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Bowel Obstruction

What is a bowel obstruction?

A bowel obstruction happens when either your small or large intestine is partly or
completely blocked. The blockage prevents food, fluids, and gas from moving through the
intestines in the normal way. The blockage may cause severe pain that comes and goes.

This topic covers a blockage caused by tumors, scar tissue, or twisting or narrowing of the
intestines. It does not cover ileus, which most commonly happens after surgery on the belly
(abdominal surgery).

Bowel obstructions

A mechanical bowel obstruction can develop in either the small intestine or the large intestine
(also called the colon). The condition partially or completely prevents the contents of the intestine
and blood from flowing normally through the bowels.
The picture on the left shows a blockage in the small intestine that might develop, for example, as
a result of scar tissue formation (adhesions). The picture on the right shows a partial blockage in
the colon caused by a tumor (cancer).

What causes a bowel obstruction?

Tumors, scar tissue (adhesions), or twisting or narrowing of the intestines can cause a bowel
obstruction. These are called mechanical obstructions .

In the small intestine, scar tissue is most often the cause. Other causes include hernias and
Crohn's disease, which can twist or narrow the intestine, and cancer, which can cause tumors. A
blockage also can happen if one part of the intestine folds like a telescope into another part,
which is called intussusception.

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In the large intestine, cancer is most often the cause. Other causes are severe constipation from
a hard mass of stool and twisting or narrowing of the intestine caused by diverticulitis or
inflammatory bowel disease.

What are the symptoms?

Symptoms include:

• Cramping and belly pain that comes and goes. The pain can occur around or below the
belly button.
• Vomiting.
• Bloating.
• Constipation and a lack of gas, if the intestine is completely blocked.
• Diarrhea, if the intestine is partly blocked.

Call your doctor right away if your belly pain is severe and constant. This may mean that your
intestine's blood supply has been cut off or that you have a hole in your intestine. This is an
emergency.

How is a bowel obstruction diagnosed?

Your doctor will ask you questions about your symptoms and other digestive problems you've
had. He or she will check your belly for tenderness and bloating.

Your doctor may do:

• An abdominal X-ray, which can find blockages in the small and large intestines.
• A CT scan of the belly, which helps your doctor see whether the blockage is partial or
complete.

How is it treated?
Most bowel obstructions are treated in the hospital.

A partial blockage may go away on its own, or you may need treatments that don't require
surgery (nonsurgical treatments). These treatments include using liquids or air (enemas), small
mesh tubes (stents), or medicine to open up the blockage. You will stay in the hospital while
waiting to see if the blockage goes away. If these treatments don't work, you'll need surgery to
remove the blockage.

Surgery is almost always needed when the intestine is completely blocked or when the blood
supply is cut off. Surgery is often done laparoscopically. This means that the surgeon uses a
lighted scope and tools inserted through a few small cuts rather than making a large cut.

If your blockage was caused by another health problem, such as diverticulitis, the blockage may
come back if you don't treat that health problem.

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Small intestine

The small intestine consists of three sections. The first portion, called the duodenum, connects to
the stomach. The middle portion is the jejunum. The final section, called the ileum, attaches to the
first portion of the large intestine.

Large intestine

The large intestine (colon) extends from the cecum to the anus and includes the ascending colon,
the transverse colon, the descending colon, the sigmoid colon, and the rectum.

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Intussusception

Illustration copyright 2000 by Nucleus Communications, Inc. All rights reserved.


http://www.nucleusinc.com
Intussusception is a condition in which part of the intestine (usually the lower part of the small
intestine) folds inward and into itself, like a telescope. It can cause swelling, pain, and a complete
or partial loss of blood supply to the affected area. If not treated, the affected intestine may burst
or die, causing a serious, life-threatening condition. Intussusception is most common in children.

**********************************************

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What Are Bowel Obstructions?
Intestinal Obstructions Are Treatable but Can Be Life-Threatening

What is a Bowel Obstruction?

A bowel obstruction is when a section of the bowel (either the small1 or the
large intestine2) becomes totally or partially blocked, so that stool cannot
pass through it. Bowel obstructions can happen to just about anyone, but
they are a common complication of Crohn's disease3.

Types of Obstruction

Mechanical obstruction: In this type of obstruction, the stool moving through


the intestines is physically blocked, much like household plumbing may be
blocked. A blockage could be caused by:

• Hernia4
• Scar tissue (adhesions5)
• Impacted stool6
• Gallstones7
• Tumor8
• Abnormal tissue growth
• Intussusception9 (a section of the bowel slides in to itself, similar to
when a telescope is closed)
• Twist or kink in the intestines (volvulus10)
• Ingested foreign body (swallowing a nonfood item)

Treating a Bowel Obstruction

An obstruction is a serious condition and may be treated in the hospital. In


some cases, it is necessary to decompress the intestine. This is accomplished
by inserting a nasogastric (NG) tube in to the stomach, which alleviates
distention and vomiting. If inserting the NG tube does not help in relieving
the blockage, surgery may be necessary. Surgery may also be necessary if
some of the tissue in the intestine has died.

