowel to ease expansion proximal to the obstruction. Inserting the nasogastric tube also helps control emesis, allows for accurate assessment of entry and exit, and reduces the risk of aspiration.

Ultimately, treatment depends on the etiology and severity of the obstruction. Stable patients with partial or mild obstruction are treated with nasogastric tube decompression and supportive care. Patients with reducible hernias require non-emergency surgical intervention to prevent future recurrence. Non-retractable or impacted hernias require emergency surgical intervention. Complete or high-grade obstruction usually requires urgent or emergency surgical intervention because of the increased risk of ischemia. Chronic disease states such as Crohn's disease and malignancies require initial supportive care and prolonged periods of conservative management. Treatment ultimately depends on the patient's disposition and the surgeon's acumen.

differential diagnosis

• abdominal hernias

• Abdominal pain in the elderly

• Appendicitis

• chronic megacolon

• colon polyps

• Diverticulitis

• Empirical treatment of diverticulitis

• Operation of pseudomembranous colitis

• small bowel obstruction

• toxic megacolon

forecast

If intestinal obstruction is treated immediately, the result will be good. In general, the recurrence rate with nonsurgical treatment of a bowel obstruction is much higher than with surgical treatment.

complications

• intra-abdominal abscess

  (Video) Intestinal Obstruction - Small Bowel Obstruction vs Large Bowel Obstruction

• WEIL

• inability

• wound dehiscence

• Aspiration

• Kurzdarm syndrome

• lung infection

• Darmperforation

• Apnea

• Anastomoseninsuffizienz

• renal insufficiency

• Tod

Postoperative and rehabilitation care

Postoperative recovery is slow in most cases of bowel obstruction. These patients require deep vein thrombosis prophylaxis and atelectasis prevention. walking is necessary. Feeding time may vary depending on the ileus.

Interrogate

• Surgeon

• radiologist for drainage of an abscess

• Ostomy Nurse

• Infectious disease

Pearls and Other Issues

Most bowel obstructions require hospitalization and surgical consultation. Rapid detection and diagnosis are essential to improve morbidity and mortality. The most important step in the initial treatment of a bowel obstruction is identifying the type, severity, and cause. Understanding the difference between emergency and non-emergency surgical procedures is important to improve outcomes and prevent sequelae of complications such as intestinal necrosis, perforation and sepsis. The disposition ultimately depends on the type and etiology of the obstruction, as well as the patient's medical history, current health status, and risk factors.

Improving health team outcomes

The key to avoiding high mortality from intestinal obstruction is early diagnosis, resuscitation, and surgical intervention. An interprofessional team is essential to ensure that the patient is treated promptly. The triage nurse needs to be aware of signs of intestinal obstruction and expedite admission. The emergency physician, nurse, or treating physician should examine the patient and perform the appropriate radiological test. Even if no intervention is planned, the surgeon should be consulted. While awaiting surgery, it may be necessary to decompress the bowel with a nasogastric tube, and the nurse is essential to monitor vital signs and worsening obstruction. Communication between healthcare professionals is essential.[9][4][Tier V]

Results

The morbidity and mortality of intestinal obstruction depend on early diagnosis and treatment. If a herniated bowel is left untreated, the mortality rate is almost 100%. However, if the operation is performed within 24-48 hours, the mortality rate is less than 10%. Factors that determine morbidity include patient age, comorbidity, and delay in treatment. Today, the overall mortality from intestinal obstruction is still around 5% to 8%.[3][10][Level 3]

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references

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(Video) Small Bowel Obstruction (SBO) Signs & Symptoms, & Why They Occur