Bowel obstruction

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Clinical science

Bowel obstruction is the interruption of the normal passage of bowel contents either
due to a functional decrease in peristalsis or mechanical obstruction. Functional bowel
obstruction, or paralytic ileus, is a temporary disturbance of peristalsis in the absence of
mechanical obstruction. Postoperative ileus is the most common cause of paralytic ileus,
which can also be caused by metabolic disturbances (e.g., hypokalemia),
endocrinopathies (e.g., hypothyroidism), and certain drugs (e.g., anticholinergics).
Mechanical bowel obstruction is classified according to the location as either small bowel
obstruction (SBO) or large bowel obstruction (LBO) and, depending on the severity of
obstruction, as either partial or complete. The most common cause of SBO is
postoperative bowel adhesions, while the most common cause of LBO is malignant
tumors. Regardless of the cause, bowel obstruction typically manifests with nausea,
vomiting, abdominal pain, abdominal distention, and constipation or obstipation. In
paralytic ileus, bowel sounds are usually absent on auscultation, whereas a high-pitched
tinkling sound would be heard in the early phase of a mechanical bowel obstruction.
Bowel distention leads to third-space volume loss, resulting in dehydration and
electrolyte abnormalities. Symptoms are less severe in partial bowel obstruction.
Diagnosis is confirmed on imaging with contrast-enhanced CT scan and abdominal x-
rays. Typical findings in mechanical bowel obstruction include dilated bowel loops
proximal to the obstruction, collapse of bowel loops distal to the obstruction, and, on
contrast-enhanced imaging, a cut-off or transition point at the site of obstruction. In
paralytic ileus, findings include generalized dilatation of bowel loops with no transition
point and air that is visible in the rectum. Additional laboratory tests include CBC and
BGA for the assessment of infection, electrolyte imbalances (e.g., hypokalemia), and
metabolic imbalances (e.g., alkalosis). Surgical intervention (i.e., exploratory laparotomy)
is recommended for suspected closed-loop bowel obstruction, if there are signs of
perforation or peritonitis, or if there is no improvement following conservative
management. In all other cases, conservative treatment is usually successful and
involves bowel rest, gastric decompression (nasogastric suction), fluid resuscitation, and
correction of electrolyte abnormalities.

Etiology Interruption in the normal passage due to a Temporary

structural barrier impairment of
peristalsis in the
absence of a
mechanical
obstruction

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 Adhesions (e.g., Recent abdominal
prior abdominal surgery
surgery, Atherosclerotic
abdominal disease
tuberculosis) Abdominal
Incarcerated infections or
hernias: second inflammatory
most common conditions
cause of SBO Certain
medications
(opioids,
anticholinergics,
antiparkinsonian
agents)

Clinical Colicky abdominal pain Diffuse, continuous

features Vomiting abdominal pain
Bilious vomiting is an early symptom Vomiting
of SBO. Obstipation or
Feculent vomiting is a late symptom of constipation
LBO. Marked abdominal
Obstipation or constipation distention
Abdominal distention Tympany on
High-pitched, tinkling bowel sounds (early) percussion
Absent bowel sounds (late) Absent bowel sounds

Findings Dilated bowel loops proximal to obstruction Diffusely dilated small

on Collapsed bowel loops distal to obstruction and large bowel loops
imaging No air within rectum Air within rectum
Multiple air-fluid levels No evidence of
Cause of obstruction (e.g., tumor) mechanical
obstruction

References: [1][2][3][4]

An interruption in the normal passage of bowel contents.

Etiology
Mechanical bowel obstruction: an interruption in the normal passage of intestinal
contents due to a structural barrier (e.g., bowel cancer, adhesions)
Paralytic ileus: a temporary impairment of peristalsis in the absence of a
mechanical obstruction

Degree of obstruction

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 Partial bowel obstruction: bowel obstruction in which passage of some intestinal
content through the blocked segment is possible
Complete bowel obstruction: total interruption of the passage of intestinal
contents
Closed loop obstruction: a type of complete mechanical bowel obstruction in which
a segment of bowel is occluded at two contiguous points (e.g., volvulus)

Site of obstruction

Progression
Simple bowel obstruction: obstruction without evidence of bowel ischemia
Strangulated bowel obstruction: obstruction with compromised intestinal blood
flow, resulting in bowel ischemia

Reference:[5]

Etiology [1] [6]

Most Adhesions (e.g., prior abdominal

common surgery, abdominal tuberculosis):
causes most common cause of SBO
Incarcerated hernias: second most
common cause of SBO

Other Diverticulitis
causes Adhesions (e.g.,
postoperative, prior
abdominal surgery)
Strictures (e.g.,
inflammatory bowel
disease, congenital
strictures)
Fecal impaction
Foreign body impaction