Complications

If not treated, a bowel obstruction could lead to more serious problems, such
as the death of the bowel tissue. If part of the bowel dies, it could result in
infection and/or gangrene11. The intestine can also perforate (get a hole in
it), which is a medical emergency and will require surgery.

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Symptoms

An obstruction can cause the complete absence of stool or gas (obstipation),


because no stool can pass through the intestine. Or it can cause diarrhea,
because only liquid stool can pass beyond the point of obstruction. Other
symptoms are intense pain and cramping, abdominal fullness and abdominal
bloating. The symptoms of a bowel obstruction are:

• A feeling of fullness in the abdomen


• Bad breath12
• Bloating (distention)13
• Constipation14
• Diarrhea15
• Pain and cramping
• Vomiting

Diagnosis

The diagnosis of a bowel obstruction is made through both a physical exam


and diagnostic tests.

Bowel sounds. The bowel normally makes some sounds, such as gurgling and
clicking, which can be heard at irregular intervals by using a stethoscope. If
an obstruction is present, a health care provider may hear high-pitched
sounds while listening to the abdomen. If the obstruction has been present
for some time, there may be no bowel sounds at all.

X-Ray (abdominal radiograph)16. This is normally the first test that is used to
determine if there is an obstruction. A radiologist or other specialist can
determine if the x-ray shows the signs of a bowel obstruction.

Barium enema17. This test used to be used to determine the location of the
obstruction. This method, however, is not always good for showing whether
an obstruction is caused by something pressing on the bowel.

Upper GI18 with small bowel series19. Much like the barium enema, this test
used to be used to help pinpoint the obstruction, especially if it was in the
upper gastrointestinal tract. This is almost never used for diagnosis anymore.

Abdominal CT scan20. This is the primary test used for bowel obstruction.

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Preventing Obstructions

Some causes of obstructions are not preventable, such as those where there
is no mechanical reason for the obstruction. In cases where the obstruction is
caused by another condition, such as a tumor or a hernia, treating the
underlying problem can help prevent the development of an obstruction.

Obstruction, Small Bowel


http://emedicine.medscape.com/article/774140-print

Background
A small-bowel obstruction (SBO) is caused by a variety of pathologic processes. The leading cause of
SBO in developed countries is postoperative adhesions (60%) followed by malignancy, Crohn's
disease, and hernias, although some studies have reported Crohn disease as a greater etiologic factor
than neoplasia. Surgeries most closely associated with SBO are appendectomy, colorectal surgery,
and gynecologic and upper gastrointestinal (GI) procedures. One study from Canada reported a higher
frequency of SBO after colorectal surgery, followed by gynecologic surgery, hernia repair, and
appendectomy. Lower abdominal and pelvic surgeries lead to obstruction more often than upper GI
surgeries.

SBOs can be partial or complete, simple (ie, nonstrangulated) or strangulated. Strangulated


obstructions are surgical emergencies. If not diagnosed and properly treated, vascular compromise
leads to bowel ischemia and further morbidity and mortality. Because as many as 40% of patients
have strangulated obstructions, differentiating the characteristics and etiologies of obstruction is critical
to proper patient treatment.

Pathophysiology
Obstruction of the small bowel leads to proximal dilatation of the intestine due to accumulation of GI
secretions and swallowed air. This bowel dilatation stimulates cell secretory activity resulting in more
fluid accumulation. This leads to increased peristalsis both above and below the obstruction with
frequent loose stools and flatus early in its course.

Vomiting occurs if the level of obstruction is proximal. Increasing small-bowel distention leads to
increased intraluminal pressures. This can cause compression of mucosal lymphatics leading to bowel
wall lymphedema. With even higher intraluminal hydrostatic pressures, increased hydrostatic pressure
in the capillary beds results in massive third spacing of fluid, electrolytes, and proteins into the
intestinal lumen. The fluid loss and dehydration that ensue may be severe and contribute to increased
morbidity and mortality.

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Strangulated SBOs are most commonly associated with adhesions and occur when a loop of
distended bowel twists on its mesenteric pedicle. The arterial occlusion leads to bowel ischemia and
necrosis. If left untreated, this progresses to perforation, peritonitis, and death.

Bacteria in the gut proliferate proximal to the obstruction. Microvascular changes in the bowel wall
allow translocation to the mesenteric lymph nodes. This is associated with an increase in incidence of
bacteremia due to Escherichia coli, but the clinical significance is unclear.

Frequency
United States

SBO accounts for 20% of all acute surgical admissions.

Mortality/Morbidity
Mortality and morbidity are dependent on the early recognition and correct diagnosis of obstruction. If
untreated, strangulated obstructions cause death in 100% of patients. If surgery is performed within 36
hours, the mortality rate decreases to 8%. The mortality rate is 25% if the surgery is postponed beyond
36 hours in these patients.

Clinical

History
Obstruction can be characterized as either partial or complete versus simple or strangulated.

• Abdominal pain (characteristic with most patients)


o Pain, often described as crampy and intermittent, is more prevalent in simple
obstruction.
o Often, the presentation may provide clues to the approximate location and nature of
the obstruction. Usually, pain that occurs for a shorter duration of time and is colicky
and accompanied by bilious vomiting may be more proximal. Pain lasting as many as
several days, which is progressive in nature and with abdominal distention, may be
typical of a more distal obstruction.
o Changes in the character of the pain may indicate the development of a more serious
complication (ie, constant pain of strangulated or ischemic bowel).
• Nausea
• Vomiting, which is associated more with proximal obstructions
• Diarrhea (an early finding)
• Constipation (a late finding) as evidenced by the absence of flatus or bowel movements
• Fever and tachycardia - Occur late and may be associated with strangulation
• Previous abdominal or pelvic surgery, previous radiation therapy, or both (may be part of
patient's medical history)
• History of malignancy (particularly ovarian and colonic)

Physical

• Abdominal distention

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o Duodenal or proximal small bowel has less distention when obstructed than the distal
bowel has when obstructed.
o Hyperactive bowel sounds occur early as GI contents attempt to overcome the
obstruction.
o Hypoactive bowel sounds occur late.
o Exclude incarcerated hernias of the groin, femoral triangle, and obturator foramina.
o Proper genitourinary and pelvic examinations are essential.
o Look for the following during rectal examination:
 Gross or occult blood, which suggests late strangulation or malignancy
 Masses, which suggest obturator hernia
o Check for symptoms commonly believed to be more diagnostic of intestinal ischemia,
including the following:
 Fever (temperature >100°F)
 Tachycardia (>100 beats/min)
 Peritoneal signs
o No reliable way exists to differentiate simple from early strangulated obstruction on
physical examination. Serial abdominal examinations are important and may detect
changes early.

Causes

• The most common cause of SBO is postsurgical adhesions.


o Postoperative adhesions can be the cause of acute obstruction within 4 weeks of
surgery or of chronic obstruction decades later.
o The incidence of SBO parallels the increasing number of laparotomies performed in
developing countries.
o The second most common identified cause of SBO is an incarcerated groin hernia.
• Other etiologies of SBO include malignant tumor (20%), hernia (10%), inflammatory bowel
disease (5%), volvulus (3%), and miscellaneous causes (2%).
• The causes of SBO in pediatric patients include congenital atresia, pyloric stenosis, and
intussusception.

Differential Diagnoses
Abortion, Threatened Inflammatory Bowel Disease
Alcoholic Ketoacidosis Mesenteric Ischemia
Appendicitis, Acute Obstruction, Large Bowel
Cholangitis Ovarian Torsion
Cholecystitis and Biliary Colic Pancreatitis
Cholelithiasis Pediatrics, Appendicitis
Constipation Pediatrics, Diabetic Ketoacidosis
Diverticular Disease Pediatrics, Gastroenteritis
Dysmenorrhea Pediatrics, Intussusception
Endometriosis Pelvic Inflammatory Disease
Esophageal Perforation, Rupture and Tears Urinary Tract Infection, Female

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Foreign Bodies, Gastrointestinal Urinary Tract Infection, Male
Gastroenteritis
Workup

Laboratory Studies

• Essential laboratory tests


o Serum chemistries: Results are usually normal or mildly elevated.
o BUN level: If the BUN level is increased, this may indicate decreased volume state
(eg, dehydration).
o Creatinine level: Creatinine level elevations may indicate dehydration.
o CBC: WBC count may be elevated with a left shift in simple or strangulated
obstructions. Increased hematocrit is an indicator of volume state (ie, dehydration).
o Lactate dehydrogenase tests
o Urinalysis
o Type and crossmatch: The patient may require surgical intervention.
• Laboratory tests to exclude biliary or hepatic disease
o Phosphate level
o Creatine kinase level
o Liver panels