Specific to
infants and
children

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Pathophysiology [7]
Bowel obstruction → stasis of luminal contents and gas proximal to the obstruction
→ ↑ intraluminal pressure, which leads to the following:
Gaseous abdominal distention → sequestration of fluids within the distended
bowel loops (third spacing) → dehydration and hypovolemia
Vomiting → loss of fluid and Na +, K+, H +, and Cl - → hypokalemia, metabolic
alkalosis, and hypovolemia
Compression of intestinal veins and lymphatics → bowel wall edema →
compression of intestinal arterioles and capillaries → bowel ischemia
→ ↑ Bowel wall permeability → translocation of intestinal microbes to
the peritoneal cavity → sepsis
→ Necrosis and perforation of the bowel wall → peritonitis
→ Anaerobic metabolism and lysis of ischemic cells → accumulation of
lactic acid and release of intracellular K +→ metabolic acidosis and
hyperkalemia

Clinical features [4][8][9]

Abdominal pain Colicky, periumbilical Colicky or constant

Vomiting/nausea Early-onset Late-onset

Large volume Initially bilious
Bilious Progresses to fecal vomiting

Constipation or Late-onset in proximal Early-onset in distal LBO

obstipation SBO

Abdominal Typically less significant Early and significant

distention than in LBO abdominal distention

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 Examination Dehydration and possible hypovolemia (hypotension, dry
findings mucous membranes)
Diffuse abdominal tenderness
Tympanic percussion
Increased high-pitched, tinkling bowel sounds (early) or absent
bowel sounds (late)
Collapsed, empty rectum on digital rectal examination

Partial bowel obstruction causes gradually progressive symptoms that are milder than
those of complete obstruction. Obstipation is absent in partial bowel obstruction.

Diagnostics
In the workup of suspected mechanical bowel obstruction, imaging allows for quick
confirmation of the diagnosis as well as detection of conditions requiring immediate
surgery (e.g., perforation). Laboratory tests may further help to assess the severity of the
condition (e.g., electrolyte imbalance due to vomiting).

Laboratory tests
If recurrent vomiting
Hypochloremic hypokalemic metabolic alkalosis
Hyponetremia
If bowel strangulation
Metabolic acidosis
Hyperkalemia
Neutrophilic leukocytosis (left shift)
If dehydration: ↑ Hct
If sepsis: abnormal coagulation profile
Potentially prerenal azotemia

Imaging [10][11][12][13]

Abdominal series
Consists of erect and supine abdominal x-rays and an erect chest x-ray.

Indication: Best initial test in hemodynamically unstable patients or in resource-

poor health centers
Findings
Dilatation of bowel loops proximal to the obstruction
3-6-9 rule to define bowel dilatation on imaging
Small bowel dilatation if > 3 cm
Large bowel dilattaion if > 6 cm
Cecal dilatation if > 9 cm
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 In SBO: The dilated loops are predominantly central.
In LBO (esp. distal LBO): The dilated loops are predominantly
peripheral.
Minimal/no air within the bowel loops distal to the obstruction
Stepladder sign (x-ray)
Multiple air-fluid levels and a stacked appearance of dilated small
bowel loops
Best seen on an erect abdominal x-ray

CT abdomen and pelvis

More sensitive than x-ray

Indications
With IV and oral contrast: Best initial test in hemodynamically stable patients
with suspected partial bowel obstruction [14][15] [16]
With IV contrast: Indicated in patients with suspected complete bowel
obstruction.
Non-contrast: Indicated in patients with contrast-allergy and suspected
complete bowel obstruction.
Findings
Transition point: sudden narrowing of bowel lumen at the site of obstruction
Dilatation of proximal loops
Signs of bowel ischemia
Unenhanced bowel loops
Pneumatosis intestinalis
Mesenteric fat stranding
Pneumoperitoneum indicates bowel perforation

MRI abdomen and pelvis (with and/or without IV contrast)[17] [16]

Indication: patients who have a contraindication for radiation exposure
Findings: similar to CT

Abdominal ultrasound
Indication: critically ill patients (easy bedside test) or patients with a suspected SBO
and a contraindication for CT (e.g., contrast allergy) or radiation exposure (e.g.,
pregnancy)
Findings

Barium or water-soluble contrast enema

Indication: in suspected distal LBO
Findings
Tapering of bowel lumen at the site of obstruction
Complete bowel obstruction: contrast would not be visible beyond
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 obstruction
Partial bowel obstruction: a trickle of contrast would be visible beyond
obstruction
Bird beak sign seen in volvulus
Apple core sign seen in colonic malignancy

When imaging with contrast (CT, enema) and perforation is expected,

use water-soluble oral contrast.