Imaging Studies

• Plain radiography
o Obtain plain radiographs first for patients in whom SBO is suspected.
o At least 2 views, supine or flat and upright, are required.
o Plain radiographs are diagnostically more accurate in cases of simple obstruction;
however, diagnostic failure rates of as much as 30% have been reported. In one
small study, the sensitivity of plain radiographs was reported as 75%, and specificity
was reported to be 53%. Similar findings were reported in a second study.
o In one study, plain films were more accurate in the detection of an acute SBO and the
accuracy was higher if interpreted by more experienced radiologists.
o Plain radiography is of little assistance in differentiating strangulation from simple
obstruction. Some have used abdominal radiography to distinguish between
complete obstruction and partial or no SBO. A study by Lappas et al proposed that 2
findings were more predictive of a higher grade or complete SBO: presence of air-
fluid differential height in the same small-bowel loop and presence of a mean level
width greater than 25 mm.1 The study found that when the 2 findings are present, the
obstruction is most likely high grade or complete. When both are absent, the authors
proposed that a low-grade (partial) SBO is likely or nonexistent.
o Dilated small-bowel loops with air fluid levels indicate SBO.
o Absent or minimal colonic gas indicates SBO.
• Enteroclysis
• Enteroclysis is valuable in detecting the presence of obstruction and in differentiating
partial from complete blockages.
• This study is useful when plain radiographic findings are normal in the presence of
clinical signs of SBO or if plain radiographic findings are nonspecific.

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• It distinguishes adhesions from metastases, tumor recurrence, and radiation damage.
• Enteroclysis offers a high negative predictive value and can be performed with 2
types of contrast.
• Barium is the classic contrast agent used in this study. It is safe and useful when
diagnosing obstructions provided no evidence of bowel ischemia or perforation exists.
Barium has been associated with peritonitis and should be avoided if perforation is
suspected.
• CT scanning
o CT scanning is useful in making an early diagnosis of strangulated obstruction and in
delineating the myriad other causes of acute abdominal pain, particularly when
clinical and radiographic findings are inconclusive. It also has proved useful in
distinguishing the etiologies of SBO, that is, extrinsic causes such as adhesions and
hernia from intrinsic causes such as neoplasms or Crohn disease. It also
differentiates the above from intraluminal causes such as bezoars.
o CT scanning is about 90% sensitive and specific in detecting SBO.
o CT scanning is the study of choice if the patient has fever, tachycardia, localized
abdominal pain, and/or leukocytosis.
o It is capable of revealing abscess, inflammatory process, extraluminal pathology
resulting in obstruction, and mesenteric ischemia.
o CT scanning enables the clinician to distinguish between ileus and mechanical small
bowel in postoperative patients.
o CT scanning does not require oral contrast for the diagnosis of SBO because the
retained intraluminal fluid serves as a natural contrast agent.
o Obstruction is present if the small-bowel loop is greater than 2.5 cm in diameter
dilated proximal to a distinct transition zone of collapsed bowel less than 1 cm in
diameter.
o A smooth beak indicates simple obstruction without vascular compromise; a serrated
beak may indicate strangulation.
o Bowel wall thickening indicates early strangulation.
o Portal venous gas indicates early strangulation.
o Pneumatosis indicates early strangulation.
o CT scanning is useful in identifying abscesses, hernias, and tumors.
o CT may be less useful in the evaluation of small bowel ischemia associated with
obstruction.
o One small series reported a sensitivity of 93%, specificity of 100%, and accuracy of
94% in detecting obstruction. Another reported a sensitivity of 92% and specificity of
71% in correct identification of partial or complete SBO.
• CT enterography (CT enteroclysis)
o This modality is replacing enteroclysis in clinical practice.2,3,4
o This is also the examination of choice for intermittent SBO or in patients with
complicated surgical history (eg, prior surgery, tumors).5
o It displays the entire thickness of the bowel wall and allows evaluation of
surrounding mesentery and perinephric fat.2
o Newer imaging technique that uses CT technology to perform thin slices of
bowel along while simultaneously using large volume enteric contrast material for
imagery.2
o More accurate than conventional CT at finding cause of SBO (89% vs 50%), as well
as locating site (100% vs 94%).6

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o Helpful in patients being managed conservatively (ie, nonoperatively).6
• MRI
o The accuracy of MRI almost approaches that of CT scanning for detection of
obstruction.2
o MRI is also effective in defining location and etiology of obstruction.7
o MRI has several limitations, such as lack of availability (transporting sicker patients is
difficult) and poor visualization of masses or inflammation.8,9

• Ultrasonography
o Ultrasonography is less costly and less invasive than CT scanning.
o It may reliably exclude SBO in as many as 89% of patients.
o Specificity is reportedly 100%.

Other Tests

• Studies have been performed to evaluate the use of water-soluble oral contrast as a tool in
the management of small-bowel obstruction and as a predictive tool for nonoperative
resolution of adhesive SBO. It does not cause resolution of the SBO, but it may reduce the
hospital stay in patients not requiring surgery.

Procedures

• Nasogastric tube placement and suction should be performed for patients with severe nausea
and vomiting.

Treatment

Emergency Department Care


Initial ED treatment consists of aggressive fluid resuscitation, bowel decompression, administration of
analgesia and antiemetic as indicated clinically, antibiotics, and early surgical consultation.

• Initial decompression can be performed by placement of a nasogastric (NG) tube for


suctioning GI contents and preventing aspiration.
• Antibiotics are used to cover against gram-negative and anaerobic organisms.
• Monitor airway, breathing, and circulation (ABCs).
o Blood pressure monitoring
o Cardiac monitoring in selected patients (especially elderly patients or those with
comorbid conditions)

Consultations

• General surgeon (early and without delay): Laparoscopy is being used in addition to
laparotomy and has been shown to reduce hospital stay, speed recovery, and decrease
morbidity.

Medication

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Fluid replacement with aggressive intravenous resuscitation using isotonic saline or lactated Ringer
solution is indicated. Oxygen and appropriate monitoring are also required. Antibiotics are used to
cover gram-negative and anaerobic organisms.

Antibiotics
These agents are for prophylaxis in surgical intervention, if needed.

Cefazolin (Ancef, Kefzol, Zolicef)

First-generation semisynthetic cephalosporin that arrests bacterial cell wall synthesis, inhibiting
bacterial growth.

Dosing

Adult
1-2 g IV 1 h before surgery

Pediatric
20 mg/kg IV 1 h before surgery

Interactions

Probenecid prolongs effect of cefazolin; coadministration with aminoglycosides may increase renal
toxicity; may yield false-positive urine-dip test results for glucose

Contraindications

Documented hypersensitivity

Precautions

Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions
Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections and
promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy

Cefoxitin (Mefoxin)

Second-generation cephalosporin indicated for gram-positive cocci and gram-negative rod infections.
Infections caused by cephalosporin- or penicillin-resistant gram-negative bacteria may respond to
cefoxitin.

Dosing

Adult

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2 g IV 1 h before surgery

Pediatric
20 mg/kg IV 1 h before surgery

Interactions

Probenecid may increase effects of cefoxitin; coadministration with aminoglycosides or furosemide


may increase nephrotoxicity (closely monitor renal function)

Contraindications

Documented hypersensitivity

Precautions

Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions
Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections and
promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy

Cefotetan (Cefotan)

Second-generation cephalosporin indicated for infections caused by susceptible gram-positive cocci


and gram-negative rods.
Dosage and route of administration depend on condition of patient, severity of infection, and
susceptibility of causative organism.

Dosing

Adult
1-2 g IV 1 h before surgery

Pediatric
Not established

Interactions

Consumption of alcohol within 72 h of cefotetan may produce disulfiramlike reactions; may increase
hypoprothrombinemic effects of anticoagulants; coadministration with potent diuretics (eg, loop
diuretics) or aminoglycosides may increase nephrotoxicity

Contraindications

Documented hypersensitivity

Precautions

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Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions
Reduce dosage by one half if CrCl is 10-30 mL/min and by one fourth if <10 mL/min (high doses may
cause CNS toxicity); bacterial or fungal overgrowth of nonsusceptible organisms may occur with
prolonged or repeated therapy

Cefuroxime (Ceftin, Kefurox, Zinacef)

Second-generation cephalosporin maintains gram-positive activity of first-generation cephalosporins;


adds activity against Proteus mirabilis, Haemophilus influenzae, Escherichia coli, Klebsiella
pneumoniae, and Moraxella catarrhalis.
Condition of patient, severity of infection, and susceptibility of microorganism determine proper dose
and route of administration.

Dosing

Adult
1.5 g IV 1 h before surgery

Pediatric
50 mg/kg IV 1 h before surgery

Interactions

Disulfiramlike reactions may occur when alcohol is consumed within 72 h after taking cefuroxime; may
increase hypoprothrombinemic effects of anticoagulants; may increase nephrotoxicity in patients
receiving potent diuretics such as loop diuretics; coadministration with aminoglycosides increases
nephrotoxic potential

Contraindications

Documented hypersensitivity

Precautions

Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if
benefits outweigh risk to fetus

Precautions
Reduce dosage by one half if CrCl is 10-30 mL/min and by three fourths if <10 mL/min (high doses
may cause CNS toxicity); bacterial or fungal overgrowth of nonsusceptible organisms may occur with
prolonged or repeated therapy

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Meropenem (Merrem)

Bactericidal broad-spectrum carbapenem antibiotic that inhibits cell-wall synthesis. Effective against
most gram-positive and gram-negative bacteria.

Dosing

Adult
1 g IV q8h

Pediatric
40 mg/kg IV q8h

Interactions

Probenecid may inhibit renal excretion of meropenem, increasing meropenem levels

Contraindications

Documented hypersensitivity

Precautions

Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions
Pseudomembranous colitis and thrombocytopenia may occur, requiring immediate discontinuation of
medication

Antiemetic
These agents should be administered for symptomatic relief, usually in conjunction with GI
decompression via placement of an NG tube to suction.

Promethazine (Phenergan)

For symptomatic treatment of nausea and vomiting. Antidopaminergic agent effective in treating
emesis. Blocks postsynaptic mesolimbic dopaminergic receptors in brain and reduces stimuli to
brainstem reticular system.