Treatment

Conservative management
Indications
Partial bowel obstruction cases
Complete bowel obstruction with no signs of ischemia/necrosis or signs of
clinical deterioration
Measures
Fluid resuscitation, correction of electrolyte imbalance
Intestinal decompression: nasogastric tube insertion
Bowel rest (NPO)
Administration of IV analgesics and antiemetics
Gradual increase of oral intake, starting with clear fluids, can be initiated once
the abdominal pain and distention subside and bowel sounds return to
normal.
Etiology-specific treatments
Fecal impaction: stool evacuation (manual disimpaction, distal
softening/washout with enemas or suppositories, proximal
softening/washout with oral solutions such as polyethylene glycol or sodium
phosphate)
Sigmoid volvulus with no signs of strangulation: rigid/flexible sigmoidoscopic
detorsion

Peristalsis-inducing medication (e.g., metoclopramide) is contraindicated in complete

mechanical bowel obstruction.

Surgery
Indications
Suspected bowel obstruction and hemodynamic instability or features of
sepsis
Complete bowel obstruction with signs of ischemia/necrosis or clinical

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 deterioration
Persistent partial obstruction (> 3–5 days)
Closed-loop obstruction
Procedure: exploratory laparotomy
Restoration of intestinal transit: depends on intraoperative findings
If bowel resection is required, the intervention may be carried out in a single
procedure with anastomosis or permanent ostomy creation, or in a
multistaged procedure with a temporary diverting ostomy.

Bowel obstruction requires a swift workup to establish whether emergent surgery is

necessary!

Prognosis
100% mortality in cases of untreated intestinal strangulation
Mortality rate for those undergoing surgery: 8–25%
High risk of recurrence, particularly with chronic or recurring etiologies (Crohn
disease, adhesions, radiation enteritis, volvulus, etc.)

References: [10][18][19][11][20]

Definition
Paralytic ileus: temporarily impaired peristalsis of the gastrointestinal tract in the
absence of mechanical obstruction

Etiology
Intra-abdominal surgery (postoperative ileus)
Abdominal trauma (e.g., due to retroperitoneal hemorrhage)
Endocrine abnormalities (e.g., hypothyroidism, porphyria, uremia)
Electrolyte disturbances (e.g., hypokalemia)
Neuropathy (e.g., diabetes mellitus, spinal injury)
Neurosurgical procedures (e.g., spinal surgery)
Vascular diseases (e.g., mesenteric ischemia)
Peritonitis
Inflammation of intra-abdominal organs (e.g., appendicitis, cholecystitis,
pancreatitis, severe gastroenteritis)
Medications (e.g., anticholinergics, opioids, antidepressants)

The common causes of paralytic ileus can be memorized using “5 Ps”: Peritonitis,
Postoperative, low Potassium, Pelvic and spinal fractures, and Parturition. [21]

References: [22][20]

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Pathophysiology
Stressful stimuli to the bowel (e.g., surgery, peritonitis) → sympathetic nervous
system activation → decreased/arrested peristalsis
Inflammation or intraoperative manipulation → local release of nitric oxide →
relaxation of intestinal smooth muscles → decreased/arrested peristalsis
Decreased/arrested peristalsis → bowel wall distention → progresses as detailed
above in mechanical bowel obstruction

Clinical features
Continuous (noncolicky) abdominal pain or discomfort
Nausea, vomiting
Abdominal distention
Percussion: tympany
Palpation: no tenderness unless peritonitis is present
Auscultation: bowel sounds are absent (silent abdomen) or decreased (early
paralytic ileus)

Diagnostics

Laboratory[23]
Leukocytosis with left shift suggests intestinal infection or ischemia.
Anemia may be a sign of intra-abdominal hemorrhage (e.g., in postoperative or
trauma patients).
Hypokalemia, hypomagnesemia

Imaging[24][25]
Abdominal x-ray: best initial test
Generalized small and large bowel gaseous distention
Visible gas shadows in the rectum
No transition or cut-off point on contrast x-rays, such as enteroclysis or
barium/water-soluble contrast enema
If caused by retroperitoneal hemorrhage: obliteration of the psoas muscle
outline
Abdominal CT: to rule out suspected mechanical bowel obstruction or if abdominal
x-ray is inconclusive
Has the highest sensitivity and specificity for differentiating ileus from
mechanical obstruction
Identifies uniformly distended loops with no transition point and no
structural/mechanical cause

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Treatment
Conservative treatment: in patients with no signs of localized or diffuse sepsis (e.g.,
appendicitis, secondary peritonitis)
Bowel rest
Nasogastric tube insertion
IV fluids and electrolyte repletion
Stop or decrease causative medications (e.g., opioids).
Gradual increase in enteral feeding as tolerated by the patient
Early postoperative ambulation (although still recommended to prevent DVT)
and use of prokinetics have not been proven to improve peristalsis.
Surgical intervention: in patients with signs of peritonitis (e.g., appendectomy,
exploratory laparotomy)

A change in the character of pain (colicky pain becoming continuous), rebound

tenderness on examination, and/or signs of sepsis in a patient with bowel obstruction
indicate the onset of complications and necessitate emergency surgical intervention!

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