Dosing

Adult
12.5-25 mg PO/IV/IM/PR q4h prn

Pediatric
<2 years: Contraindicated
>2 years: 0.25-1 mg/kg PO/IV/IM/PR 4-6 times/d prn

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Interactions

May have additive effects when used concurrently with other CNS depressants or anticonvulsants;
elderly persons may be particularly susceptible to experience decreased mental status;
coadministration with epinephrine may cause hypotension

Contraindications

Documented hypersensitivity; children <2 y (incidences of death due to respiratory depression)

Precautions

Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if
benefits outweigh risk to fetus

Precautions
Caution in cardiovascular disease, impaired liver function, seizures, sleep apnea, and asthma; start
with lower dose in elderly patients

Ondansetron (Zofran)

Selective 5-HT3-receptor antagonist that blocks serotonin both peripherally and centrally, used in the
prevention of nausea and vomiting. Metabolized in the liver through the P-450 pathway.

Dosing

Adult
4-8 mg PO q8h; alternatively, 4 mg IV q8h

Pediatric
4 mg PO q8h; alternatively, 0.1-0.15 mg/kg IV q8h

Interactions

Although potential exists for cytochrome P-450 inducers (barbiturates, rifampin, carbamazepine, and
phenytoin) to change half-life and clearance of ondansetron, dosage adjustment is not usually required

Contraindications

Documented hypersensitivity

Precautions

Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions
May cause headache

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Analgesics
Pain control is essential to quality patient care. Analgesics ensure patient comfort, promote pulmonary
toilet, and have sedating properties, which are beneficial for patients who experience pain.

Morphine sulfate (Astramorph, MS Contin, MSIR, Oramorph)

DOC for analgesia due to reliable and predictable effects, safety profile, and ease of reversibility with
naloxone.
Various IV doses are used; commonly titrated until desired effect obtained.

Dosing

Adult
Starting dose: 0.1 mg/kg IV/IM/SC
Maintenance dose: 5-20 mg/70 kg IV/IM/SC q2-4h
Relatively hypovolemic patients: Start with 2 mg IV/IM/SC and reassess hemodynamic effects of dose

Pediatric
Neonates: 0.05-0.2 mg/kg dose IV/IM/SC prn
Children: 0.1-0.2 mg/kg dose IV/IM/SC q2-4h prn

Interactions

Phenothiazines may antagonize analgesic effects of opiate agonists; tricyclic antidepressants, MAO
inhibitors, and other CNS depressants may potentiate adverse effects of morphine

Contraindications

Documented hypersensitivity; hypotension; potentially compromised airway where establishing rapid


airway control would be difficult

Precautions

Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if
benefits outweigh risk to fetus

Precautions
Caution in hypotension, respiratory depression, nausea, emesis, constipation, urinary retention, atrial
flutter, and other supraventricular tachycardias; has vagolytic action and may increase ventricular
response rate

Follow-up

Further Inpatient Care

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• Continued NG suction: This provides symptomatic relief, decreases the need for
intraoperative decompression, and benefits all patients. No clinical advantage to using a long
tube (nasointestinal) instead of a short tube (NG) is observed.
• Nonoperative treatment: A nonoperative trial of as many as 3 days is warranted for partial or
simple obstruction. Provide adequate fluid resuscitation and NG suctioning. Resolution of
obstruction occurs in virtually all patients with these lesions within 72 hours.
• Good data regarding nonoperative management suggest it to be successful in 65-81% of
partial SBO cases without peritonitis.2,10
• Surgical treatment: A strangulated obstruction is a surgical emergency. In patients with a
complete SBO, the risk of strangulation is high and early surgical intervention is warranted.
Patients with simple complete obstructions in whom nonoperative trials fail also need surgical
treatment but experience no apparent disadvantage to delayed surgery.
• Laparoscopy has been shown to be safe and effective in selected cases of SBO.11
• Adhesions: Decreasing intraoperative trauma to the peritoneal surfaces can prevent adhesion
formation.
• Malignant tumor: Obstruction by tumor is usually caused by metastasis. Initial treatment
should be nonoperative; surgical resection is recommended when feasible.
• Inflammatory bowel disease: To reduce the inflammatory process, treatment generally is
nonoperative in combination with high-dose steroids. Consider parenteral treatment for
prolonged periods of bowel rest. Undertake surgical treatment, bowel resection, and/or
stricturoplasty if nonoperative treatment fails.
• Intra-abdominal abscess: CT-guided drainage is usually sufficient to relieve obstruction.
• Radiation enteritis: If obstruction follows radiation therapy acutely, nonoperative treatment
accompanied by steroids is usually sufficient. If obstruction is a chronic sequela of radiation
therapy, surgical treatment is indicated.
• Acute postoperative obstruction: This is difficult to diagnose because symptoms often are
attributed to incisional pain and postoperative ileus. Treatment should be nonoperative.
• Incarcerated hernia: Initially use manual reduction and observation. Advise elective hernia
repair as soon as possible after reduction.

Further Outpatient Care

• Treat all patients as inpatients including trial of observation.

Complications

• Sepsis
• Intra-abdominal abscess
• Wound dehiscence
• Aspiration
• Short-bowel syndrome (as a result of multiple surgeries)
• Death (secondary to delayed treatment)

Prognosis

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• With proper diagnosis and treatment of the obstruction, prognosis is good. Complete
obstructions treated successfully nonoperatively have a higher incidence of recurrence than
those treated surgically.

Intestinal Obstruction

Intestinal obstruction is significant mechanical impairment or complete arrest of the


passage of contents through the intestine. Symptoms include cramping pain, vomiting,
obstipation, and lack of flatus. Diagnosis is clinical, confirmed by abdominal x-rays.
Treatment is fluid resuscitation, nasogastric suction, and, in most cases of complete
obstruction, surgery.

Mechanical obstruction is divided into obstruction of the small bowel (including the
duodenum) and obstruction of the large bowel. Obstruction may be partial or complete.
About 85% of partial small-bowel obstructions resolve with nonoperative treatment,
whereas about 85% of complete small-bowel obstructions require operation.

Etiology
Overall, the most common causes of mechanical obstruction are adhesions, hernias,
and tumors. Other general causes are diverticulitis, foreign bodies (including gallstones),
volvulus (twisting of bowel on its mesentery), intussusception (telescoping of one
segment of bowel into another—see Gastrointestinal Disorders in Neonates and Infants:

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Intussusception), and fecal impaction. Specific segments of the intestine are affected
differently (see Table 5: Acute Abdomen and Surgical Gastroenterology: Causes of
Intestinal Obstruction ).

Table 5
Causes of Intestinal Obstruction
Location Causes
Colon Tumors (usually in left colon), diverticulitis
(usually in sigmoid), volvulus of sigmoid or
cecum, fecal impaction, Hirschsprung's disease

Duodenum

Adults Cancer of the duodenum or head of pancreas,


ulcer disease

Neonates Atresia, volvulus, bands, annular pancreas

Jejunum
and ileum

Adults Hernias, adhesions (common), tumors, foreign


body, Meckel's diverticulum, Crohn's disease
(uncommon), Ascaris infestation, midgut volvulus,
intussusception by tumor (rare)

Neonates Meconium ileus, volvulus of a malrotated gut,


atresia, intussusception

Pathophysiology
In simple mechanical obstruction, blockage occurs without vascular compromise.
Ingested fluid and food, digestive secretions, and gas accumulate above the obstruction.
The proximal bowel distends, and the distal segment collapses. The normal secretory
and absorptive functions of the mucosa are depressed, and the bowel wall becomes
edematous and congested. Severe intestinal distention is self-perpetuating and
progressive, intensifying the peristaltic and secretory derangements and increasing the
risks of dehydration and progression to strangulating obstruction.

Strangulating obstruction is obstruction with compromised blood flow; it occurs in nearly


25% of patients with small-bowel obstruction. It is usually associated with hernia,
volvulus, and intussusception. Strangulating obstruction can progress to infarction and
gangrene in as little as 6 h. Venous obstruction occurs first, followed by arterial

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occlusion, resulting in rapid ischemia of the bowel wall. The ischemic bowel becomes
edematous and infarcts, leading to gangrene and perforation. In large-bowel obstruction,
strangulation is rare (except with volvulus).

Perforation may occur in an ischemic segment (typically small bowel) or when marked
dilation occurs. The risk is high if the cecum is dilated to a diameter ≥ 13 cm. Perforation
of a tumor or a diverticulum may also occur at the obstruction site.

Symptoms and Signs


Obstruction of the small bowel causes symptoms shortly after onset: abdominal
cramps centered around the umbilicus or in the epigastrium, vomiting, and—in patients
with complete obstruction—obstipation. Patients with partial obstruction may develop
diarrhea. Severe, steady pain suggests that strangulation has occurred. In the absence
of strangulation, the abdomen is not tender. Hyperactive, high-pitched peristalsis with
rushes coinciding with cramps is typical. Sometimes, dilated loops of bowel are
palpable. With infarction, the abdomen becomes tender and auscultation reveals a silent
abdomen or minimal peristalsis. Shock and oliguria are serious signs that indicate either
late simple obstruction or strangulation.

Obstruction of the large bowel usually causes milder symptoms that develop more
gradually than those caused by small-bowel obstruction. Increasing constipation leads to
obstipation and abdominal distention. Vomiting may occur (usually several hours after
onset of other symptoms) but is not common. Lower abdominal cramps unproductive of
feces occur. Physical examination typically shows a distended abdomen with loud
borborygmi. There is no tenderness, and the rectum is usually empty. A mass
corresponding to the site of an obstructing tumor may be palpable. Systemic symptoms
are relatively mild, and fluid and electrolyte deficits are uncommon.

Volvulus

Volvulus often has an abrupt onset. Pain is continuous, sometimes with superimposed
waves of colicky pain.

Diagnosis
• Abdominal series
Supine and upright abdominal x-rays should be obtained and are usually adequate to

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diagnose obstruction. Although only laparotomy can definitively diagnose strangulation,
careful serial clinical examination may provide early warning. Elevated WBCs and
acidosis may indicate that strangulation has already occurred.

Small-Bowel
Obstruction (Supine)

Small-Bowel
Obstruction
(Upright)

On plain x-rays, a ladderlike series of distended small-bowel loops is typical of small-


bowel obstruction but may also occur with obstruction of the right colon. Fluid levels in
the bowel can be seen in upright views. Similar, although perhaps less dramatic, x-ray
findings and symptoms occur in ileus (paralysis of the intestine without obstruction—see
Acute Abdomen and Surgical Gastroenterology: Ileus); differentiation can be difficult.
Distended loops and fluid levels may be absent with an obstruction of the upper jejunum
or with closed-loop strangulating obstructions (as may occur with volvulus). Infarcted
bowel may produce a mass effect on x-ray. Gas in the bowel wall (pneumatosis
intestinalis) indicates gangrene.

In large-bowel obstruction, abdominal x-ray shows distention of the colon proximal to the
obstruction. In cecal volvulus, there may be a large gas bubble in the mid-abdomen or
left upper quadrant. With both cecal and sigmoidal volvulus, a contrast enema shows
the site of obstruction by a typical “bird-beak” deformity at the site of the twist; the
procedure may actually reduce a sigmoid volvulus. If contrast enema is not done,
colonoscopy can be used to decompress a sigmoid volvulus but rarely works with a
cecal volvulus.

Treatment
• Nasogastric suction
• IV fluids
• IV antibiotics if bowel ischemia suspected
Patients with possible intestinal obstruction should be hospitalized. Treatment of acute

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intestinal obstruction must proceed simultaneously with diagnosis. A surgeon should
always be involved.

Supportive care is similar for small- and large-bowel obstruction: nasogastric suction, IV
fluids (0.9% saline or lactated Ringer's solution for intravascular volume repletion), and a
urinary catheter to monitor fluid output. Electrolyte replacement should be guided by test
results, although in cases of repeated vomiting serum Na and K are likely to be
depleted. If bowel ischemia or infarction is suspected, antibiotics should be given (eg, a
3rd-generation cephalosporin, such as cefotetan 2 g IV) before laparotomy.

Specific measures
Obstruction of the duodenum in adults is treated by resection or, if the lesion cannot be
removed, palliative gastrojejunostomy (for treatment in children, see Congenital
Gastrointestinal Anomalies: Duodenal Obstruction).

Complete obstruction of the small bowel is preferentially treated with early laparotomy,
although surgery can be delayed 2 or 3 h to improve fluid status and urine output in a
very ill, dehydrated patient. The offending lesion is removed whenever possible. If a
gallstone is the cause of obstruction, it is removed through an enterotomy, and
cholecystectomy need not be done. Procedures to prevent recurrence should be done,
including repair of hernias, removal of foreign bodies, and lysis of the offending
adhesions. In some patients with early postoperative obstruction or repeated obstruction
caused by adhesions, simple intubation with a long intestinal tube (many consider a
standard NGT to be equally effective), rather than surgery, may be attempted in the
absence of peritoneal signs.

Disseminated intraperitoneal cancer obstructing the small bowel is a major cause of


death in adult patients with GI tract cancer. Bypassing the obstruction, either surgically
or with endoscopically placed stents, may palliate symptoms briefly.

Obstructing colon cancers can often be treated by a single-stage resection and


anastomosis. Other options include a diverting ileostomy and distal anastomosis.
Occasionally, a diverting colostomy with delayed resection is required.

When diverticulitis causes obstruction, perforation is often present. Removal of the


involved area may be very difficult but is indicated if perforation and general peritonitis
are present. Resection and colostomy are done, and anastomosis is postponed.

Fecal impaction usually occurs in the rectum and can be removed digitally and with

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enemas. However, a fecal concretion alone or in a mixture (ie, with barium or antacids)
that causes complete obstruction (usually in the sigmoid) requires laparotomy.

Treatment of cecal volvulus consists of resection and anastomosis of the involved


segment or fixation of the cecum in its normal position by cecostomy in the frail patient.
In sigmoidal volvulus, an endoscope or a long rectal tube can often decompress the
loop, and resection and anastomosis may be deferred for a few days. Without a
resection, recurrence is almost inevitable.

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